Station I Respiratory Examination

1. Scrub Your Hands with Antiseptic liquid. Antiseptic liquid is

provided to you in the station.
2. Greet The Patient, Introduce Yourself And Take Permission. 3.
Position The Patient 45 Degrees In Bed.
4. Expose The Patient From Head To Mid Abdomen.
5. Stand At The End Of The Bed, Take Your Time To Observe:
Ask The Patient to Breath in & Cough; “Can You Take A Deep
Breath In For Me Please; Can You Cough For Me Please?” And
note:
The patient`s type of Cough, is it productive?
Bed side clues:
Sputum pots
Excessive Coughing of patient
Inhalers
Chest drains
Oxygen Masks, Nasal Cannula, BIPAP/CPAP machine.

Age:
Young= Asthma, Bronchiectasis, Pneumonia, Pneumothorax. Old =
COPD, Fibrosis, CA (cancer), Pneumonia, E usion, Lobectomy,
Pneumonectomy, Pneumothorax.

Comfortable vs Tachypnea Built

Overweight: OSA (obstructive sleep apnoea), OHS (Obesity

hypoventilation syndrome).

Cachexia: COPD, Bronchiectasis, Cancer.

Any Audible wheeze COPD

Asthma Carcinoid Acute bronchitis Cardiac Asthma Anaphylaxis

Face and Neck

Use of Accessory muscles = Respiratory Distress

Horner`s ? CA Lung
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Radiation burn = CA Lung = Collapse, Cavity, Fibrosis,
Consolidation.

Amiodarone pigmentation? Fibrosis

SLE Rash = Fibrosis, E usion.

Tipped nose, Skin Puckering around mouth,

Sclerodactyly, Telangectasia = Systemic Sclerosis = Fibrosis, PH

Cushingoid face = Steroid use = Sarcoidosis, Asthma, COPD,

Wegner`s granulomatosis (granulomatosis with polyangiitis) Lupus

Pernio = Sarcoidosis = look for Fibrosis if present.

Heliotrope rash = Dermatomyositis = Look for Lung brosis.

Chest “Take A Deep Breath For Me Please” Asymmetry:

Increased A-P diameter = COPD

Bulge = Pneumothorax, Pleural e usion

Retraction = Fibrosis, Collapse ,Lobectomy, Pneumonectomy You

will note the diseased side by decreased expansion on that side.

Pectus Excavatum

Pectus Carinatum

Limited chest expansion on both sides or 1 side

Intercostals indrawing = Hoover sign COPD / Obstructive Lung

Disease
Scars

Lateral thoracotomy scar = Pneumonectomy/Lobectomy

Chest drain scar = E usion / Empyema / Pneumothorax
Dilated veins over the chest with congested face and congested
arms = SVCO CA Lung
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Radiation tattoos

Radiation burn

Cardiac apex beat site, if on Rt. = Kartagner`s syndrome =

Bronchiectasis

Hands
RA (Z deformity, ulnar deviation, buttoniere, swan neck) = Basal
Lung Fibrosis, E usion, Bronchiolitis Obliterans.
Sclerodactyly ,Thin stretched shiny skin, Curling of Fingers =
Systemic Sclerosis = Lung Fibrosis, PH (Pulmonary HTN
Clubbing = Bronchiectasis, ILD , CA , Empyema , Abscess Yellow
nails = Yellow Nail Syndrome = E usion, Bronchiectasis Cyanosis
Tar staining

Arms
Purpura ? Steroid use = COPD, Fibrosis

Legs
Lower limb swelling
Unilateral ? DVT
Bilateral ? L.L edema ? Core pulmonale
Clubbing of nails
Cyanosis
Erythema Nodosum = T.B, Sarcoid, Streptococcal Infection
Erythema Multiform = Mycoplasma infection
Purpuric Eruptions ? Steroid use = Fibrosis or COPD
6. Ask The Patient To Extend His Hands And
Examine Dorsum Of Hands for:
Clubbing
Peripheral Cyanosis
Yellow nail syndrome
Tar staining
Purpura
Wasting of small muscles of the hands = Lung CA, RA.
Fine tremors = B2 agonist = COPD
Feel For Thinning Of Skin = steroids use = Fibrosis, COPD, Asthma.
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7. Ask Patient To Turn His Hands Up And
Examine Palms for
Palmar erythema = CO2 retention
Feel Radial Pulse = If Collapsing = CO2 retention.
Count respiratory rate in 15 secs x 4 whilst feeling the pulse. Look
for signs of ABG sampling signs.

8. Ask The Patient To Pull His Wrist Back And

Examine For
Flapping Tremors Flapping = CO2 retention respiratory failure.
9. Examine Both Eyes Same Time For Pallor :”Can
You Look Up For Me Please” Horner`s (Ptosis &
Miosis)

10. Examine Mouth For:

Central Cyanosis at the dorsal surface of the tongue
Fish mouth (Narrow with Skin puckering around mouth and
telangiectasia = Systemic Sclerosis = Look for PH, Fibrosis.

