Makindo Medical Notes.com Comprehensive Medical Encyclopedia | Education for Healthcare Professionals

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MEDICAL DISCLAIMER:The contents are under continuing development and improvements and despite all efforts may contain errors of omission or fact. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice by healthcare workers or laypeople. It is for educational purposes only. Please adhere to your local protocols. Use the BNF for drug information. If you are unwell please seek urgent healthcare advice. If you do not accept this then please do not use the website. Makindo Ltd

Respiratory Examination (OSCE)

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Resp exam: Overall plan
Wash hands, Introductions, consent End of bed: Inspect head to toe and environment Look at hands, pulse Look at neck - JVP : Hepatojugular reflex Look at chest - thoracotomy scars, pulsations, deformity, pacemaker Detect position of trachea and apex Percuss and ausculate anteriorly 3 areas upper/middle/lower on each side Percuss and ausculate posteriory 3 areas upper/middle/lower on each side Thank patient, wash hands, present findings

Resp exam: Overall plan

Wash hands, Introductions, consent
End of bed: Inspect head to toe and environment
Look at hands, pulse
Look at neck - JVP : Hepatojugular reflex
Look at chest - thoracotomy scars, pulsations, deformity, pacemaker
Detect position of trachea and apex
Percuss and ausculate anteriorly 3 areas upper/middle/lower on each side
Percuss and ausculate posteriory 3 areas upper/middle/lower on each side
Thank patient, wash hands, present findings

Introduction (Use the acronym WIPER to prepare for the examination)

W - Wash your hands
I - Introduce yourself and confirm patient details
P - Permission - gain consent to proceed with the examination, including explaining relevant details
E - Expose the patient appropriately, gather Equipment
R - Position the patient lying back at 45 degrees comfortably

Ask the patient to cough first to remove any phlegm that can add noises to the auscultatory findings. Ask the patient to breathe through an open mouth as less resistance pathway and more air shifted and so more to hear normal breathing pattern expiration more prolonged than inspiration 2:1

Stand back and Inspect from end of bed
Bedside table
- Sputum pots full of phlegm (bronchiectasis, COPD)
- Oxygen cylinder (Suggests hypoxia - COPD, Pneumonia etc.)
- Inhalers (COPD, asthma)
- Chest drain in place - is it swinging
- Nebulisers (COPD or Asthma)
- Peak flow charts (Asthma)
Person
- Respiratory rate - normal 12-15/minute and breathing
  - Hypoventilating - obese, oversedated, COPD "Blue bloater", raised ICP
  - Hyperventilating: COPD, Asthma, LVF, Pneumonia, PE, Panic attack
  - Intercostal indrawing of ribs suggests increased effort
  - Prolonged expiratory phase - COPD, Asthma
  - Tripod position in severe COPD
  - Pursed lips respiration (COPD) : seen in emphysema as the patient maintains a positive airway pressure to prevent small airway collapse
  - Audible wheeze (COPD/Asthma)
- Hoarse voice - Recurrent laryngeal nerve palsy from bronchogenic carcinoma
- Thin, cachexia - malignancy, end-stage COPD, pulmonary fibrosi
- Visible scars on chest
- Smell of cigarettes, Unkempt, emaciated - ? TB, Cancer, Alcoholism
- Cushingoid (steroid treatment/Cushing's disease/Paraneoplastic)
- Kyphosis and/or scoliosis (Ankylosing spondylitis -apical lung fibrosis)
Examine Hands
- Clubbing (suppurative conditions, lung cancer, fibrosis)
  - Bulbous swelling of terminal phalanges with loss of angle of nail bed
  - Aetiology unsure possibly circulating prostaglandins
  - Associated with Hypertrophic pulmonary osteoarthropathy- onion skin like bone formation at the wrist associated with clubbing
    - Causes of Clubbing
      - Malignancy - Lung cancer, Mesothelioma
      - Infection - Lung abscess, Empyema, Bronchiectasis
      - Cryptogenic fibrosing alveolitis
      - Endocarditis, Atrial myxoma
      - Congenital cyanotic cardiac disease
      - Cirrhosis, Congenital (AD)
      - Inflammatory bowel disease
- Tar (Nicotine) staining
- Wasting of small muscles
- Tremor + CO₂ retention
- Cyanosis - central if lips blue
Radial pulse
- Bounding pulse - CO₂ retention
- Irregularly irregular - Atrial fibrillation
- Tachycardia - fever, distress, arrhythmias
Respiratory rate
Eyes
- Horner syndrome (Apical lung tumour causing Pancoast syndrome: Miosis and mild ptosis)
- Anaemia
- Jaundiced (liver metastases with lung cancer)
- Conjunctiva - pale and anaemic or pink and suffused with SVC obstruction
Face
- Plethora (polycythaemia or SVC obstruction)
- Eyes: anaemia
Mouth: Central cyanosis, Dry, Poor dentition
Neck
- JVP (raised >4 cm) in Cor pulmonale, PE, Tamponade, LVF
- Palpate lymph nodes
- Tracheal deviation
- Cricoid–suprasternal notch distance (les than three finger breadths in hyperinflation)

