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                  Respiratory Exam




© Copyright Medical Educator Limited   www.medicaleducator.co.uk
Respiratory Exam
In any encounter you may be given a short history or have taken a short history yourself.


Introduction
Use 2 names e.g. James Bateman / Mr Bateman not James. It can be seen as
unprofessional to use your first name only and is not acceptable for clinical use.
Seek permission for the examination and be polite to the patient.
“Stop me at any time if it becomes uncomfortable or I cause you any discomfort.”


Positioning and inspection
Position the patient correctly - at 45 degrees and with chest fully exposed but be guided by
the examiners and the clinical setting.

For example:
60 y male: consider exposing thorax immediately
35 y female: take into account the clinical situation / examiners etc.

Firstly inspect the patient from the end of the bed.

Note peripheral signs and clues around the bed: Stand with your hands behind your back
and take time to inspect only.


Patient - General appearance
   •   SOB?
   •   Pursed lips
   •   Cachexia
   •   Cyanosis
   •   Using accessory muscles of respiration
   •   Wheezing
   •   Prolonged expiratory phase seen in COPD
   •   Oedema
   •   Respiratory rate: Count this and demonstrate it confidently.
   •   Features of SVCO
   •   Cough: is it dry/ productive. Is there a sputum pot? If so, look in it.



Around the bed
   •   Inhalers/ flutter devices (bronchiectasis/ cystic fibrosis)
   •   Oxygen
   •   CPAP machine (Obstructive sleep apnoea - 2% population)
   •   Sputum Pots




    © Copyright Medical Educator Limited                           www.medicaleducator.co.uk
Examination of the hands
   •    Nicotine staining
   •    Clubbing - lung cancer/ chronic suppurative lung diseases (bronchiectasis/CF/lung
        abscess/empyema), pulmonary fibrosis, mesothelioma
   •    CO2 retention flap
   •    Bruising/ thin skin: steroid therapy
   •    Peripheral cyanosis
   •    Other conditions: e.g. Yellow Nails/ RA hands/ Scleroderma/ Wasting of the intrinsic
        muscles of the hands (cachexia/ pancoast tumour)
   •    Hypertrophic pulmonary osteoarthropathy (HPOA) associated with lung malignancy


Pulse
   •    Pulse: palpate rate, rhythm, character.
   •    Tachycardia: e.g. AF associated with pulmonary disease. Tachycardia associated
        with beta 2 agonists (nebulised salbutamol)


Face
   •    Horner’s Syndrome (MEAP! Myosis, enophthalmos, anhydrosis, ptosis)
   •    Central Cyanosis (4g of Hb has to be deoxygenated)
   •    Acneform eruptions associated with immunosuppressive therapy
   •    Cushingoid appearance with long-term steroid use – fibrosis etc.



The Neck
   •    Position of the trachea
   •    Lymph node enlargement (tuberculosis, lymphoma, malignancy, sarcoidosis)
   •    Scars (phrenic nerve crush for old TB)
   •    Tracheostomy scar previous ventilation in COPD etc. Central line scars
   •    Scar from LN biopsy
   •    JVP - ? right sided heart failure (cor pulmonale as a result of chronic lung disease)



Chest
Inspection

Scars
   •    Pneumonectomy
   •    Lobectomy
   •    Transplant
   •    VATS
   •    Chest Drains
   •    Thoracocentesis
   •    Radiation Tattoo’s (previous radiotherapy)



   © Copyright Medical Educator Limited                           www.medicaleducator.co.uk
•   Chest wall deformity – pectus excavatum / carinatum

Size
   •    Hyper-inflated?

Movements
  • Expansion. Equal or reduced on one side?

