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Introduce yourself to the patient. Explain to the patient what you are going to do by asking them “I would like to examine your chest, do I have your permission to do this?” To examine the respiratory system, the patient should be undressed to the waist and sitting at 45° for the measurement of the JVP. In women the breasts should be covered with a blanket. Look at the patient carefully-making it obvious to the examiner that you are doing this. In particular you should check whether the patient is in respiratory distress (this will be signified by an increased respiratory rate, nasal flaring and intercostal recession.) Does the patient look like a typical pink puffer or a blue bloater? Both pink puffers and blue bloaters suffer from chronic obstructive pulmonary disease (COPD) but are at different ends of the spectrum between emphysema and chronic bronchitis. Pink puffers have predominantly emphysema. They are thin, have an increased respiratory rate and breathe through pursed lips. Blue bloaters however are cyanosed from hypoxia and oedematous as a result of cor pulmonale. Also look to see whether the patient is Cushingoid, as this is a clue that the patient is a severe asthmatic on oral steroids. Look for evidence of weight loss in the patient. This could indicate carcinoma of the lung or chronic disease such as COPD. Also look around the bed for paraphernalia related to the patient (e.g. Sputum pot). If there are any such items, take time to examine them carefully. If there are inhalers or nebulisers make sure you take note of what drug they are delivering.
2. Nails and hands
Without making it obvious to the examiner, quickly glance at the pupils to check whether they are equal. If there is one constricted pupil the patient is likely to have ipsilateral wasting of the muscles of the hand due to an apical lung cancer (Pancoast’s syndrome). It is a good idea to look at the eyes first as the pupil asymmetry is far easier to spot than the muscle wasting. Glance at both the hands quickly. It is important to always check both hands as otherwise wasting of the muscles of the patient’s left hand might be missed. Only if you are stopped at this point and asked what you are examining for should you recite the following; “I am examining the hand for evidence of… 1. nicotine staining 2. clubbing 3. peripheral cyanosis 4. wasting of the intrinsic muscles of one hand”
You should now check for tremor. Two different types of tremor may exist in a patient with respiratory disease: 1. a fine finger tremor related to use of beta-agonist bronchodilators. 2. Asterixis-this is a coarse tremor which looks like the flap associated with liver failure. It signifies CO2 retention, the other features of which are warm peripheries, a bounding pulse, papilloedema and headache.
3. The radial pulse
Palpate the radial pulse for 15 seconds if it is regular or 30 seconds if it is irregular. Note the rate and whether there is pulsus paradoxus. Pulsus paradoxus is defined as a fall in the systolic blood pressure by more than 10 mmHg on inspiration. It occurs in severe asthma, constrictive pericarditis and pericardial effusion. If you suspect pulsus paradoxus you should go on to take the blood pressure at the end of inspiration and expiration. However, it is very unlikely to be present in exam patients as it signifies a severe asthma attack. Once you have estimated the rate of the pulse, it is now necessary to measure the patient’s respiratory rate. This should be done while taking the patient’s pulse so that the patient is unaware respiratory rate is being measured as this may make him anxious. A normal rate is between 12-16/minute. In practice, if the patient is not in apparent respiratory distress, it saves time to just say that the rate is 16.
4. The Eyes
Look at both the eyes quickly. Tell the patient “I would like to take a look in your eyes” before pulling down one of the lower lids to check for conjunctival pallor. Also check for the ptosis and constricted pupil of a Horner’s Syndrome. If you mention the name of any syndrome in an exam, it is likely one examiner will ask you for the syndrome’s other features. The features of a Horner’s syndrome are: 1. Miosis (pupil constriction) 2. Enopthalmos (sunken eye) 3. Ptosis 4. And ipsilateral anhydrosis (loss of sweating) Pancoast’s Syndrome is the association of a Horner’s Syndrome with a cancer at the apex of the lung. Other features are related to the destruction of the brachial plexus and include arm pain and wasting of the intrinsic muscles of the hand. If the recurrent larnygeal nerve is also affected, a hoarse voice and bovine cough may also occur.
