General Points

 

The respiratory examination is one of the key 'bread and butter' examinations in medicine and as such should be mastered as soon as possible.  As with all systems examinations it follows the basic format:

 

  • Inspection
  • Palpation
  • Percussion
  • Auscultation

 

As a common examination station in OSCE's it is important not to just learn the examination sequence and regurgitate this page back to your examiner; you need to understand what you are looking for and which diagnoses are suggested by the signs which you may elicit.

Never forget to wash your hands, even in practise, as these are points often missed in the OSCE by those adopting the 'I'll do it on the day' attitude.

 

Inspection

 

In order to inspect the chest, the patient's chest should be adequately exposed; this usually involves asking the patient to remove all upper garments.  They should be allowed to do this in private and given a gown or other item with which to cover themselves. Be prepared for both male and female examination subjects and remember that adequate exposure is still necessary and need not compromise patient dignity given the correct approach.

When you think about what you are inspecting it is useful to have a system to ensure you don't forget anything.  I have described the way I work through the examination but there is no right or wrong way, just do whatever works for you.

 

BEFORE EXPOSING THE CHEST (to maintain dignity)

First comment on the patient's surroundings -

  • Are there oxygen cylinders/are they using oxygen?
  • Can you see a nebuliser?/spacer?/inhalers?
  • Is there a sputum pot (remember to look inside)?

 

Comment on the patient's general state -

  • Do they appear to be tachypnoeic?  Does this correlate with their Respiratory Rate? (normally 12-18 breaths per minute in adults)
  • Body habitus i.e. BMI - obesity or wasting?
  • Is the patient distressed?
  • Are they using accessory muscles to help them breathe? This may be obvious from the end of the bed.

 

HANDS

  • Is there any obvious cyanosis?  Is it central or peripheral?  
  • Are the nails clubbed or is there any koilonichyia?  Is there any tar staining?
  • Is there any hypertrophic pulmonary osteoarthropathy (HPOA), or palmar erythema suggesting hyperdynamic circulation?
  • Is there any flap (with arms and wrists fully extended, suggests carbon dioxide retention) or tremor (which may indicate salbutamol use)?
  • Take the pulse - Brady <60, Tachy >100.

 

NOW EXPOSE THE CHEST...

Having already done the hands, I now move to the neck, head, then chest.  Look for and comment on any of the following:

 

NECK

  • JVP - is it visible?  Is it raised?  Make sure you are not looking at the carotid artery pulsation.  Be sure the patient is positioned appropriately at 45 degrees with their head turned to the left and resting on the pillow so no muscles are tense in the neck.
  • Accessory muscle use - Sternocleidomastoid and Scalene muscles in particular?
  • Lymphadenopathy - routine LN examination of the neck plus supraclavicular nodes.  
  • Tracheal tug

 

HEAD

  • Ptosis or Horners syndrome in the face
  • Look at the tongue - the underside for central cyanosis, the dorsal (top) surface for signs of IDA
  • Angular stomatitis (some argue this is a CV examination point, but IDA may be present in chronic bleeding from malignancy in any system. Anaemia is also a cause of dyspnoea should your examiner ask).  

 

CHEST

  • Scars - remember to check front and back.  
  • Bony deformity of the chest - pectus excavatum or carinatum.  
  • Spinal problems that may contribute to respiratory difficulty - scoliosis, kyphoscoliosis
  • Intercostal recession.  

 

 

Scars can be easily missed if you do not look carefully. This type of scar is called a thoracotomy a

Palpation

 

There are three things to remember to palpate in a respiratory examination.  

 

  • Position of the Trachea - this is uncomfortable and should be done gently
  • Chest expansion - should be done in at least 3 places, both front and back.  
  • Apex Beat

 

Additionally, some perform tactile vocal fremitus (TVF) in palpation by applying the ulnar border of the right hand to points on the chest wall and asking the patient to say '99' to create palpable resonance. This can be used to effectively pick up pleural effusions (reduced TVF), or sometimes consolidation (increased TVF).

 

Percussion

 

The chest should be percussed front and back, making sure to cover all lobes and paying particular attention to the bases. 

 

You should use your dominant hand's middle finger to percuss, and should use it to tap your middle finger from the opposite hand 2-3 times - this amplifies the sound.  When percussing the apical segments of the lungs, use this technique in the supraclavicular fossae, but percuss the clavicle directly (i.e. you don't need your second hand).  The technique takes some practice - especially to get the percussing motion to come from the wrist - but we all have chests to practice on (!) and when that's not appropriate you can tap tables, books, etc.  

 

My routine for percussion:

 

  • Start at the apices - percuss one side, then the contralateral side at the same level - this provides comparison in order to increase the likelihood of detecting pathology.  

 

  • Move down through the anterior chest, percussing the intercostal spaces of each side alternately.  

 

  • Percuss in the axillae

 

  • Ask the patient to lean forward and repeat on the back, ensuring you percuss right down into the bases.  

 

Auscultation

 

Sites for auscultation are the same as those for percussion.  The bell should be used in the supraclavicular fossae and the diaphragm elsewhere.  

 

On auscultation you are looking for:

  • Breath sounds - vesicular (normal) or bronchial (pathological)
  • Reduced air entry
  • Added sounds

 

    Added sounds include:

    • Wheeze
    • Crepitations
    • Pleural rub

     

    Once you have done this, repeat the same process and ask the patient to say "one one one" or "ninety nine" each time you move your stethoscope.  This is assessing vocal resonance (an alternative to TVF in palpation).  

     

    In a healthy lung, only the low pitched components will be heard.  In a consolidated lung (eg. pneumonia) the words are clearly audibly and in an effusion the words sound muffled.  

     

    Summary of findings on examination for common respiratory complaints

    To Complete My Examination...

     

    In an OSCE situation, the examiner may not want you to actually perform all of the above but it is generally accepted that you should offer to as part of your main examination.  Considering time constraints in an exam situation it is acceptable to list a few further things you would ideally like to examine for at the end of the examination.  For a respiratory examination these might include:

     

    • Taking the patient's BP
    • Abdominal Examination for hepatomegaly
    • Examine for sacral or peripheral oedema (you may wish to perform this routinely, but be sure to keep an eye on the patient as pitting oedema is often uncomfortable)

     

    Investigations you may like to perform might include:

    • Chest x-ray
    • Sputum microscopy, culture and sensitivity
    • Pulse Oximetry
    • Arterial blood gas analysis
    • Spirometry
    • Peak expiratory flow rate

     

    Once you are really confident with this examination, one way to appear really slick to an examiner (and also be kinder to any patient's you examine) is to go through this system for the front of the chest, then ask the patient to lean forward and do it for the back - this saves them sitting up/lying back multiple times.

     

    Never forget to thank the patient and wash your hands. Invite them to cover themselves back up, or assist them in doing so where needed.

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