Respiratory Examination

Question 1

Introduction

Answer 1

Introduce yourself
Confirm patient name and DOB
Ask how they'd like you to address them
Explain what you plan to do, gain consent
Are they in any pain
PPE, handwashing
Adjust bed to 45 degrees

Question 2

Step 1 General inspection (clinical signs)

• what might you find
• what does this mean

Answer 2

Age

• young => asthma, CF?
• old => COPD, ILD, malignancy

Complexion

• pallor => anemia (haemorrhagic/chronic disease), poor perfusion (CCF)
• cyanosed => poor circulation (peripheral VC, inadequate oxygenation)

Habitus
- pedal/abdomen edema => RV failure, cor pulmonale
- cachexic => malignancy, end stage COPD

Breathing
- SOB, can’t speak in full sentences, tripod, accessory muscle use => asthma, pulmonary edema, pulmonary fibrosis, lung cancer, COPD
- stridor => foreign body inhalation, subglottic stenosis
- wheeze => asthma, COPD, bronchiectasis

Cough
- productive => pneumonia, bronchiectasis, COPD, CF
- dry => asthma, ILD

Question 3

Step 1 General inspection (objects, equipment)

• what might you find
• what does this mean

Answer 3

O2 delivery, ventilation
- nasal prongs, venturi, non rebreathe
- CPAP, BiPAP?

Sputum pot colour and contents
- white => COPD exacerbation
- yellow, green => bacterial infection (pneumonia?)

Medical equipment
- ECG
- medications (nebulisers, inhalers, catheters, IVs)

Charts
-NEWS, fluid balance, drug charts

Mobility
-wheelchairs, frames

Cigarettes, vapes
-COPD, lung cancer?

Question 4

Step 2 Hands, general observations

• what might you find, look for
• what does this mean

Answer 4

Colour
- cyanosis => hypoxemia
- tar stains => smoker (COPD, lung cancer?)
- bruising, thin skin (long term steroid use) => asthma, COPD, ILD?
- joint swelling, deformity => RA with pleural effusions, pulmonary fibrosis

Question 5

Step 2 Hands

-what is clubbing indicative of?

Answer 5

Cancer
-squamous
-mesothelioma (caused by asbestos)

Chronic suppuration
- bronchiectasis
- ILD
- empyema

Cystic fibrosis

Chronic autoimmune
-sarcoidosis

Question 6

Step 2 Hands

-what can tremor and flap tell you

Answer 6

Fine tremor => B2ag use

Asterixis => CO2 retention (T2RF, COPD)

Question 7

Step 2 Hand palpation

• what info can you get from this
• what does this tell you

Answer 7

Temperature, should be symmetrically warm
- cool => poor peripheral perfusion
- excessively warm => CO2 retention?

HR
- bounding => CO2 retention
- pulsus paradoxus (pulse wave volume decreases significantly on inspiration) => cardiac tamponade, severe acute asthma, COPD

RR
- bradypnoea => opiate OD?
- tachpnoea => acute asthma?
- asymmetrical => expiration prolonged in COPD exacerbations

Question 8

Step 3 Neck, JVP

• how would you measure this
• what is abnormal and what does this mean?

Answer 8

45, turn head to left
- look for biphasic flicker in supraclavicular fossa
- measure the vertical distance between sternal angle and top of pulsation (up to 4cm)

Raised => venous HTN (cor pulmonale due to COPD, ILD)

Hepatojugular reflex
NORMALLY JVP REMAINS CONSTANT OR TEMPORARILY RISES
-sustained rise => decreased venous return

Question 9

Step 4 Face, general observations

• what might you find
• what does this mean

Answer 9

Plethoric (congested red face) => polycythemia (COPD), CO2 retention (T2RF)

Question 10

Step 4 Face (eyes)

• what might you find
• what does this mean

Answer 10

Conjunctival pallor => anemia

Ptosis, miosis (excess pupil constriction), enopthalmos (retraction of eye into orbit) => Horners syndrome (sympathetic trunk damaged <= pancoast tumour compression)

Question 11

Step 4 Face (mouth)

• what might you find
• what does this mean

Answer 11

Central cyanosis => hypoxemia

Oral candida above erythmatous mucosa => steroid inhaler use, immunosuppresion

Question 12

Step 5 Chest (inspection)

• what might you find
• what might this be indicative of?