5. The Mouth
Using your pen torch take a quick look in the patient’s mouth. Ask the patient to stick their tongue “outwards and upwards towards their nose” and examine the tongue for central cyanosis. Remember, central cyanosis develops when there is at least 5g/dL unsaturated haemoglobin in the blood. If a patient is centrally cyanosed they will automatically be peripherally cyanosed also. Note the converse is not true: conditions such as Raynaud’s Phenomenon cause a sluggish circulation in the extremities, resulting in a patient who is in peripherally cyanosed only.
6. The Neck
Examination of the neck as part of the respiratory system focuses on the following three points: 1 JVP 2 Trachea
The Jugular Venous Pressure
When examining the JVP, the patient should be sitting at 45° with their head resting back on a pillow and turned slightly to the left. In this position, the right internal jugular vein should be just visible between the 2 heads of sternocleidomastoid. The JVP is raised if the vertical height of the pulse above the sternal angle is greater than 4cm. Textbooks tend to go into a lot of detail about the JVP. For the purpose of medical finals only a few facts need memorising: 1. A raised JVP means increased pressure in the right atrium. Common causes of this include right ventricular failure and fluid overload. There are 2 waves, the a wave represents atrial contraction and coincides with the 1st heart sound, whereas the v wave represents venous filling of the atrium and coincides with the 2nd heart sound For the purpose of medical finals, it is probably only necessary to be able to distinguish whether the JVP is raised or not. However, several conditions affect the JVP in a stereotyped way. • • • atrial fibrillation, causes the a waves to be absent. tricuspid regurgitation causes a large v wave which may cause the ear lobes to waggle! Cannon waves are large a waves with a rapid descent. They are caused by atrial contraction when the tricuspid valve is closed. They are therefore found in patients with ventricular pacemakers and patients in complete heart block or ventricular extrasystoles.
Before attempting to check that the trachea is central ask the patient “I would like to press on your windpipe, it may be a little uncomfortable”. This is an important question to ask as otherwise the patient may be startled by you suddenly placing your fingers onto their neck. Quickly check that the tracheal deviation by placing the index and ring fingers either side of the trachea at the sternal angle and using the middle finger to feel the tracheal rings. Keeping the middle finger in place over the tracheal rings, try to detect tracheal tug by asking the patient “could you please breathe in deeply”. Tracheal tug is present if your middle finger moves upwards when the patient breathes in. It signifies lung pathology. Now check the cricosternal distance. This is the distance between the cricoid cartilage and the sternal angle. If it is less than 3 fingerbreaths this indicates hyperinflation of the lungs. 3. Cervical Lymphadenopathy
The lymph nodes of the neck should be examined from behind with the patient sitting upright. Start off by asking the patient “Would it be possible for you to sit up so that I can examine the glands in your neck?” When the patient sits up it is wise to glance down at their back as you may notice a chest drain or a surgical scar. This can give you a clue as to the diagnosis. Start off by placing the fingers in the submental region (under the chin). Work backwards and laterally, feeling the submandibular glands and finishing behind the ears where you may detect enlarged posterior auricular nodes.
Then place the fingers just medial to the top of the sternocleidomastoid muscle. Work down the medial border of this muscle, palpating the cervical lymph node chain. Finish in the supraclavicular fossae. An enlarged node in the left supraclavicular fossa is known as Virchow’s node and its presence is called Troissier’s sign. It is indicative of stomach cancer.
