Respiratory

Examination

3rd years early bird

Clinical Teaching Fellows

Dr G. Aidoo-Micah

Learning outcomes

• Describe an initial approach to all patients

• Identify the relevant components in a respiratory examination

• Know how to demonstrate a fluent and professional respiratory examination

• Recognise abnormal signs, in the hands, face neck and chest.

Respiratory Examination

• Things to think about before you start

• SOB/distress…

• Exposure/dignity…

Things to do before you start…

1) Wash hands

2) Introduce yourself and ask patient’s name

3) Permission/Pain - explain exam and gain consent

4) Expose patient

5) Re-position to 45⁰

“WIPER”

Inspection – “end-of-the-bedogram”

• 1. Patient: - What can you see/hear/smell? - General appearance - Chest deformities and operative scars. - Respiratory rate, regularity and depth. - Asymmetry of chest expansion. - Use of accessory muscles and positioning. • 2. Around bed: - Oxygen, drugs chart, inhalers, nebs, peak flow meters, IV lines, chest drains (and contents), sputum pots (mmm).

Systematic 3. HANDS

• Inspect for: - Colour - ?peripheral cyanosis - Tremor - Tar staining - Clubbing - Asterixis - Thenar wasting

• Feel for: - Capillary refill - ?how many seconds - Radial pulse – rate, rhythm, character (sneakily check RR) - Temperature - Ask for BP

Take the hands of the person next to you…

Respiratory causes of clubbing

4. Face/neck

a) Face: -Plethora -Moon face -Anhidrosis

b) Eyes: -Partial ptosis -Miosis -Conjunctival pallor

c) Mouth: -Central cyanosis – underside of tongue -Pursed lip breathing -Tar staining of teeth

d) Neck: -JVP -Trachea -LN’s -Tracheostomy scar

5. Chest – anterior then posterior (IPPA)

• Inspection (for any system)

– DWARFS

• Deformity, Wasting, Asymmetry, Redness,

Fasciculations, Scars.

• Palpation - Apex beat

- Chest expansion

- Tactile vocal fremitus

Chest percussion

• Percussion - Start at apex of one lung, compare each side. Clavicles. - Resonant = normal - Dull = consolidation, collapse, pleural thickening - Stony dull = pleural effusion - Hyper-resonant = pneumothrax

• Tips Don’t forget over clavicles and axillae! Practise, practise, practise – on selves, doors, each other! Trim nails!!

• Auscultation

• Ask patient to take slow, deep breaths through mouth.

• Breath sounds: - Normal = vesicular

- Diminished = obesity, effusion, pneumothorax, COPD

• Added sounds = crackles wheeze (expiratory, high pitched – e.g. asthma), stridor (airway obstruction).

• (Vocal resonance: “ninety-nine”)

• DON’T FORGET TO EXAMINE THE BACK (IPPA)

6. Completion • (Legs): If time - Inspect for erythema and swelling - Palpate for tenderness and pitting oedema a) Unilateral red, swollen, tender calf – think DVT b) Bilateral pitting oedema - ? R-sided heart failure

• To patient: - Thank, cover, comfort. Wash hands!! • To examiner: To complete my examination I would like to… - Take a full history - Ask for O2 sats (obs chart), sputum sample, PEFR, CXR. - Relevant bloods and ABG - Summarise findings and differential diagnosis.

Watch the experts in action…

http://geekymedics.com/respiratory-examination-2/

Task Adequate? Comments Y N

Introduce self, task and exposure Consent Ask about pain Inspection End of the bed – makes obvious they look! Notes nebs, inhalers, oxygen, sputum pots Inspect Hands for … tar staining, clubbing, cyanosis, muscle wasting

Check for tremor (salbutamol or CO2 retention) Check radial pulse – comment on rate rhythm and character Face – plethora, moon face Eyes – inspect for pallor, signs of Horners Mouth – inspect for central cyanosis under tongue Neck – raised JVP, use of SCM? Check trachea is central. LNs. Chest – use of accessory muscles, shape deformities, scars, drains, bandages

Count RR Look for pursed lip breathing Palpation *Check trachea central if not done already. Apex beat if trachea is deviated Expansion – anterior and posterior Vocal fremitus (unless doing vocal resonance)- 1 will do! Percussion Anterior, posterior and axillae Auscultation Anterior, posterior and axillae Vocal resonance anterior, posterior and axillae To conclude – ask for 02 sats/obs and CXR/PEFR if appropriate Thank the patient and cover them up

Respiratory exam mark sheet

Practise, practise, practise

• On patients

• Colleagues

• Unsuspecting friends and family

• Teddy bears

• Doors

• Practice makes perfect!

Any questions?

• Thank you!

• Have a go…

• Good luck!

Special thanks to Dr Emma Figures (CTF 2015)