Palpation
   • Chest expansion – upper and lower chest expansion


                                                                              Key Clinical Fact

Percussion                                                                Always describe the chest
                                                                          in terms of anterior and
    •   Technique                                                         posterior.
    •   Look slick                                                        Then describe the lungs
    •   Simple                                                            as zones NOT lobes
    •   Compare like with like                                            I.e. Upper/ Middle/ Lower
                                                                          Zones
    •   Normal distribution but don’t forget the axillae
    •   Hyper resonant/ normal/ dull or stony dull. Nothing else.
                                                                          Remember the Left lung
        Compare both sides
                                                                          has 2 lobes (upper lower&
    •   Hyper = pneumothorax/ COPD                                        lower lobe with the upper
        Dull = Consolidation/collapse                                     lobe being anterior / LL
        Stony Dull = Fluid                                                posterior)

                                                                          Right lung has 3 lobes
                                                                          upper middle and lower,
Auscultation                                                              and it’s difficult to locate
                                                                          chest signs specifically to
                                                                          each lobe. Instead use
Comparing two sides:                                                      ZONE.
Breath sounds                                                             This goes the same for
Louder                                                                    chest radiographs:
Normal                                                                    however on X-rays there
Reduced: Reduced air entry/ perceiving less air entry due to              are clues as to where the
         fluid/ consolidation/ collapse/ fat                              consolidation is. e.g. if the
                                                                          right heart border is
How do you know which side is abnormal?                                   obscured by the
                                                                          consolidation on a chest
You don’t unless there are other features present         you have        x-ray then this implies it’s
to hypothesise                                                            a middle lobe pathology.
e.g. one side sounds to have “louder” air entry than the other? It is
probably the quiet side that has the pathology due to ……..                If the consolidation sits
                                                                          above the horizontal
•   Inspiration                                                           fissure then it must be in
•   Expiration                                                            the RUL.
•   Added sounds and their timing e.g. inspiratory / expiratory/
    pan inspiratory                                                       Do not say “x-ray” in the
        o Wheeze                                                          exam, say radiograph
        o Crackles. They are not creps or crepitations, they
            are crackles


    © Copyright Medical Educator Limited                            www.medicaleducator.co.uk
Crackles
•   Quality
       Fine: Pulmonary oedema/ interstitial lung disease (fibrosis etc)
       Velcro: Fibrosis
       Course: Infection or bronchiectasis
•   When do they occur?
       Early inspiratory: COPD/Bronchitis

       Mid-Late inspiratory:
               Velcro™ like crackles of pulmonary fibrosis*
               Pulmonary oedema
•   Do they clear / change on coughing?
       Yes = Bronchiectasis (will not totally clear but may change)
       No = Pulmonary fibrosis/ Pulmonary oedema*

*If you’ve got pulmonary oedema you’re generally unwell and the signs will come and go. For
exams held in “out patients” with patients coming from home, they’re very unlikely to have
pulmonary oedema. So Mid-late inspiratory crackles in this situation Pulmonary Fibrosis



Tactile Vocal Fremitus & Vocal resonance
    •   These techniques aim to detect the same findings
    •   Louder if consolidated lung that transmits the sound
    •   Quieter if there’s either
           o An effusion leading to an insulating layer of water outside the lung
           o Fat
           o COPD (hyperinflated lungs with holes in them!)

“Normally I would like to complete my examination by reviewing the temperature and
observations chart and examine for features of cor pulmonale. (inspect the JVP / look for
peripheral oedema / other signs of right heart failure)

I would like to check the patient’s peak flow and forced expiratory time” (see video on
website).


Forced expiratory time
Clever stuff like this often impresses examiners. To do this, instruct the patient:

I am going to ask you to take in as deep breath in as deep as you can and then hold it. On
my instruction, I will then ask you breathe out as forcefully and as quickly as possible. For
this to work you have to blow as hard as you can until all the air has emptied from your lungs.

Then do the above and time it with your wristwatch. If you had a spirometer the air blown out
in 1 second would be the FEV1 (forced expiratory volume in 1 second). If you can’t empty
your lungs in 6 seconds, this suggests a degree of obstruction i.e. COPD.
It’s a surrogate for bedside spirometry.




