Respiratory Examination

Question 1

What are the steps before examination?

Answer 1

Introduce yourself
Confirm name and DOB
Gain consent
Adjust bed to 45 degree angle
Ask patient to expose chest
Ask if patient is in any pain

Question 2

What are you looking for in a general inspection?

Answer 2

Cyanosis or Pallor
Shortness of Breath
Cough or Wheeze
Stridor
Oedema
Cachexia

Question 3

What does cyanosis indicate?

Answer 3

Poor circulation or inadequate oxygenation of blood

Question 4

What does shortness of breath look like?

Answer 4

Use of accessory muscles
Nasal flaring

Question 5

What is stridor and what does it indicate?

Answer 5

A high pitched breath sound
Indicates turbulent flow

Question 6

What does pallor indicate?

Answer 6

Anaemia or poor perfusion

Question 7

What does peripheral oedema or Ascites indicate?

Answer 7

Right ventricular failure

Question 8

What does pulmonary oedema indicate ?

Answer 8

Left Ventricular Failure

Question 9

What does Cachexia indicate?

Answer 9

End stage lung diseases ( COPD, lung cancer )

Question 10

What objects/ equipment should you look out for?

Answer 10

Oxygen
ECGs leads
Medications
Catheters
IV
Mobility aids

Question 11

What do you look out for on the hands?

Answer 11

Tar staining
Clubbing
Cyanosis
Bruised/thinned skins
Joint swelling/deformity

Question 12

How do you assess finger clubbing?

Answer 12

Schamroth’s Window ( diamond test)

Question 13

What else do you assess for on hands?

Answer 13

Fine temor
Asterixis
Symmetrical temperature
Radial pulse

Question 14

What does skin thinning/bruising indicate?

Answer 14

Long term steroid use

Question 15

What does joint swelling/ deformity indicate?

Answer 15

Rheumatoid Arthritis
( happens in pleural effusion / pulmonary fibrosis)

Question 16

What does finger clubbing indicate?

Answer 16

Chronic Low Oxygen :
Lung cancer
Interstitial lung disease
CF
Bronchiectasis

Question 17

What does a fine tremor indicate?

Answer 17

Beta-2-agonist usage ( e.g salbutamol )

Question 18

What does asterixis indicate?

Answer 18

CO2 retention ( e.g type 2 reps failure)

Question 19

What does the temperature of the hands indicate ?

Answer 19

Cold hands - poor peripheral perfusion
Excessively warm hands - CO2 retention

Question 20

Where is the radial pulse palpated?

Answer 20

The radial ( lateral ) side under wrist

Question 21

What do you assess of the radial pulse ?

Answer 21

Heart Rate
Regular Rhythm

Question 22

What does a bounding pulse indicate?

Answer 22

CO2 Retention

Question 23

What do you assess after inspecting the hands?

Answer 23

Respiratory Rate

Question 24

What do you assess after hands/resp rate ?

Answer 24

Jugular venous pressure

Question 25

How do you assess Jugular Venous Pressure?

Answer 25

Ask patient to lie at 45 degree angle Ask patient to turn their head slightly to the left Look for IJV between two sternocleidomastoid heads Measure distance between sternal angle and pulsation point

Question 26

What is the sternal angle?

Answer 26

The articulation between the sternum and the 2nd rib costal cartilages

Question 27

What should the JVP height be?

Answer 27

3cm

Question 28

What is the hepatojugular reflux?

Answer 28

Press down on the patients liver (right side) and see if IJV rises

Question 29

What general inspection of the face should you do?

Answer 29

For plethora - associated with CO2 retention

Question 30

What do you inspect the eyes for?

Answer 30

Conjunctival pallor - indicates anaemia Ptosis , meiosis and exophthalmos - indicate Horners Syndrome could be due to Pancoast Tumour

Question 31

What do you inspect the mouth for?

Answer 31

Central cyanosis Oral candidiasis - associated with steroid inhaler use

Question 32

What do you inspect the chest for?

Answer 32

Scars Asymmetry Caved in chest Protrusion of chest Barrel Chest

Question 33

How do you assess tracheal position?

Answer 33

Gently palpate tracheal borders , should be central

Question 34

What does tracheal deviation indicate?

Answer 34

Tension pneumothorax Late pleural effusion

Question 35

How do you asses cricosternal distance?

Answer 35

Measure distance between suprasternal notch and cricoid cartilage - should be 3-4 fingers

Question 36

What do you palpate on the chest?

Answer 36

Apex - 5th ICS, midclavicular line Place hand horizontally

Question 37

How do you assess chest expansion?

Answer 37

Place hands on patients chest inferior to nipples and bring thumbs together in the midline so that they touch. Ask patient to take a deep breath

Question 38

Where do you percuss on the chest wall?

Answer 38

Supraclavicular Infraclavicular Chest wall ( 4 areas bilaterally) Axilla

Question 39

What does a dull percussion indicate ?

Answer 39

Increased tissue density

Question 40

What does hyper resonance indicate?

Answer 40

Decreased tissue density ( e.g pneumothorax)

Question 41

Where do you auscultate the chest?

Answer 41

Supraclavicular Infraclavicular 3-4 areas bilaterally on chest wall Axilla

Question 42

What do you assess on auscultation ?

Answer 42

Quality ( crackles , wheeze, stridor, ) Volume

Question 43

What does wheeze indicate?

Answer 43

Asthma COPD Brochiecstasis

Question 44

What does coarse crackles indicate ?

Answer 44

Pneumonia Bronchiectasis Pulmonary Oedema

Question 45

What do fine end-inspiratory crackles indicate ?

Answer 45

Pulmonary fibrosis

Question 46

What do you do after auscultation?

Answer 46

Assess vocal resonance , repeat auscultation but get patient to say 99 each time.

Question 47

Which lymph nodes do you palpate?

Answer 47

Submental Submandibular Superficial Cervical Deep Cervical Posterior Cervical Supra clavicular Pre-auricular Occipital Post-auricular

Question 48

What do you assess after anterior chest wall?

Answer 48

Posterior chest wall

Question 49

What steps do you repeat for posterior chest wall?

Answer 49

Inspection Chest expansion Percussion Auscultation Vocal resonance

Question 50

What are the last steps?

Answer 50

Check for any evidence of pitting oedema ( sacral or pedal) Assess the calves for any signs of DVT

Question 51

What is the general order for the exam?

Answer 51

Intro Consent General Inspection Hands Face Eyes Mouth JVP Trachea Anterior chest inspection ( Inspection, Expansion, Palpation, Percussion, Auscultation ) Get the sit up on the bed Posterior chest inspection ( Examination, Expansion, Palpation, Percussion, Auscultation) Lymph nodes Get them to sit back down Pedal/Sacral Oedema