The Respiratory Examination

Introduction

• Introduce yourself to the patient
• Wash your hands
• Briefly explain to the patient what the examination involves and ask their permission to examine them
• Position the patient at 45^o
• Assess the patient from the end of the bed

Always start with the hands and proceed as below unless instructed; be prepared to be instructed to move on quickly to certain sections by the examiner.

General Condition

• Are they in respiratory distress or using accessory muscles of respiration?
• Are they in pain when they breathe?
• Do they look cachectic?

The Hand and Arm

• Tar staining
  • This is typically seen between the 2^nd and 3^rd digits and is indicative of long smoking history
• Clubbing
  • Respiratory causes of clubbing include lung cancer, tuberculosis, bronchiectasis, cystic fibrosis, interstitial lung disease, sarcoidosis, and mesothelioma
• Check the radial pulse and respiratory rate
  • Tachycardia may occur in hypoxia or hypercapnia

The Neck and Face

• Assess the Jugular Venous Pressure
  • May be raised in cor pulmonale
  • Allow patient to relax their head back onto the pillow and turn their head to the left
  • Look between the two heads of the sternocleidomastoid for the double peak of the JVP
    • If unsure between carotid pulse and JVP, press gently over the region; if the pulsations disappear, likely to be JVP
  • Measure the height of the JVP from the sternal angle vertically upwards
• Palpate lymph nodes
  • Submental, Submandibular, Pre-auricular, Anterior Cervical, Supraclavicular, Posterior Cervical, Post-Auricular, and Occipital
• Ask the patient to pull their eyelid down
  • Assess for pale conjunctivae (suggests possible anaemia)
• Check around the lips for any peripheral cyanosis

• Open the mouth and look for central cyanosis under the tongue
• Check the lips for signs of pursed lips breathing

Examining the Chest

• Expose the patient’s chest (any bra present can be left on throughout the examination)
• Look for any scars or chest wall deformity
  • Asymmetry or scoliosis
  • Barrel chest or pectus carinatum
  • Asymmetrical chest wall movements

• Inspect the chest from the end of the bed
  • Observe the patient breathing looking for use of accessory muscles

• Feel for a deviated trachea
• Feel for an apex beat
  • Apex beat becomes laterally displaced following RVH
• Assess chest expansion, repeat in 2 areas (see Appendix)
  • Look for expansion >2cm

• Percuss the anterior chest*, comparing both sides (see Appendix)
  • Start at the clavicle, comparing each side, moving inferiorly (including the axilla)

*Anterior wall = upper lobe; right lateral wall = right middle lobe; left lateral wall = lingual; posterior wall = lower lobe

• Auscultate the anterior chest (see Appendix)
  • Auscultate the same areas as percussed, including the supraclavicular fossa
  • Ask the patient to take large breathes in and out from their mouth (if possible)

• Assess vocal resonance (see Appendix)
  • Ask the patient to say “ninety nine” as each part of the chest is auscultated in turn

Repeat chest expansion, percussion, auscultation, and vocal resonance on the posterior wall

The Rest of the Examination

• Assess the ankles for signs of oedema
  • May indicate cor pulmonale
• Check the calves for tenderness
  • May indicate DVTs

Completing the Examination

Remember, if you have forgotten something important, you can go back and complete this.

To finish the examination, stand back from the patient and state to the examiner that to complete your examination, you would like to perform a:

• Peak flow measurement
• Sputum sample
• Temperature measurement

Appendix