Inspection Uncover the patient and inspect the shape of the chest. The following chest deformities may be present: • • A barrel chest is seen in conditions causing chronic lung hyperinflation (e.g. Asthma, COAD) It has an increased AP diameter and a tracheal tug is often also present. Pectus carinatum means “pigeon chest” and is used to describe a chest where the sternum is prominent. It is caused by chronic childhood asthma and rickets. If talking in front of the patient it is more polite to use the latin term as some patients may object to being called pigeon chested. Patients who have suffered from chronic childhood asthma and rickets may also have a Harrison’s sulcus. This is a groove deformity of the lower ribs at the point of attachment to the diaphragm. Kyphosis is an increased forwards spinal convexity (i.e. like the shape of the letter “K”). It can cause problems with lung ventilation. Scoliosis is an increased lateral curvature of the spine (i.e. like the shape of the letter “S”). It always occurs with a degree of kyphosis and such patients are better referred to as kyphoscoliotic.
• • •
Also look at the breathing pattern. Cheyne-Stokes respiration occurs in a range of conditions but usually indicates a brainstem lesion (CVA or raised ICP) or an increased lung to brain circulation time (poor cardiac output). It consists of cycles of increasing hyperventilation followed by apnoea. Look at the chest wall for surgical scars, chest drains and radiotherapy tattoos. Check for intercostal recession, the indrawing of the intercostal spaces as the patient breathes in. Also note whether movement of the chest wall is symmetrical. If it isn’t, the pathology lies on the side of restricted movement.
Palpation Assess chest expansion by placing the palms of the hands symmetrically on either side ofthe chest wall with the thumbs pointing towards the midline. Ask the patient “Could you please take a deep breath in?” and feel whether the fingers move apart symmetrically. The thumbs should separate by at least 5cm.
An additional test which may be performed here, but is not essential, is to test for tactile vocal fremitus. This is performed by placing the ulnar borders of each hand in intercostal spaces on either side of the sternum at 3 levels. Ask the patient “would you mind saying ninety nine for me as this helps me to assess how your lungs are working.” Tactile vocal fremitus is affected by conditions in the same way as the breath sounds are (see later). Therefore, you should expect: • vesicular breathing over areas of normal tactile vocal fremitus • decreased breath sounds over areas of decreased tactile vocal fremitus • bronchial breathing over areas of increased tactile vocal fremitus However, this is not a very sensitive test so can be omitted.
Percussion Before beginning to percuss the chest it is polite to explain to the patient what you are about to do. Percuss in both supraclavicular fossae, the clavicles and at 3-4 levels on either side of the anterior aspect of the chest. You should expect dullness over the liver which extends as high as the sixth costal cartilage and over the heart. In emphysema, the liver may be pushed down by the hyperinflated lung and the area of cardiac dullness may be lost. Ask the patient “could you please place both your hands behind your head as I would like to examine the sides of your chest.” This will enable you to percuss the axillae and once on the lateral aspect of the chest. The following percussion notes may occur: • resonant-normal • dull-consolidated lung, collapsed lung or a lung abscess or neoplasm. • stony dull-plural effusion • hyper-resonant-this can be generalised, when it signifies lung hyperinflation, or localised when the cause may be a pneumothorax or a large emphysematous bulla
Auscultate the front of the chest in the same places that you percussed. It is customary to use the bell of the stethoscope when auscultating the supraclavicular fossa but the diaphragm elsewhere. If the patient is very thin, the bell may have to be use throughout. Ask the patient “I would like to sound your chest. Could you please take some deep breaths in and out though your mouth?” In frail patients it is a good idea to warn them “This may make you feel a little bit dizzy. If this happens feel free to stop straight away.” When auscultating you are listening for both the breath sounds and for added sounds.
These can be either vesicular, decreased or bronchial. Vesicular breath sounds are heard over normal lung. There is no gap between the inspiratory and expiratory parts and the expiratory part is shorter.
