Respiratory Examination

Intro

  • Wash hands, introduce self, check patient name and DOB/CHI, explain procedure and gain consent

General

  • Look from the end of the bed for
    • any signs of respiratory distress (consider an ABCDE approach)
    • general patient appearance and well being
    • any audible breathing sounds
    • any obvious abnormalities
    • any oxygen; any inhalers/nebulisers, any drugs etc
  • Look at the hands for
    • Peripheral cyanosis
    • Finger clubbing
    • Tar staining
    • CO2 flap (coarse)- ask the patient to extend their arms and wrists/fingers
  • You may want to take the patient’s pulse +/- respiratory rate now (or later in the examination)
  • Examine the JVP (may be raised in pulmonary hypertension)
  • Look at the face for
    • Eyes
      • Ptosis/meiosis (constriction) + anhydrosis + enophthalmos may suggest a Horner’s syndrome
      • Pallor of anaemia
    • Central cyanosis (blue under the tongue)
  • Palpate the trachea to check it is central 

Inspection

  • Look at the chest for any deformity (including hyperinflated chest/barrel chest), scars/wounds, any asymmetry; note the use of any accessory muscles
    • Check respiratory rate if not already done so

NB It is often easier to perform the rest of the examination on the front of the chest first then move to the back and repeat all the steps there

Palpation

  • Check for tracheal deviation if not already done so
  • Palpate for chest expansion at the front (upper and lower zones) and the back
    • Take a tight hold of the chest, letting your thumbs just meet in the centre- they should move with breathing

Percussion

  • Percuss the chest at the apex, compare sides and repeat down the chest (include the clavicle)
  • Make sure to percuss at least each lobe (on the back it is good practice to percuss the lower lobes at least twice (superiorly and inferiorly (bases))

Untitled picture

Tactile Vocal Fremitus

  • With the ulnar border of your hand at each percussion site (again comparing sides), ask the patient to say ‘ninety-nine’

Auscultation

  • Auscultate each site (comparing sides), asking the patient to inhale and exhale slowly and deeply through their mouth
    • NB For a good collection of normal/abnormal breath sounds, see here
  • Vocal resonance
    • As with TVF, ask the patient to say (or whisper) ‘ninety-nine’ whilst you auscultate the sites

End

  • You may also want to examine the patients legs for oedema or signs of DVT
  • Wash hands and thank patient
  • You may also want to look at patient’s notes/chart, arrange further testing etc
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