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Respiratory examination

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History• Six principal symptoms

• Dyspnoea

• Wheeze

• Cough

• Sputum

• Haemoptysis

• Chest pain

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History• Acute or chronic• Preceding systemic disturbance• Past medical history• Drug history• Social history – smoking, pets• Family history• Occupational history – allergens/asbestos

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Physical examination

• Look around• Hands, pulse, BP• Face & Neck• Chest examination

– Inspect– Palpate– Percuss– Auscultate

• Other bits

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Look around• Initial impression

– Audible cough– Wheeze– Stridor– Hoarseness– Dyspnoea

• O2, Nebs, Inhalers• TPR & Sputum sample

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Hands, pulse, BP• Perfusion• Peripheral cyanosis• Tremor• Flap – type II respiratory failure• Tar staining• Finger clubbing• Pulse• BP

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Face• Central cyanosis• Pursed lips

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Neck• Neck veins• Lymphadenopathy• Neck muscles• Trachea• Crepitus• Indrawing

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The Chest• Inspection

• Palpation

• Percussion

• Auscultation

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Inspection• Shape• Scars• Lesions• Respiratory rate• Respiration depth• Abnormal movement

– inspiration– expiration– asymmetry

pectus carinatum excavatum

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Palpation• Chest expansion• Tactile vocal fremitus

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Percussion• Compare both sides• Map out abnormal area

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Percussion technique• Palm over chest wall• Middle finger strikes 2nd phalanx• Movement from wrist

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Percussion• Resonant - normal

• Dull – no air– consolidation– collapse– pleural thickening

• Stony dull – pleural effusion

• Hyperresonant - pneumothorax

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Auscultation• Air entry• Vocal sounds

– vesicular– bronchial

• Added sounds– wheeze– crackles/creps– rub

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Breath Sounds• Vesicular

– normal breath sounds with a “rustling quality”

• Diminished - localised or diffuse– reduced airflow

something between the chest wall and the lung

• Bronchial – consolidation– altered quality with distinct inspiratory and expiratory

phases

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Added sounds• Wheeze

– musical notes –expiratory: mucosal oedema or spasminspiratory: secretions or obstruction

• Crackles– non-musical –

inspiratory

• Pleural sounds– rubs and clicks

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Vocal sounds• Vocal resonance

• Increased– voice sounds are louder and more distinct

e.g. consolidation

• Reduced– transmission impeded

e.g. effusion, collapse

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Information...• Type and amplitude of breath sounds

• Type of added sounds and location

• Quality of vocal sounds

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Auscultation technique• Diaphragm of stethoscope

• Mouth open

• Breathing deeply

• Systematic approach – left and right– Anteriorly to 6th rib– Posteriorly to 8th rib

• Vocal resonance: say “one one one” or “ninety nine”

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Other bits• Peak flow

• Oedema

• Pulsatile liver

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Interpretation of findings• Breath sounds

– locally reduced or absent:pleural effusion, thickened pleura, collapsed area

– diffusely reduced: emphysema, asthma

• Wheeze: asthma, COPD• Crackles: Infection, LVF

– localised in area of consolidation

• Pleural rub: pleurisy, PTE

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Pleural effusion

Pleural effusion• Trachea deviated AWAY• reduced tactile vocal

fremitus• reduced chest expansion• stony dull• reduced air entry• no added sounds• reduced vocal resonance

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Consolidation

Consolidation• increased tactile vocal

fremitus• reduced expansion• dull percussion• bronchial breathing• coarse creps• increased vocal

resonance• whispering pectoriloquy

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Collapse

Collapse

• deviated trachea TOWARDS

• reduced tactile vocal fremitus

• dull percussion

• reduced air entry

• +/- creps

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Pneumothorax

Pneumothorax

• deviated trachea (tension) AWAY

• reduced tactile vocal fremitus

• hyper-resonance

• reduced air entry

• reduced vocal resonance

pathways for clinical learning

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