11. Ask The Patient To Turn His Neck And Examine

JVP
Elevated JVP (Pulsating) PH (Pulmonary HTN) Core Pulmonale
Pulmonary embolism (PE) Heart failure
Prominent A wave = PH
Non-Pulsating raised JVP = SVCO.

12. Ask The Patient To Sit Forward And Examine

The Trachea From The Front for:
Position (Central or Deviated)
Tracheal tug = COPD
Cricoid Sternal distance (Normal >3 ngers breadths) if < 3 =COPD
Signs Of Tracheal Shift
Inspection of the neck (Unequal grooves on both sides)
Palpation with index nger In the grooves (Don’t push hard in
grooves) Palpation with middle nger to the trachea with index &
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 ring over sterno-clavicular joints & note the position of your middle
nger in accordance of the other ngers.

13. Inspect The Back Of The Chest For

Symmetry
Shape (Kyphosis, Scoliosis) Scars
Limited chest expansion

14. Palpate Chest Expansion From The Back

Ask Him To Cross His Arms Over Shoulders & To lean forward.
Con rm symmetry
Con rm Chest expansion
TVF ( You can do vocal resonance instead while you auscultate)

15. Percuss The Back Of Chest With Heavy

Percussion And Take Your Time Don`t Rush It,
Listen And Feel Carefully
Suprascapular
3 Interscapular spaces
3 Subscauplar spaces & look for
Resonance (Equal on both sides)
Hyperresonance bilaterally =COPD
Hyperresonace unilaterally = Pneumothorax
Impaired note=Fibrosis , Bronchiectasis , Collapse ,Consolidation,
Lobectomy
Stony dullness= Pleural e usion

16. Auscultate Breath Sounds at Same Sites of

Percussion For
Breath sounds
(Air entry) = Normal or Diminished. Type of breathing
Vesicular = Normal Bronchial
Consolidation Mass Cavitation
Vesicular with prolonged expiration: COPD
Asthma
Obstructive lung disease.
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 Added sounds
Wheezing:
COPD
Asthma Anaphylaxis Carcinoid Cardiac Asthma
Fine Crackles (Late Inspiratory)
Lung Fibrosis = Fine end inspiratory crackles Pulmonary edema
Coarse crackles (May be early inspiratory or expiratory)
Bronchiectasis
Pneumonia
Secretions
Pleural Rub Pleurisy

17. If You Find Any Crackles Ask The Patient To

Cough & Re- auscultate
Crackles of secretions disappear by coughing
Bronchiectasis Crackles change in character by coughing but
doesn’t disappear.
Lung brosis crackles doesn’t change in character or disappear by
coughing.

18. Ask The Patient To Say 99 Each Time You Put

Your Stethoscope Over His Back And Listen For
Increased Vocal Resonance

19. If You Find Increased Vocal Resonance Ask

Him To Whisper 99 For Positive Whispering
+ ve whispering =Bronchial breathing Causes of Increased Vocal
Resonance
Consolidation Bronchiectasis Cavitation Mass
Lung collapse with mediastinal shift to the side of the lesion.
Dense Lung brosis
Causes of decreased Vocal resonance
Pleural e usion Pneumothorax Lung brosis Lobectomy
Pneumonectomy

20. Ask The Patient To Lie On His Back

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21. Inspect The Front Of Chest for:
Symmetry.
Limited expansion.
Shape.
Scars.
Apex of the Heart.
Intercostal in drawing.
Dilated veins (usually with facial plethora, dilated arm veins) =
SVCO = CA Lung

22. Palpate The Front Of The Chest For: Expansion

& TVF
Palpable Rhonchi
Palpate Heart Apex = Shifted Or Not
Palpate Lt. Sternal Edge For Lt. Parasternal Heave = RVH (Right
Ventricular hypertrophy) = PH (Pulmonary HTN)
Palpate Pulmonary Area For Palpable P2 (Diastolic Shock)= PH

23. Percuss The Chest

Apex of the Lungs (Kronig`s Isthmus) Clavicles
2 Supra-mammary areas
Mammary area
2 infra-mammary areas
2 Axillary areas

24. If You Find Hyper-Resonance Bilaterally

Percuss For: Hepatic dullness.
Cardiac dullness (3rd , 4th Lt. ICS)
If these areas are resonant not dull this means hyper-in ated chest
25. Auscultate The Front in same sites as for Percussion As You
Have done in the Back.

26. Auscultate for Vocal resonance

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27. Ask If He Has Any Pain In The Legs and
Examine The Patient
Legs for:
Feel for L.L edema Clubbing of nails Purpura of skin Erythema
nodosum

28. Examine L.Ns (Carcinoma , T.B , Sarcoidosis ,

Lymphoma)
Cervical
Supraclavicular
If you couldn`t examine the L.Ns because of the time, mention it to
the examiner that you would like to complete your examination by
examining L.Ns.

29. Formulate Your Comment And Diagnosis

The Diagnosis (COPD , Bronchiectasis , Fibrosis , E usion)
Possible Cause (Smoking)
Possible Complications (Pulmonary HTN )
30. Thank The Patient And Greet Him 31. Cover The Patient
32. ScrubYourHandsAgain
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