    © Copyright Medical Educator Limited                           www.medicaleducator.co.uk
Condition          Expansion              Air entry        Percussion          Auscultation Vocal
                                                                                            resonance
Pneumothorax       Reduced                Reduced          Hyper-resonant      Reduced air          Reduced
                   affected side          affected                             entry
                                          side
COPD               Reduced both           Reduced          Hyper-resonant      Wheeze+/-:           Reduced
                   sides & hyper          bilaterally      if predominant      expiratory
                   inflated chest                          emphasematou        polyphonic
                                                           s changes
Pulmonary          Reduced both           Reduced          Resonant            Crackles-fine        No change /
fibrosis           sides                  bilaterally                          inspiratory          Reduced
                                                                               Mid-late
                                                                                DO NOT clear
                                                                               on coughing
Bronchiectasis     Reduced both           Reduced          No change /         Crackles-fine        No change /
                   sides                  bilaterally      Reduced             inspiratory DO       Reduced
                                                                               clear / change
                                                                               on coughing
Asthma             Reduced both           ↓both sides      Hyper-resonant      Wheeze:              No change
                   sides during           during                               expiratory
                   active disease         active                               polyphonic
                                          disease
Stridor            Reduced both           ↓both sides      No change           Wheeze:              No change
                   sides                                                       inspiratory often
                                                                               monophonic
Lobar Collapse     Reduced side of        Reduced          Reduced             Reduced air          Reduced
                   collapse(ipsilate      ipsilaterally    ipsilaterally       entry
                   rally), trachea
                   pulled to that
                   side
Pneumonia          Reduced side of        Reduced          Reduced             Bronchial            Increased
                   collapse               ipsilaterally    ipsilaterally       breathing or
                                                                               reduced air
                                                                               entry
Pulmonary          No change              No change        No change           Possible pleural     No change
Embolism                                                   (Reduced if         rub (crunching
                                                           infarcted           through snow)
                                                           tissue)             often heard over
                                                                               area
Pulmonary          Usually no             Usually no       Stony dull if       Mid –late            Reduced
oedema             change.                change.          effusions           inspiratory fine     bilaterally
                   Reduced                Reduced          present with        crackles – more      only if
                   bilaterally only if    bilaterally      pulmonary           coarse than          effusions
                   effusions              only if          oedema.             those of fibrosis.   present with
                   present with           effusions        Usually normal      DO NOT clear         pulmonary
                   pulmonary              present          otherwise           on coughing          oedema
                   oedema                 with
                                          pulmonary
                                          oedema
Pleural Effusion   Reduced side of        Reduced          Reduced             Reduced air          Reduced
                   effusion               ipsilaterally    ipsilaterally,      entry
                   (ipsilaterally),                        stony dull
                   trachea pushed
                   to other side

                                         Respiratory Findings on Examination




    © Copyright Medical Educator Limited                                       www.medicaleducator.co.uk
© Copyright Medical Educator Limited   www.medicaleducator.co.uk

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Respiratory examination - OSCE guide

