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)