The respiratory exam

1. Positioning and general inspection Good morning Mr X, my name is Jaime and I am a second year medical student. I would like to examine your breathing and your respiratory system. So that I can properly examine you, I will need you to take off your shirt. Is that ok? Do you know what the date is today? Position the patient on the edge of the bed. Now can you cough a couple of times for me? And can you stick out your tongue. Observe for breathlessness, obvious weight loss, cyanosis and their mental state. On general inspection, the patient appears comfortable and mentally alert. There is no sign of obvious weight loss or cyanosis. 2. Hands and vitals Now can you stick your hands out like this for me? Take the pulse and immediately after count the respiratory rate. Pulse normal range: 60-100bpm RR: 16-25; <8 = Bradypnoea; >25 = Tachypnoea

Observe for: Clubbing: due to respiratory disease (can also be due to HPO) NOT chronic bronchitis or emphysema INSPECT THE NAIL BED ANGLE Tar staining: cigarette smoking Wasting: wasting in intrinsic muscles of hand due to peripheral lung tumour infiltrating the lower trunk of the brachial plexus HPO Asterixis

On examination of the hands, there are no peripheral stigmata of respiratory disease. There is however 3. Face and neck Eyes Horners syndrome (due to cervical sympathetic chain compression caused by apical lung tumour) o Constricted pupils (Miosis) o Drooped eyelid (Ptosis) o Lack of sweating (Anhdrosis) Conjunctival pallor (anaemia)

Mouth Central cyanosis

Palpate the sinuses for tenderness, and the lymph nodes Frontal and maxillary sinuses (acute sinusitis) Submental, submandibular, preauricular, anterior cervical, posterior cervical, supraclavicular

The neck Tracheal deviation: place your 2nd and 3rd digits on the medial sides of the sternal ends of each clavicle, and palpate for the trachea with your 3rd digit

Now I need to check that your airway is in the right place, however I am going to need to touch your throat. It may be a little bit uncomfortable, but not painful. Is that ok? Examination of the face showed no signs of Horners, central cyanosis or acute respiratory infection. The trachea is palpable and midline. 4. The chest Inspect the chest: Front and back: o Deformities (eg. Pectus carinatum, pectus excavatum) o Scarring (trauma, surgeries, chest drains) o Asymmetries (pneumothorax) o Pattern and phasing: chest wall should expand evenly (abdomen and chest should move in phase) Intercostal muscle paresis descent of diaphragm and bring rib cage down as the intercostals normally splint the rib cage Diaphragmatic paresis Diaphragm is pulled up on inspiration - these patients will find it easier to stand Side: o AP/lateral ratio > 0.9 = barrel chest (asthma, emphysema)

The chest is symmetrical and expands in phase with the abdomen without use of accessory muscles. Inspection from the side reveals no signs of barrel chest, and there are no apparent deformities or scars present on the chest wall. Chest expansion Place your fingers over the lateral surface of the chest, just beneath the axilla, and with your thumbs just elevated over the sternum (but not pushing down onto the skin). Ask the patient to take a deep breath in and out. Do the same at the back. Vocal fremitus

Palpate the chest wall with the palm of the hand while the patient repeats ninety-nine. Have both palms on each side of the chest for both the front and back. Chest expansion is normal at about 4cm and is symmetrical. Vocal fremitus is equal on both sides. Percussion Align the fingers of your left hand with the ribs. Percuss the symmetrical areas of the anterior, posterior and axillary regions, as well as the supraclavicular fossa. Percuss the clavicle directly. Dullness: consolidated area of the lung Extreme dullness: fluid such as pleural effusion Resonance: normal

The chest wall is resonant bilaterally on percussion. Auscultation Normal and bronchial breath sounds o Normal: Caused by turbulent flow in large airways; inspiration is heard to be longer than expiration as the breath sounds rapidly fade as airflow decreases. There is no break in sound in inspiration and expiration o Bronchial: High pitched breath sound with hollow/blowing quality similar to that heard over the trachea. Occurs when normal lung tissue is replaced by uniformly conducting tissue and the underlying major bronchus is patent. Inspiration and expiration sounds are of equal lengths and there is a break between them. o Bronchial breath sounds can be caused by lung consolidation, such as in pneumonia Other lung sounds o Crackles: air bubbles through secretions in major bronchi; dilated bronchi in bronchiectasis coarse gurgling quality o Wheeze: Asthma, COPD, fixed bronchial obstruction (lung cancer wont clear on coughing). In severe airway obstruction wheeze may be absent due to reduced airflow

Intensity of normal breath sounds is equal on both sides. No bronchial breathing, wheezes or crackles were present.