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Respiratory examination

in this examination the patient should be supine and reclined at 45 degrees, with the whole of the
chest exposed. In female patients the bra needs to be removed for an effective examination, but do
not expose their chest until you are ready to perform the examination of the chest.
- there are two phases of the respiratory examination: peripheral examination and chest
examination.
- equipment: stethoscope, Peak Flow meter.

1. Peripheral examination
- look at the patient from the end of the bed for signs of breathlessness or discomfort. Also note
tachypnoea, audible breathing (wheezing, stridor).
- note treatments and adjuncts around the bed (sputum pots, nebulisers, peak-flow meters, inhalers
or oxygen tubing, chest drain).
a. Hands
- inspect both hands (back and palms) and nails.
- take the patients hand and assess warmth: cool peripheries may indicate peripheral
vasoconstriction / poor perfusion; hot, pink peripheries may be a sign of hypercapnia (carbon dioxide
retention).
- check the colour: cyanosis can be a sign of O2 saturations <85%.
- inspect the hands and note whether there are signs of clubbing lung cancer / interstitial lung
disease / bronchiectasis etc.
- look for signs of tar staining ( smoker) increased risk of COPD / lung cancer.
- check for flap of CO2 retention: ask patient to extend arms with the wrists dorsiflexed and fingers
stretched. Check for irregular, jerky flexion/extension at the wrists and MCP joints. A coarse flap may
indicate carbon dioxide retention type 2 respiratory failure. Fine tremor can be a side effect of beta 2
agonist use,
- feel the radial pulse and assess the rate, rhythm and character. Tachycardic, bounding pulse may be
a sign of hypercapnia. Pulsus paradoxus may indicate asthma / COPD.
b. Head&neck
- check for signs of Horners syndrome: ptosis (weak, droopy eyelid), miosis (constricted pupil),
anhidrosis (decreased sweating) on affected side with/without enophthalmos (inset eyeball).
- inspect the lips and tongue for central cyanosis (ask patient to open his/her mouth and stick the
tongue right out and then to the ceiling).
- inspect the conjunctiva for signs of anaemia.
- look for use of accessory muscles (such as SCM).
- palpate for enlarged lymph nodes: occipital, submandibular, submental, post-auricular, pre-auricular,
anterior and posterior cervical, supraclavicular (including scalene nodes) and axilliary nodes.
Lymphadenopathy may indicate infective/malignant pathology TB / Lung cancer.
2. Examination of the chest
- examine the chest wall completely, first the front and then the back. The examination should be
carried out from side to side, as this procedure will allow comparisons.
a. Inspection
- examine the chest wall looking specifically for chest wall deformities (e.g. pectus
excavatum/carinatum, scoliosis or kyphosis, Harrison's sulci).
- check for previous scars (mid axillary chest drains) / posterior chest lobectomy) and skin
changes may indicate recent or previous radiotherapy erythema / thickened skin.
- observe any use of accessory muscles.
- note the pattern of breathing and assess asymmetry of chest expansion. With your hands placed
firmly in the chest wall and your thumbs in the midline, ask the patient to take a deep breath in. Your

