Respiratory Examination

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Wash hands

Rapport

Positioning

  • Sitting up

Exposure to waist

Surroundings

  • Sputum mug contents
    • (blood, pus etc)
  • O2, inhalers, Peakflow meter
  • Cigarettes

From end of bed

  • General appearance
    • Cushingoid / cachectic
  • Rate and depth of respiration
  • Accessory muscles of respiration
  • Breathing pattern at rest
  • “Comfortable at rest”

Extra sounds

  • Wheeze
  • Stridor

Type of cough

Clubbing

Cyanosis (peripheral)

Nicotine staining

Wasting / weakness (finger abduction and adduction)

  • (lung cancer involving the brachial plexus)

Wrist tenderness

  • (hypertrophic pulmonary osteoarthropathy)

Pulse

  • (tachycardia, pulsus paradoxus, AF)

Tremor

  • Flapping
    • (CO 2 narcosis)
  • Fine
    • (? Salbutamol)

Sats

Temp

BP

Impression

  • Plethora
    • smoker, SVC obstruction
  • Pallor

Eyes

  • Horner’s syndrome
    • (apical lung cancer),
  • anaemia

Sinusses

Nose

  • Polyps

Mouth

  • Central cyanosis
  • Tonsils

Voice (“can you count out loud please from one to ten”)

  • [hoarseness]
    • (recurrent laryngeal nerve palsy)

Forced exp time

Trachea

Supraclavicular nodes

Inspect

  • Shape of chest and spine
    • [Barrel]
      • (COPD, Asthma)
    • [Pectus carinutum]
      • (rickets, choildhood resp disease)
    • [Harrison sulcus]
      • (asthma, rickets)
  • Scars / radio Tx
  • Prominent veins (determine direction of flow)

Palpate

  • Cervical lymph nodes
  • Expansion
    • Top
    • Bottom (< 5cm abN)
  • Rib tenderness
  • Vocal fremitus

Percuss

  • Supraclavicular region
  • Back
  • Axillae
  • [Stony dull]
    • (effusion)
  • [Hyperresonant]
    • (PTX, hyperexpansion)
  • Tidal percussion
    • (diaphragm paralysis)

Auscultate

  • Breath sounds
    • Intensity
    • Quality
    • R vs L
    • Added sounds
      • [Stridor]
      • [Wheeze]
      • [Crackles]
        • Fine
          • (pulm fibrosis)
        • Medium
          • (LVF)
        • Course
          • (Bronciectasis, secretions)
  • Vocal resonance (“Repeat 99 out loud please”)

Inspect

  • Radiotherapy marks, other signs as noted above

Palpate

  • Expansion
  • Surg emphysema
  • Vocal fremitus
  • Apex beat

Percuss

  • Supraclavicular
  • Clavicles
  • Liver displacement?

Auscultate

  • Breath sounds
    • Intensity
    • Quality
    • R vs L
    • Added sounds
  • Forced expiratory time

Pemberton’s sign

  • (SVC obstruction)

Jugular venous pressure

  • (SVC obstruction etc)

? Cor pulmonale

  • Heave
  • Liver palpable?

? Pulmonary hypertension

  • Loud S2

Lower limbs

  • oedema, cyanosis
  • ? DVT

Temperature chart

  • (infection)

Evidence of malignancy or pleural effusion:

  • “ I would like to examine the breasts, abdomen, rectum, lymph nodes”

Respiratory rate after exercise

CXR

Spirometry

ECG

Positives

Negatives

Diff Dx