James Wight

Examination of the Respiratory System • Wash your hands. • Introduce yourself to the patient, and ask permission to examine them. • Expose the patient, and position them at 45°.

Inspection
Look around the bed Look at the patient Oxygen mask/nasal prongs, sputum pot, drips, PEFR, inhalers, nebuliser, cigarettes Comfortable at rest, cyanosis, breathless, use of accessory muscles, scars (eg following a rib for pneumonectomy), asymmetry, deformity, hyperexpansion (Barrel chest), pectus carinatum, pectus excavatum, cachexia, radiotherapy marks, chest drain Clubbing (purulent lung disease – CF, bronchiectasis, bronchogenic carcinoma – but not small cell), peripheral cyanosis, nicotine staining, muscle wasting, CO2 retention flap, tremor (β2-agonists) Assess rate and count respirations Enquire about pulsus paradoxus Ptosis, Miosis and Anhydrosis (Horner’s), SVC obstruction Anaemia Central cyanosis, pursed lips, tonsils, hoarse voice, stridor. Examine the JVP (raised in cor pulmonale and tension pneumothorax)

Look at the hands

Feel the radial pulse Ask for blood pressure Look at the face Look in the eyes Look in the mouth Look at the neck

Palpation
Check trachea is central Including the cricosternal distance Check for lymphadenopathy Feel for the apex beat May be displaced, eg in pneumothorax or effusion Assess chest expansion anteriorly

Percussion
Percuss anteriorly Compare L with R, and don’t forget the axillae and supraclavicular regions. Can be normal, hyperresonant, dull and stony dull.

Auscultation
Auscultate anteriorly, asking pt to breath though their mouth Assess vocal resonance, asking pt to say 99 Compare L with R, listening for air entry, crackles, wheeze and bronchial breathing. Don’t forget the supraclavicular regions and axillae. Compare L with R, listening for increased vocal resonance

Repeat chest expansion, percussion and auscultation posteriorly, with the patient’s arms crossed in front of them.

Final manoeuvres
Examine for ankle and sacral oedema Thank the patient and cover them up

I would complete my examination by….
“I would like to take a blood pressure, examine the sputum pot, look at the observations chart (temperature, sats) and perform a peak flow measurement”.

Glossary
Pectus carinatum – a chest deformity in which the sternum bulges forwards (‘pigeon chest deformity’) Pectus excavatum – a chest deformity in which the sternum caves inwards Cachexia – severe wasting usually associated with cancer