Although decreased breath sounds are sometimes referred to as decreased air entry this isn’t necessarily the case and so this description is best avoided. Decreased breath sounds can be localised or generalised. Localised decreased breath sounds occurs in the following conditions: • pneumothorax • pleural effusion • tumour • collapse
Generalised decreased breath sounds occurs in: • emphysema • asthma • muscular chest wall • obesity • fibrotic lung disease
In bronchial breathing, there is a gap between the inspiratory and expiratory parts and both parts are of the same length. The quality of the sound is “harsher” than vesicular breathing.
inspiration expiration Bronchial breathing is heard in the following situations: • consolidation • abscess near the chest wall • bronchial neoplasm (when the airway is still patent) • dense fibrosis • the top of a pleural effusion
You must listen to both the nature and the timing of added sounds. Added sounds can be divided into wheezes, crepitations and pleural rubs. Wheezes usually occur in expiration and indicates narrowing of an airway. The smaller the airway, the higher the pitch of the wheeze. Thus high pitched polyphonic wheeze occurs in asthma and COAD where asthma is a component of the disease. On the other hand, a low pitched monophonic wheeze indicates narrowing of a single large airway due to bronchial carcinoma. Crepitations are produced when airways “pop” open as the chest expands in inspiration. As a general rule, the smaller the airway, the finer the crepitation and the later it occurs in inspiration.
The following conditions cause fine, late inspiratory crepitations that affect both lung bases equally: • pulmonary oedema • fibrosis The following conditions cause coarse crepitations that tend to be present thoughout inspiration: • COAD • bronchiectasis Pneumonia causes a mixture of fine and coarse crepitations which tend to be localised to one lobe of the lung.
Pleural Rub This is caused by the 2 inflamed layers of pleural membrane rubbing against each other. If it present the patient may also have pleuritic chest pain at the same site. It can be caused by: • pneumonia • pulmonary embolus
In order to test vocal resonance ask the patient “would you mind saying ninety nine for me as I sound your chest? It helps me to assess how the lungs are working.” Place the stethoscope in all the areas you auscultated previously and listen to see whether vocal resonance is normal, decreased or increased.
Vocal resonance is the “speaking equivalent” of the breath sounds and can be used to confirm what you suspected on auscultation. Therefore you should expect: • normal vocal resonance over areas of vesicular breathing • decreased vocal resonance over areas of decreased breath sounds • increased vocal resonance over areas of bronchial breathing.
All this information can be summarised in the following table, which should be learnt:
central or away
central or away
decreased, bronchial breathing at surface decreased
bronchial if airway patent
coarse crepitations ±rub fine late inspiratory crepitations none
decreased or bronchial if severe decreased
collapse (blocked bronchus) COAD
central, with tug
normal or hyper-resonant
normal or decreased
crepitations and wheezes
* for medical finals, you should learn the list of pathologies causing a pleural effusion
8. Examination Of The Posterior Aspect Of The Chest
At this point in the examination, ask the patient "please could you sit up as I would like to examine the back of your chest" The same examination routine should be performed as when examining the front of the chest, namely:
Inspection Look at the shape of the chest and note whether patient has a kyphoscolisis. Also look at the chest wall for surgical scars, chest drains and radiotherapy tattoos. Check for intercostal recession and whether movement of the chest wall is symmetrical.
Palpation Assess chest expansion at 2 levels on the back of the chest. Ask the patient “Could you please take a deep breath in?” and feel whether the fingers move apart symmetrically. The thumbs should separate by at least 5cm. You may also palpate for changes in tactile vocal fremitus.
Percussion Percuss the back of the chest at 3 or 4 levels on either side of the spine. Again you are listening whether the percussion note is normal, dull or stony dull.
Remember the lungs extend down to the tenth rib posteriorly.
Auscultate the back of the chest in the same places that you percussed listening for the breath sounds and whether there are added sounds. You can also test for changes in vocal resonance.
9. Finishing off the examination
It is very important at this stage say to the patient “thank-you, you may sit back now” and to cover them up with the blanket.
You should complete any examination of the respiratory system by turning to the examiner and saying "I would also like to examine the sputum, look at the temperature chart and perform a peak expiratory flow test."
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