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Respiratory Examination, Summaries of Anatomy

Washington University in St. Louis (WUSTL)Anatomy

Clinical Examination Guide ... chest expansion, vocal fremitus/resonance, percussion, auscultation ... Note any signs of recent ABGs test at the wrists.

Typology: Summaries

2021/2022

Uploaded on 09/27/2022

wilbur
wilbur 🇺🇸

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Document Owner: Clinical Skills/LK
Last Updated: March 2018
Clinical Examination Guide
Respiratory Examination
Components of the examination
• Introduction and general inspection
• Hands
• Neck
• Face
• Anterior Chest - close inspection, palpation, chest expansion, vocal fremitus/resonance, percussion, auscultation
• Posterior Chest - close inspection, palpation, chest expansion, vocal fremitus/resonance, percussion, auscultation
• Sacrum and Ankles
• Conclusion
Surface markings for Chest Examination
• Each lung extends 3cm above the clavicle (apex)
• Anterior borders of lungs are closest at the sternal angle – 2nd costal cartilage (cc)
• Left: Moves away from the midline at the 4th cc
• Right: Moves away from the midline at the 6th cc
• Both cross the midclavicular line at the 8th cc
• Both cross the midaxillary line at the 10th cc
• Pleura have the same surface markings as the lungs but reach further down to the 12th cc
Introduction
• Introduce yourself, confirm patient ID
• Explain examination and gain consent, position patient at 45o and expose chest. Ask if they are in any pain
• Gel hands and clean stethoscope
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Document Owner: Clinical Skills/LK Last Updated: March 2018

Clinical Examination Guide

Respiratory Examination

Components of the examination

  • Introduction and general inspection
  • Hands
  • Neck
  • Face
  • Anterior Chest - close inspection, palpation, chest expansion, vocal fremitus/resonance, percussion, auscultation
  • Posterior Chest - close inspection, palpation, chest expansion, vocal fremitus/resonance, percussion, auscultation
  • Sacrum and Ankles
  • Conclusion

Surface markings for Chest Examination

  • Each lung extends 3cm above the clavicle (apex)
  • Anterior borders of lungs are closest at the sternal angle – 2nd costal cartilage (cc)
  • Left: Moves away from the midline at the 4th cc
  • Right: Moves away from the midline at the 6th cc
  • Both cross the midclavicular line at the 8th cc
  • Both cross the midaxillary line at the 10th cc
  • Pleura have the same surface markings as the lungs but reach further down to the 12th cc

Introduction

  • Introduce yourself, confirm patient ID
  • Explain examination and gain consent, position patient at 45o^ and expose chest. Ask if they are in any pain
  • Gel hands and clean stethoscope

General Inspection

  • General inspection: Overall condition / colour / shape of the chest, scars
  • Breathing: Observe if talking in full sentences / rate / pattern / noise / cough / pursed lips / use of accessory muscles / Arms forward in a tripod position splinting the chest /
  • Surroundings: Look for O2 masks / nasal prongs / walking aids / portable O2 tank / inhalers / nebuliser / cigarettes / nicotine replacements / sputum pot

Hands

  • Inspect nails for clubbing - assess for loss of angle of the nail bed AND increased nail bed fluctuation. May be increased nail curvature and bulk of distal tissues in later stages.
  • Inspect skin for general colour and tar staining
  • Ask patient to extend arms and abduct fingers, assess for fine finger tremor associate with salbutamol use.
  • In suspected CO 2 retention ask the patient to hold hands outstretched with wrists dorsiflexed for 30sec to assess for asterixis
  • Note any signs of recent ABGs test at the wrists
  • Assess pulse, respiratory rate, BP and O 2 Saturation Course flapping tremor (asterixis) from CO 2 retention in respiratory failure (caused by failure of parietal mechanisms to maintain posture, so there are many underlying causes).

Neck

  • Examine for scars over trachea and larynx
  • Palpate for enlarged cervical lymph nodes (see ENT examination guide)
  • Ask patient to turn head to left whilst you look across the sternocleidomastoid for the JVP. If visible pulsation, measure the vertical distance from the manubriosternal angle.
  • To differentiate JVP from arterial pulse consider the following:
  • JVP disappears when occluding venous return at base of the neck
  • JVP is not palpable
    • Warn the patient before using index and ring finger to palpate for tracheal deviation by putting index finger and ring fingers on sterno-clavicular joints and use your middle finger to GENTLY assess if trachea is in the midline Tracheal Deviation: Pulled towards a fibrotic, collapsed, surgically removed lung, pushed away from tension pneumothorax, large pleural effusion

Face

  • Inspect eyes for conjunctival pallor (anaemia), miosis and, ptosis (Horner’s syndrome)
  • Palpate face with back of your hand for anhidrosis (Horner’s syndrome)
  • Inspect under the tongue for central cyanosis Horner’s Syndrome: miosis (small pupil), partial ptosis (drooping eyelid) and anhidroisis (reduced sweating) ALL ON THE SAME SIDE OF FACE. It is a sign of impaired sympathetic innervation to the face, which may be caused by obstruction to the sympathetic chain at apex of the lung Suprasternal Notch Sternoclavicular Joints
  • Assess Vocal Resonance (Bronchophony) using the same approach of asking the patient to repeat the sound “99”, auscultate with the diaphragm of the stethoscope across all areas of the chest bilaterally.
  • In a normal examination, you will hear muffled sounds in all areas It is not necessary to perform vocal resonance AND vocal fremitus. Percussion and Auscultation
  • Percuss the same areas as above, and in addition, percuss the clavicles directly. You are listening for the pitch, loudness and symmetry of the percussion note.
  • Auscultate the areas with the diaphragm of the stethoscope whilst asking the patient to breathe through their mouth each time you move the stethoscope. If you mirror this, you will not make them uncomfortable. You are listening for the quality and symmetry of the breath sounds.

Posterior Chest

With the patient sitting forward and hands brought into their chest

  • Inspect for scoliosis, scars
  • Palpate for tenderness
  • Check for upper and lower chest rib cage expansion as before. This is more difficult, but is assessing for lower lobe inflation Working systematically, alternating either side of these chest examine at the apices and 3 levels in lower lung fields for:
  • Tactile vocal frematis / vocal resonance
  • Percussion
  • Auscultation

Sacrum and Ankles

  • Assess for sacral oedema at the base of the spine if the patient has been lying in bed, of ankle oedema if the patient is ambulatory.
  • To do this, firmly press the skin with your index finger and hold for 1-2 seconds. On removal of your finger, an indent on the patient’s skin suggests oedema.

Conclusion

  • Thank the patient, ask them to get dressed, report/record findings
  • Consider cardiovascular examination and peak flow measurement “99”