Answer 12

Scars
Radiotherapy associated skin changes (lung cancer)
-dry skin, scale, hyperkeratosis
-depigmentation, telangiectasia

Asymmetry => pneumonectomy, thoracoplasty
Pectus excavatum, carinatum
Hyperexpansion (wider and taller than normal) => asthma, COPD

Question 13

Step 6 Trachea

• how would you assess its position
• what could this tell you

Answer 13

Warn patient before hand, might be painful
Dip index finger into thorax next to trachea, gently apply pressure
Compare this space to other side

Deviation away => tension pneumothorax, large pleural effusions
Deviation towards => lobar collapse, pneumonectomy

Question 14

Step 6 Trachea
Cricosternal distance
-how would you assess this
-what could this tell you

Answer 14

Distance between suprasternal notch and cricoid cartilage
-3-4 finger distance is normal

Smaller => hyperinflation (asthma, COPD)

Question 15

Step 7 Chest palpation

• what would you assess
• what would this tell you

Answer 15

Apex beat
-displaced => LVH (pulmonary HTN, COPD, ILD), large pleural effusion, tension pneumothorax

Symmetrical reduced chest expansion => pulmonary fibrosis
Asymmetrical reduced chest expansion => pneumothorax, pneumonia, pleural effusion

Question 16

Step 8 Chest percussion

• what are you looking for
• what can this tell you

Answer 16

NORMALLY RESONANT
Dullness => consolidation, tumour, lobar collapse
Stony dullness => pleural effusion
Hyper resonant => pneumothorax

Vocal fremitus

• increased resonance => consolidation, tumour, lobar collapse
• decreased resonance => fluid, air outside lung (pleural effusion, pneumothorax)

Question 17

Step 9 Chest auscultation

• what would you find
• what does this mean

Answer 17

Quality
- vesicular => normal
- bronchial => harsh sounding, inspiration, expiration equal (consolidation)

Volume
-quiet => reduced air entry (pleural effusion, pneumothorax

Added sounds
- wheeze => coarse (asthma, COPD, bronchiectasis)
- stridor => high pitched from turbulent flow (foreign body inhalation, subglottis stenosis)
- coarse => discontinuous brief popping (pneumonia, bronchiectasis, pulmonary edema)
- fine crackles => Velcro (pulmonary fibrosis)

Question 18

Step 10 lymph node palpation

• which ones would you palpate
• what are you looking for

Answer 18

Examine from behind the patient
Tilt chin downwards slightly
-inspect for lymphadenopathy/abnormalities
-use both hands to assess symmetry in both sides
-use pads of fingers to roll nodes over surrounding tissue

Submental, submandibular 
Preauricular, postauricular
Superficial, deep cervical
Anterior, posterior chain
Occipital 
Supraclavicular

Lung cancer with mets
TB
Sarcoidosis

Question 19

Step 11 Posterior chest

• what are you doing
• what are you looking for

Answer 19

Ask patient to hug their knees

• inspect
• expansion
• percussion, vocal fremitus
• auscultation

Same as anterior thorax

Question 20

Step 12 Peripheral edema

• what are you testing
• what does this mean

Answer 20

Pitting sacral, pedal edema (RVF)
Erythema nodosum (swollen fat under skin causing bumps and patches) => sarcoidosis, TB, pneumonia,
Signs of DVT

Question 21

Completion of examination

Further examinations

Answer 21

SaO2
Sputum sample if coughing
Peak flow
CXR if abnormalities found
ABG
CV exam to rule out CV causes