#7525 - The Respiratory Examination - Medical Finals & OSCEs 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 nodes may be enlarged in lung cancer.

Apex beat may be difficult to feel in overexpanded lungs and may be displaced in heart failure. It may be moved acutely in massive pleural effusion or huge tension pneumothorax.

Lung expansion can be assessed using hands anteriorly and posteriorly. Thumbs should move equally apart. Thumbs should move more than 5cm. Low in COPD. Patient should be erect.

Chest one could look for fractures/feel for pain. Pectus carinatum indicates severe childhood asthma or other lung disease, or rickets. Pectus excavatum is a developmental defect. Barrel chest is hyperinflation in COPD. Look for scars. Kyphoscoliosis can affect breathing. Harrison’s sulcus is indentation of the lower ribs due to childhood severe pulmonary disease e.g. asthma or rickets.=, like pectus carinatum.

Tactile fremitus can be assessed with the palm or side of the hand whilst the patient says ninety-nine. Differences in vibration can be detected; same as for vocal resonance. Consolidated lung transmits more sound. Sound conduction is decreased in collapse, PTX, COPD, pleural effusion. Decreased in fat people.

Percussion can show consolidation, dullness, stony dullness, hyperresonance, liver dullness (liver displaced downwards, below the sixth rib midclavicular line, due to hyperinflation), cardiac dullness can be displaced. It is possible to get localised hyperresonance in large emphysematous bullae or pneumothorax.

Auscultation shows bronchial breathing in consolidation, localised fibrosis, above a pleural effusion and above a collapse, and in cavities caused by e.g. TB. Consolidation implies pneumonia. Normal breath sounds are described as vesicular. Breath sounds should be decreased as normal or reduced. Reduced breaths sounds are in pleural effusions, pneumothoraces, pneumonia, large neoplasm or other masses, collapse, fibrosis, COPD. Beware silent chest in asthma. Wheezes. A localised wheeze can be due to a single bronchus obstruction e.g. cancer. Crackles: early suggest airways, later or paninspiratory suggests alveoli. Fine crackles are found in IPF. Medium crackles are due to LVFpulmonary oedema. Coarse crackles are secretions in pneumonia and bronchiectasis; in the latter they may clear upon coughing. A pleural friction rub is heard at the height of inspiration and may...