  • 1. One Minute Revision Guides Respiratory Exam © Copyright Medical Educator Limited www.medicaleducator.co.uk
  • 2. Respiratory Exam In any encounter you may be given a short history or have taken a short history yourself. Introduction Use 2 names e.g. James Bateman / Mr Bateman not James. It can be seen as unprofessional to use your first name only and is not acceptable for clinical use. Seek permission for the examination and be polite to the patient. “Stop me at any time if it becomes uncomfortable or I cause you any discomfort.” Positioning and inspection Position the patient correctly - at 45 degrees and with chest fully exposed but be guided by the examiners and the clinical setting. For example: 60 y male: consider exposing thorax immediately 35 y female: take into account the clinical situation / examiners etc. Firstly inspect the patient from the end of the bed. Note peripheral signs and clues around the bed: Stand with your hands behind your back and take time to inspect only. Patient - General appearance • SOB? • Pursed lips • Cachexia • Cyanosis • Using accessory muscles of respiration • Wheezing • Prolonged expiratory phase seen in COPD • Oedema • Respiratory rate: Count this and demonstrate it confidently. • Features of SVCO • Cough: is it dry/ productive. Is there a sputum pot? If so, look in it. Around the bed • Inhalers/ flutter devices (bronchiectasis/ cystic fibrosis) • Oxygen • CPAP machine (Obstructive sleep apnoea - 2% population) • Sputum Pots © Copyright Medical Educator Limited www.medicaleducator.co.uk
  • 3. Examination of the hands • Nicotine staining • Clubbing - lung cancer/ chronic suppurative lung diseases (bronchiectasis/CF/lung abscess/empyema), pulmonary fibrosis, mesothelioma • CO2 retention flap • Bruising/ thin skin: steroid therapy • Peripheral cyanosis • Other conditions: e.g. Yellow Nails/ RA hands/ Scleroderma/ Wasting of the intrinsic muscles of the hands (cachexia/ pancoast tumour) • Hypertrophic pulmonary osteoarthropathy (HPOA) associated with lung malignancy Pulse • Pulse: palpate rate, rhythm, character. • Tachycardia: e.g. AF associated with pulmonary disease. Tachycardia associated with beta 2 agonists (nebulised salbutamol) Face • Horner’s Syndrome (MEAP! Myosis, enophthalmos, anhydrosis, ptosis) • Central Cyanosis (4g of Hb has to be deoxygenated) • Acneform eruptions associated with immunosuppressive therapy • Cushingoid appearance with long-term steroid use – fibrosis etc. The Neck • Position of the trachea • Lymph node enlargement (tuberculosis, lymphoma, malignancy, sarcoidosis) • Scars (phrenic nerve crush for old TB) • Tracheostomy scar previous ventilation in COPD etc. Central line scars • Scar from LN biopsy • JVP - ? right sided heart failure (cor pulmonale as a result of chronic lung disease) Chest Inspection Scars • Pneumonectomy • Lobectomy • Transplant • VATS • Chest Drains • Thoracocentesis • Radiation Tattoo’s (previous radiotherapy) © Copyright Medical Educator Limited www.medicaleducator.co.uk
  • 4. Chest wall deformity – pectus excavatum / carinatum Size • Hyper-inflated? Movements • Expansion. Equal or reduced on one side? Palpation • Chest expansion – upper and lower chest expansion Key Clinical Fact Percussion Always describe the chest in terms of anterior and • Technique posterior. • Look slick Then describe the lungs • Simple as zones NOT lobes • Compare like with like I.e. Upper/ Middle/ Lower Zones • Normal distribution but don’t forget the axillae • Hyper resonant/ normal/ dull or stony dull. Nothing else. Remember the Left lung Compare both sides has 2 lobes (upper lower& • Hyper = pneumothorax/ COPD lower lobe with the upper Dull = Consolidation/collapse lobe being anterior / LL Stony Dull = Fluid posterior) Right lung has 3 lobes upper middle and lower, Auscultation and it’s difficult to locate chest signs specifically to each lobe. Instead use Comparing two sides: ZONE. Breath sounds This goes the same for Louder chest radiographs: Normal however on X-rays there Reduced: Reduced air entry/ perceiving less air entry due to are clues as to where the fluid/ consolidation/ collapse/ fat consolidation is. e.g. if the right heart border is How do you know which side is abnormal? obscured by the consolidation on a chest You don’t unless there are other features present you have x-ray then this implies it’s to hypothesise a middle lobe pathology. e.g. one side sounds to have “louder” air entry than the other? It is probably the quiet side that has the pathology due to …….. If the consolidation sits above the horizontal • Inspiration fissure then it must be in • Expiration the RUL. • Added sounds and their timing e.g. inspiratory / expiratory/ pan inspiratory Do not say “x-ray” in the o Wheeze exam, say radiograph o Crackles. They are not creps or crepitations, they are crackles © Copyright Medical Educator Limited www.medicaleducator.co.uk