thumbs should not move apart more than 5 cm. Measure this distance at the top and bottom of the
lungs and also on the back.
b. Palpation
- tracheal deviation: place the index finger either side of the trachea and compare the distances
between the trachea and the sternomastoid tendons. They should be equal on both sides; deviation
indicates mediastinal shift. Palpation of the trachea can be uncomfortable, so warn the patient first and
perform it gently.
- chest expansion: place your hands on the patient's chest, below the nipples, with thumbs extended,
in the middle, and elevated from the chest wall. Ask patient to take a deep breath. Your thumbs will
move apart. Observe the amount and symmetry of movement. Reduced expansion may suggest lung
collapse or pneumonia.
- apex beat (see cardiovascular examination). Apex beat displacement may indicate mediastinal shift
(tension pneumothorax) a collection of air in the pleural space that results in the collapse of the lung
on the affected side; it causes compression of the lung on the unaffected side.
- palpate for tactile vocal fremitus by placing the edge or flat of your hand on the patient's upper,
middle and lower back. Ask your patient to say ninety nine while you palpate both sides
simultaneously. Compare each side and cover all areas of the front and back of the thorax (including
the axilla).
c. Percussion
- perform percussion on both sides comparing similar areas on both sides.
- start percussion by tapping directly in the middle of both clavicles (indicates the resonance in the
apex) then percuss the lung fields.
- place your hand on the chest wall, with your middle finger on the area you want to percuss (in the
intercostal space). Remove quickly the striking finger or you may muffle the resulting percussion note.
Do not percuss more heavily than necessary as this can be discomforting for the patient.
- percuss the following areas, comparing side to side: supraclavicular lung apices, infraclavicular,
chest wall, axilla.
- each area of the chest wall correlates with different areas of the lungs in both percussion and
auscultation: anterior wall - upper lobes; posterior wall - lower lobes; right lateral wall - middle
lobe; left lateral wall lingula.
- types of percussion note:
- resonant (normal degree of resonance);
- increased resonance:
hyper-resonant (sign of decreased tissue density: pneumothorax)
tympanitic resonance (suggests emphysema pneumothorax)
- diminished resonance:
dullness (suggests increased tissue density consolidation / fluid
/ tumour / collapse)
- abolished resonance:
stony dullness (sign of pleural effusion haemothorax - empyema)
d. Auscultation
- auscultation is performed using the diaphragm of your stethoscope.
- ask the patient to take deep breaths through the mouth (too many deep breaths may become
distressing). Start above at the clavicle and work gradually down the chest, comparing each side with
the other; remember to include the axillary region. Listen at the same places that you percussed, during
both inspiration and expiration.
- listen for breath sounds:
- vesicular (normal), bronchial (tubular, amphoric, bronchovesicular).
- added sounds:
wheeze / rhonchi (high-pitched: wheeze, low-pitched: rhonchi)
- may indicate asthma / COPD.
coarse crackles - could suggest pneumonia / fluid.

fine crackles - may indicate pulmonary fibrosis.


pleural rubs - common in pneumonia, pulmonary embolism,
pleurisy.
stridor - in epiglottitis, foreign body, laryngeal oedema, croup.
inspiratory gasp - caused by pertussis (whooping cough).
- assess vocal resonance: ask the patient to say ninety nine repeatedly and listen the chest using the
diaphragm, comparing side to side. If necessary test for whispering pectoriloquy, asking patient to
whisper. Increased volume over an area indicates increased tissue density consolidation / fluid /
tumour.
Character of the vocal resonance: normal, diminished, increased (bronchophony, aeogophony).
To complete the examination:
- checking for ankle oedema (may indicate cor pulmonale);
- measure the peak flow rate (if asthmatic);
- measure the oxygen saturation;
- examine the contents of the sputum pot;
- request a CXR if abnormalities were found on examination;
- take an arterial blood gas if appropriate;
- perform a full cardiovascular examination if necessary.
Choose the correct plural form of the nouns in the first column:
forceps
forcepses
forcipes
glottis
glottes
glottides
virus
virus
viruses
appendix
appendices
appendixes
abscess
abscesses
abscessi
villus
villa
villi
meatus
meatus
meatus
fibula
fibulae
fibulas
glomerulus
glomerulae
glomeruli
arthrosis
arthroses
arthrosises
joint
jointes
joints
bulla
bullae
bullas
testis
testises
testes
septum
septa
septums
oesophagus
oesophaguses
oesophagi
perfusion
perfusa
perfusions
calculus
calculus
calculi
syringe
syringes
syringae
anus
ani
anuses
aorta
aortae
aorti
lemma
lemmae
lemmata
mamma
mammata
mammae
varix
varices
varixis
biceps
bicepses
bicipites
ganglion
ganglions
ganglia
atrium
atria
atriums
pons
pontes
ponses
corpus
corpi
corpora
bout
bouts
boutae
cortex
cortexes
cortices
femur
femurs
femora

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