Chest

Palpates
- Palpates apex beat
- Measures chest expansion (6–8 cm is normal) at three places on the anterior and three on the posterior chest
Percusses three areas on right/left side
Auscultate three areas on right/left side and axillae
- Breath sounds
  - Normal breathing pattern expiration more prolonged than inspiration 2:1
  - Vesicular: Normal breath sounds and are soft and low pitch with a more blowy quality.
  - Bronchial breath: harsh high pitch and equal duration inspiratory and expiratory phases. Sounds like listening over one's trachea. They are abnormal when heard on the chest surface. They usually suggest consolidation
  - - Reduced air entry suggests pathology
    - Collapse, consolidation
    - fibrosis, pleural thickening
    - Hypoventilation if bilateral
    Reduced breath sounds
    - Hypoventilation
    - Pleural effusion
    - Pneumothorax
  - Added sounds
- Pleural rub: fine crackling noise with respiration
- Rhonchi/Wheeze suggests asthma or COPD
- Fine crepitations "crackles" or rales can suggest pulmonary oedema, resolving consolidation or infection or pulmonary fibrosis
- Coarser crackles heard with Bronchiectasis or cystic fibrosis
Auscultate at three areas right and left side of chest on the anterior and posterior chest and over axillae to listen for right middle lobe signs
Auscultate for vocal fremitus: Say "99" and is increased over consolidation to the point that one gets "whispering pectoriloquy"

Elsewhere

Palpates shins or ankles for peripheral oedema

Extras

Ask if you can measure the patient's PEFR (ensure you can do this properly)
Look at observations chart for O₂ sats and temperature and respiratory rate

Finishing

Thank patient and offers to help patient get dressed
Wash hands and think about how to present your findings
Present Findings and suggest a differential diagnosis
Suggests appropriate investigations and management

Background Information

Pathology	Aetiology	History/Inspection	Mediastinum	Palpation/Percussion	Auscultation
Consolidation	Lobar Pneumonia	Dyspnoea, Cough, fever, Pleurisy	Central and reduced movement same side	Dull to percussion, Increased Tactile fremitus and reduced expansion	Bronchial breathing, Added sounds, wheeze and creps and increased vocal resonance (whispering pectoriloquy)
Collapse of lobe or lung	Occluded bronchus	No shift	Dull over pathology	Bronchial	Reduced same side
Pleural Effusion	Fluid in pleural space	Progressive breathlessness, fever, weight loss	Central or away from pathology if > 1 L. Reduced movement affected side	Stony Dull over pathology, Reduced Tactile fremitus,	Reduced vesicular breath sounds. Crackles at upper edge with pleural friction rub
Asthma	Bronchospasm and mucus plugs	Central	Resonant	Exp Wheeze	Reduced Vesicular breath sounds bilateral, Ominous silent chest
COPD	Chronic cough, wheeze, smoker, distressed	Central	Resonant	Exp Wheeze	Decreased vesicular sounds, exp wheeze
Pneumothorax	Air in Pleural space	Dyspnoea, wheeze, distressed	Central or towards PTX and reduce movement same side	Hyper/Resonant, Reduced Tactile fremitus	Reduced Vesicular breaths, added sounds
Tension Pneumothorax	Air under pressure in Pleural space	Dyspnoea, wheeze, distressed, hypotensive, cardiac arrest	Hyper/Resonant	Reduced	Reduced vesicular breath sounds, affected side
Pulmonary Fibrosis	Air under pressure in Pleural space	Away from PTX	Hyper/Resonant	Reduced	Reduced affected side

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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