  • 5. Crackles • Quality Fine: Pulmonary oedema/ interstitial lung disease (fibrosis etc) Velcro: Fibrosis Course: Infection or bronchiectasis • When do they occur? Early inspiratory: COPD/Bronchitis Mid-Late inspiratory: Velcro™ like crackles of pulmonary fibrosis* Pulmonary oedema • Do they clear / change on coughing? Yes = Bronchiectasis (will not totally clear but may change) No = Pulmonary fibrosis/ Pulmonary oedema* *If you’ve got pulmonary oedema you’re generally unwell and the signs will come and go. For exams held in “out patients” with patients coming from home, they’re very unlikely to have pulmonary oedema. So Mid-late inspiratory crackles in this situation Pulmonary Fibrosis Tactile Vocal Fremitus & Vocal resonance • These techniques aim to detect the same findings • Louder if consolidated lung that transmits the sound • Quieter if there’s either o An effusion leading to an insulating layer of water outside the lung o Fat o COPD (hyperinflated lungs with holes in them!) “Normally I would like to complete my examination by reviewing the temperature and observations chart and examine for features of cor pulmonale. (inspect the JVP / look for peripheral oedema / other signs of right heart failure) I would like to check the patient’s peak flow and forced expiratory time” (see video on website). Forced expiratory time Clever stuff like this often impresses examiners. To do this, instruct the patient: I am going to ask you to take in as deep breath in as deep as you can and then hold it. On my instruction, I will then ask you breathe out as forcefully and as quickly as possible. For this to work you have to blow as hard as you can until all the air has emptied from your lungs. Then do the above and time it with your wristwatch. If you had a spirometer the air blown out in 1 second would be the FEV1 (forced expiratory volume in 1 second). If you can’t empty your lungs in 6 seconds, this suggests a degree of obstruction i.e. COPD. It’s a surrogate for bedside spirometry. © Copyright Medical Educator Limited www.medicaleducator.co.uk
  • 6. Condition Expansion Air entry Percussion Auscultation Vocal resonance Pneumothorax Reduced Reduced Hyper-resonant Reduced air Reduced affected side affected entry side COPD Reduced both Reduced Hyper-resonant Wheeze+/-: Reduced sides & hyper bilaterally if predominant expiratory inflated chest emphasematou polyphonic s changes Pulmonary Reduced both Reduced Resonant Crackles-fine No change / fibrosis sides bilaterally inspiratory Reduced Mid-late DO NOT clear on coughing Bronchiectasis Reduced both Reduced No change / Crackles-fine No change / sides bilaterally Reduced inspiratory DO Reduced clear / change on coughing Asthma Reduced both ↓both sides Hyper-resonant Wheeze: No change sides during during expiratory active disease active polyphonic disease Stridor Reduced both ↓both sides No change Wheeze: No change sides inspiratory often monophonic Lobar Collapse Reduced side of Reduced Reduced Reduced air Reduced collapse(ipsilate ipsilaterally ipsilaterally entry rally), trachea pulled to that side Pneumonia Reduced side of Reduced Reduced Bronchial Increased collapse ipsilaterally ipsilaterally breathing or reduced air entry Pulmonary No change No change No change Possible pleural No change Embolism (Reduced if rub (crunching infarcted through snow) tissue) often heard over area Pulmonary Usually no Usually no Stony dull if Mid –late Reduced oedema change. change. effusions inspiratory fine bilaterally Reduced Reduced present with crackles – more only if bilaterally only if bilaterally pulmonary coarse than effusions effusions only if oedema. those of fibrosis. present with present with effusions Usually normal DO NOT clear pulmonary pulmonary present otherwise on coughing oedema oedema with pulmonary oedema Pleural Effusion Reduced side of Reduced Reduced Reduced air Reduced effusion ipsilaterally ipsilaterally, entry (ipsilaterally), stony dull trachea pushed to other side Respiratory Findings on Examination © Copyright Medical Educator Limited www.medicaleducator.co.uk
  • 7. © Copyright Medical Educator Limited www.medicaleducator.co.uk