Respiratory Examination

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Respiratory Examination

• James Stevenson

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General Tips

• Read information outside station
• Get down to level of patient
• Remember to introduce yourself
• Gain consent
• Ask patient details

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Likely cases
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Taking the History

• Youll be told which bits to concentrate on!
• Be systematic
• Take one symptom at a time

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Common presenting complaints

• Dyspnoea
• Cough (inc. haemoptysis sputum production)
• Chest pain
• Wheeze

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Dyspnoea

• Nocturnal
• Orthopnoea/ paroxysmal nocturnal dyspnoea
• Speed of onset

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Cough

• Nocturnal
• Bovine
• Sputum
• Mucoid normal
• Green/ yellow bronchiectasis/ infection
• Rusty pneumonia
• Bloodstained haemoptysis

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Chest pain

• Pleuritic
• Worse on inspiration
• Inflammatory or malignant cause
• Mediastinal
• Poorly localised
• Chest wall tenderness
• Malignant invasion

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Wheeze

• Stridor
• Mono-/ polyphonic

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More History!

• PMHx
• MedHx usually provided by examiner
• FHx
• Atopy
• Ca lung
• SHx
• Smoking
• Occupation
• Pets?

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Examine this patients chest

• Introduce yourself
• Position the patient
• Expose the chest

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Be systematic

• Observe from end of the bed
• Examine
• Hands
• Face
• Neck
• Chest
• Ankles

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From the end of the bed

• Around the patient

• The patient

• Oxygen
• Inhalers/ nebulisers
• Sputum pot
• Cigarettes???

• Respiratory rate
• Chest shape/ movement
• Stridor
• Cachexia
• Accessory muscle use
• Pursed lip breathing

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Hands

• Clubbing
• Tar staining
• Tremor
• Asterixis
• Steroidal skin
• Wasting of small muscles
• Pulse
• Hypertrophic pulmonary osteoarthropathy (HPOA)

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Clubbing

• 4 clinical stages
• Increased sponginess of nail bed
• Loss of nail bed angle
• Increased curvature of nail
• Drumstick appearance

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Respiratory causes

• Ca bronchus
• Fibrosis/ asbestosis
• Chronic sepsis
• Bronchiectasis
• CF
• Abscess

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Face

• Pallor
• Dilated pupils
• Central cyanosis
• Horners syndrome
• Cushingoid appearance
• Plethoric swollen
• ? Hoarse voice

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Neck

• Trachea
• Crico-sternal distance
• JVP
• Lymphadenopathy

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Chest

• Inspect
• Scars
• Dilated veins
• Palpate
• Chest expansion
• Surgical emphysema
• Percuss
• Auscultate
• Tactile fremitus/ vocal resonance

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Ankles

• Check for pitting oedema

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To complete my examination

• Thank and cover up the patient
• Look at patients temperature chart
• Perform a CVS exam
• Do a peak flow

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And then...

• Volunteer a list of differentials
• Say what investigations you would like to perform

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Likely investigations

• Bloods
• FBC, UEs, LFTs, Ca2, ABGs
• Secretions
• Sputum cytology
• Imaging others
• Pulse oximetry, ECG, spirometry, CXR,
  bronchoscopy, aspiration, biopsy, CT thorax

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Question time!!!

• Likely to be on management of the patient youve
  just examined
• Examiner may prompt about investigations youve
  forgotten or signs you may have missed

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Common LOCAS questions

• COPD acute vs. chronic management
• Pulmonary fibrosis investigations management
• Acute management of breathless patient
• Indications for pneumonectomy

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Common questions (cont...)

• Clinical signs differentiating consolidation from
  effusion
• Causes of transudates exudates
• Bronchiectasis causes management
• Pneumonia causative organisms

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Take home message...

• Practice!!!

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Any questions???

• Thanks for listening