Examination of the Respiratory System

The following document is one way of examining the lungs. There are obviously many ways and techniques to do this which aren't mentioned here. I suspect you will only use this as a guide to your own examining technique which you should evolve to suit your own approach and style. I have also assumed that you have some knowledge of medicine throughout this examination. If you are uncertain to the reasons why i have mentioned things in my examination or need clarification there are some excellent books you can refer to.

I have written this with the idea that this will be used in an exam setting - so you will be presenting your findings as opposed to a clinic setting. i would try and talk constantly whilst examining the patient. It keeps the examiner interested and shows off what you know.

---

Introduction

– introduce yourself and explain what you would like to do, then ask for permission.

General – make a show of standing back from the patient and look at the environment around the patient – check for any equipment, temperature chart, monitors. Make sure that the patient is adequately exposed.

"The patient is lying comfortably at rest at 45 degrees, and appears not to be grossly cyanosised, anaemic nor seems in pain or breathless."

Hands

Assess temperature using the back of your own hand. Pallor in the palm creases.
Clubbing for Ca bronchus, cryptogenic fibrosing alveolitis, asbestosis, and chronic pulmonary sepsis (empyema, lung abscess, bronchiectasis, cystic fibrosis).
Koilonychia – soft, thin, brittle, spoon shaped – evidence of severe iron deficiency.
nicotine staining around the fingers – indicates only that the patient smokes cigarettes down to the base – it reveals no information about how much the patient actually smokes.
Look for small muscle wasting (T1 distribution) – prominent extensor tendons – this could be evidence of brachial plexus invasion - possibly from an apical bronchial carcinoma (pancoast’s tumour).
Asterixis – Assess CO2 retention tremor (indistinguishable from liver flap). Extend the arms out straight in front and then extend the wrists whilst the patient’s eyes are closed.

Pulse – assess rate and rhythm. – try also to assess respiration rate (RR).
Blood pressure – pulsus paradoxus in severe asthma or constrictive pericarditis.

Assess JVP – non pulsatile and very high – evidence for obstruction of SVC (Ca bronchus?) Cor-pulmonale (right-sided heart failure due to lung disease) will show a raised pulsatile JVP.

Face

– Inspect the conjunctiva for pallor
Inspect the buccal mucous membranes and tongue for blue discolouration for evidence of cyanosis .

Horner's syndrome – miosis (contraction of the pupil), enophthalmos (backwards displacement of the eyeball in the orbit), ptosis, and reduced sweating on the affected side of the face. Due to damage to the sympathetic chain (due to involvement by a bronchial carcinoma on the posterior chest wall)

Consider examination of the fundi – papilloedema can be caused by CO2 retention and cerebral metastases.

Assess whether the Trachea is central or not.

Chest

– Inspection

"there seem to be no scars or deformities on inspection nor is there a visible use of the accessory muscles for respiration"

barrel chest = emphysema
pectus carinatum / pigeon chest (increased prominence of the upper sternum)
pectus excavatum / funnel chest (depression of the lower sternum)

Palpation – position of the apex beat. Be seen to calculate the mid-clavicular line and 5th or 6th intercostal space then palpate the apex.
Palpate for the right ventricular heave.

Chest Expansion difficult to describe properly - i would suggest that you hold the chest tightly near the bases with your thumbs at the midline a few inches apart. This way you can see any small change in the chest dimensions. For the upper chest, place your hands flat on either side and try and assess a difference in the filling of one lung compared to the other.

Vocal Fremitus – place the flat of your hand on both sides of the chest and ask the patient to say '99'.

Percussion – start with the clavicles and work your way down.

Auscultation – start above the clavicles and work your way down. Measure RR if not done.

Vocal resonance – ask the patient to say '99'. if need be try whispering pectoriloquy (whisper '99').

Follow this system (inspection, chest expansion, vocal fremitus, percussion, auscultation and vocal resonance) for the back, axilla and lateral chest.

"Breath sounds are vesicular, and no gross abnormality was found".

Examine the Lymph nodes down the trapezius, around the clavicles and up the neck and jaw (remember the parotid).


Remember to examine the shins for erythema nodosum = sarcoidosis, TB


If you think it will sound reasonable ask for a chest radiograph or a pulse oximeter reading / blood gas reading.


There are some excellent resources online www.qub.ac.uk

Disclaimer

The authors of this document have attempted to provide information that is medically sound and up-to-date. The authors nor Clinicaljunior.com cannot take any reponsibility for the accuracy or completeness of this article. The reader should confirm the statements made in this website before using the information outside this website.