Respiratory Exam

Respiratory Exam

·        For Chest X-ray, see Chest X-ray Topic

Inspection, Palpation and Percussion *

·        Inspection:

o   Count respiratory rate (at rest should be < 14 per minute)

o   Chronic airways disease ® barrel (expended chest) ® can‟t find apex beat

o   Look for use of accessory muscles. Are intercostals depressed (ie being used a lot)? Look for paradoxical breathing of the abdomen

o   Cyanosis (eg tongue)

·        Ask patient to cough.  Listen for wheeze, gurgling, etc

·        Inspect sputum

·        Listen for stridor or hoarseness (laryngitis, cancer affecting left recurrent nerve or larynx)

·        Hands:

o   Clubbing (and maybe Hypertrophic Pulmonary Osteoarthropathy – „swollen‟ metacarpals and elsewhere, eg in lung cancers).  

o   Staining from cigarettes

o   Wasting (Pancoast tumour)

o   Pulse rate: tachycardia

o   Flapping tremour: late and unreliable sign of severe CO₂ retention

·        The face:

o   Eyes for Horner‟s syndrome (constricted pupil, partial ptosis)

o   Tenderness over sinuses ® sinusitis

o   Nose: check for polyps (associated with asthma), deviated septum (nasal obstruction), etc

o   Throat for URTI

o   Check lymph nodes

·        Trachea:

o  Check for displacement

o  Tracheal Tug: trachea moves inferiorly with inspiration, due to over expansion of the lung in airflow obstruction

·        Chest:

o  Inspect:

§  Shape and symmetry, including funnel chest (= pectus excavatum or sunken sternum), kyphosis (forward curvature) and scoliosis (lateral bowing)

§  Scars, signs of radiotherapy

§  Subcutaneous emphysema – crackling under the skin due to air from pneumothorax

§  Prominent veins in SVC obstruction

§  Movement when breathing in and out – better from behind. Look for uni-lateral or bi-lateral reduction in movement

o  Palpation:

§  Check expansion: the affected side dose NOT expand – regardless of pathology

§  Apex beat: if not found then ® ?hyper-expanded. Maybe displaced by pathology (pneumothorax, fibrosis, etc)

§  Vocal fremitus: Feel with hand while patient says 99, each side font and back

§  Compress sternum to spine ® pain if fracture or bone tumour

o  Percussion:

§  Ask patient to move elbows forward to move scapula off the lungs

§  Around lung and also directly on the clavicle 

§  Normal lung is resonant, pneumothorax is hyper-resonant, liver is dull, consolidation is dull, effusion is stony dull

·       Chest Sounds

·        When auscultating, ask patient to breath through mouth – not to take deep breaths

·        Crackle:

o  = Crepitations

o  Coarse or fine (like hair rubbing)

o  Short, discontinuous, non-musical sounds heard mostly during inspiration

o  Fine (high pitched) are from distal air-spaces, coarse (low pitched) are proximal air spaces

o  Produced when there is fluid inside a bronchus with collapse of the distal airways and alveoli

o  Wheeze= Rhonchi, rhonchus, rale

o  Continuous musical sounds heard mostly during expiration

o  Produced by airflow through narrowed bronchi

o  Narrowing may be due to swelling, secretions, spasm, tumour, or a foreign body

·        Pleural Rub

o  Grating sound like Velcro ripping or walking on snow on inspiration and expiration

o  Produced by motion of roughened or thickened pleura

o  Caused by inflammatory or neoplastic cells or fibrin deposits

·        Differentiating Consolidation from Pleural Effusion

o   Consolidation = exudate into alveoli.  Signs are:

§  Expansion: reduced on affected side

§  Vocal resonance and tactile fremitus (patient says „99‟ and listen with stethoscope/feel with hand): ­on affected side

§  Percussion: dull but not stony dull

§  Breath Sounds: increased volume and bronchial not vesicular (ie will hear coarse breath sounds like over the trachea)

§  Additional Sounds: inspiratory crackles (as pneumonia resolves)

§  Vocal Resonance: increased

§  Plural Rub: may be present

o   Effusion = fluid in pleural space (but not blood – that‟s haemothorax, and not pus – that‟s empyema). Signs of effusion are:

§  Displaced trachea if massive effusion

§  Expansion: reduced on affected side

§  Percussion: stony dullness over effusion

§  Breath Sounds: reduced or absent

§  Vocal Resonance: reduced

o   The key differences are therefore:

·        Common presentations:

Other systems *

·        Check JVP for right heart failure

·        Listen to P₂ of second heart sound, at 2^nd intercostal space on the left. If louder ® ?pulmonary hypertension

·        Check liver for tumour 2^nd to lung cancer, and for „ptosis‟ – displaced downwards in emphysema

·        Pemberton‟s sign: SVC obstruction – hold arms over head ® facial plethora, inspiratory stridor and ­JVP

·        Feet: check for oedema (pulmonary hypertension) and DVT