Respiratory

Question 1

What do you look for on inspection of the patient?

Answer 1

General - colour, breathing, comfort, position, nutritional state etc
Hands - clubbing, tar staining, tremor (ie flapping asterexis in respiratory/liver failure; fine due to beta-agonists), wasting?
Pulse (+ respiratory rate) - rate, rhythm, character (bounding in CO2 retention), pulseless paradoxus?
Raised JVP (assess at 45 degrees, head turned away, seen between 2 heads of SCM as a double wave, can press liver to increase prominence, measure distance above sternal angle, should be <4cm)
Eyes - conjunctival pallor with anaemia, Horner’s
Face/mouth - oedema, central cyanosis (stick out tongue then touch tip to roof of mouth)

Question 2

What do you look for on inspection of the chest?

Answer 2

Shape - Barrel chest (hyperinflation, emphysema), severe kyphoscoliosis, pectus excavatum or carinatum
Symmetry
Scars - pneumonectomy (in line with rib spaces on posterior chest wall), chest drains, any cardiac
Wasting
Chest vs diaphragmatic breathing, use of accessory muscles

Question 3

What do you look for on palpation?

Answer 3

Trachea - check deviation by placing index and ring finger either side of trachea above sternal notch and feeling with the middle finger

Apex beat - 5th intercostal space mid clavicular line (may be displaced in cardiac hypertrophies, poss secondary to resp disease)

Chest expansion - place hands around rib cage, pulling skin towards mid-line, bring thumbs nearly together and slightly elevated off the patient, ask patient to fully breath in and out, assess for symmetry. Repeat from the back.

Tactile vocal fremitus - edge of hand placed in between rib spaces on both sides, patient is asked to speak ‘ninety-nine/blue balloons’.
Repeat from the back

Question 4

What do you look for on percussion?

Answer 4

Starting at the apices of the lungs (supraclavicular), percuss each side alternately - about 3 different rib spaces down each side in the mid axillary line then also in the axilla

Longer time can be taken if any areas of dullness are present

Repeat on the back

Question 5

What do you look for on auscultation?

Answer 5

Ask patient to breathe normally with their mouth slightly open.

Starting at the apices of the lungs (subclavicular), listen to each side alternately - in the mid clavicular and axillary planes

If anything is found, can ask patient to breathe deeper to help bring it into better focus

Looking for: air entry - even? vesicular/normal breath sounds, bronchial breathing, wheezes, crepitations (base of lungs, posterior), pleural rub

Assess for a change in any sounds after coughing (secretions = change in noise, fibrotic = fixed creptiations)

Assess vocal resonance - 99’s - increased vol (consolidation, tumour; even more suspicious with dull percussion note) vs decreased vol (pleural effusion)

Perform whispering pectoriloquy if consolidation suspected
Repeat on the backing

Question 6

What else do you need to examine?

Answer 6

(state in OSCE)

SLOPS CXR

Checks Sputum pot (ie bronchiectasis patient, if present) - volume, consistency, colour, odour, blood?

Palpate cervical, supraclavicular and axillary Lymph nodes (from behind) and the ankles (for Oedema - cor pulmonale) (if not already assessed)

Peak flow

Sats - oxygen levels

Chest X-ray if any findings on examination