The Respiratory Examination Notes

The Respiratory Examination

General inspection

Dyspnoea, SOB, respiratory distress. RR should be 12-20. Are the accessory muscles of respiration being used? E.g. sternocleidomastoid. These try to elevate shoulders to increase expansion. The pattern of breathing may be altered: Cheyne-Stokes alternates between slow/apnoea and increased RR. Kussmaul’s occurs in metabolic acidosis, ‘air hunger’. Central cyanosis is seen on the underside of the tongue; lips are peripheral. Cyanosis is about O2<6.6kPa. Tripod position uses the arms to splint the chest. Can they talk and complete sentences? Assess severity of SOB.

Cough A dry cough may be infection, cancer, asthma, fibrosis, LVF. A productive cough is bronchitis, pneumonia or bronchiectasis. A wheeze is obstruction; bovine is a lack of explosive beginning and is vocal cord paralysis.

Sputum

Inspect this as part of the ‘to complete my examination’. Large volume of purulent=bronchiectasis. Pink frothy secretions in pulmonary oedema are not sputum. Some sputum tinged with blood suggests pneumonia. Haemoptysis occurs in cancer, infarction, bronchiectasis, abscess, pneumonia, tuberculosis, foreign body, basement membrane breakdown syndromes, ruptured vessels after vigorous coughing and can be acute LVF. Do not confuse with epistaxis or haematemesis. Foul dark sputum may indicate an abscess.

Stridor Usually in inspiration, very bad if in expiration. Obstruction to any airway including larynx and trachea. Can be due to a foreign body as well as inflammation and a tumour. Oedema due to anaphylaxis. Croup and epiglottitis in children. this raises concerns over the need for a definitive airway. They may need nebulised salbutamol/ipratropium/adrenaline, dexamethasone, or heliox. Wheezing is more from peripheral airways and often only heard on auscultation. It is ‘musical’, usually louder and more prominent on expiration but can also be in inspiration. Could have a long expiratory phase in asthma due to airways obstruction. Can arise in pulmonary oedema, airway obstruction, airway collapse.

Hoarseness Is there a recurrent laryngeal nerve palsy due to Pancoast tumour or laryngeal cancer?

Hands

Clubbing is due to cancer (usually not small cell), chronic suppurative disease such as bronchiectasis, abscess or empyema, and congenital cyanotic heart disease which may cause lung pathology. Also cystic fibrosis. Remember familial. COPD does not cause clubbing. Tar stains. Wasting and weakness of the small muscles of hand can be caused by a tumour obstructing C8 and T1 nerves. Warm hands with venodilation are seen in CO2 retention. Look for Schamroth’s diamond-shaped window with the nails pressed together.

Asterixis can indicate carbon dioxide retention, supposed to be held for thirty seconds with dorsiflexed wrists and arms outstretched and fingers wide. Late and unreliable and technically called ‘CO2 retention flap’. Salbutamol in asthma/COPD can also cause a fine tremor.

Pulse a fast bounding pulse can be found in CO2 retention. Subtly count respiratory rate with pulse. A pulsus paradoxicus is a decreased pulse in inspiration. (There is a large decrease in SPB.) this is usually associated with constrictive pericarditis/pericardial effusion/cardiac tamponade, but can occur in respiratory obstruction such as status asthmaticus, COPD, tension pneumothorax; also SVCO.

Face

Horner’s syndrome can result from Pancoast tumour. Mouth can show URTIs and cyanosis. Sinusitis? Thick neck in obstructive sleep apnoea. Conjunctival pallor. Central cyanosis. Breathing through pursed lips to prolong expiration is a sign of COPD.

Neck The JVP may be raised in right heart failure which can be due to cor pulmonale in chronic lung disease or due to left ventricular failure causing right heart failure and pulmonary oedema on the way. It is also raised but non-pulsatile in SVCO.

Trachea is deviated away from the side of the lesion in a large pleural effusion and a large/tension pneumothorax. It is deviated to areas of loss of volume such as collapse, pneumonectomy and possibly upper lobe fibrosis. It can be deviated either way by large masses such as a large tumour or retrosternal goitre. Push a finger up from the suprasternal notch and slide in until the trachea is felt. Is there a larger space on one side than the other? Tracheal tug is where you feel the trachea sink inwards with inspiration and shows the chest is overexpanded due to obstructive disease, or that respiratory distress is generating so much force the entire respiratory tree is being dragged down. It is in respiratory distress and COPD.

Supraclavicular lymph...

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