Introduction
At the start:
Wash hands, introduce yourself, obtain consent.
Patient position:
Sitting upright (45o) & adequately exposed (undress to waist).
NB - if you have a female patient, the textbooks classically require bras to beremoved for 'full' exposure. It might therefore be worth mentioning to the examiner that 'for the sake of modesty', you will not ask the patient to remove her bra during the examination. This conveys that you appreciate both the need foradequate exposure, as well as the need to maintain a patient's dignity wheneverpossible.
General Observations:
Search for any clues eluding to the diagnosis. Like looking at your mirrors in a driving test, make sure you 'over-dramatise' your observations so that the examinerknows that you are making an effort to make good observations.
Look around the bed:
Supplementary oxygen, nebulisers, inhalers, sputum pots, etc.
Look at the patient:
- Do they appear well/comfortable/unwell
- Position (eg. sitting forward)?
- SOB/respiratory distress (using accessory muscles, pursed lips)?
- Cyanosis
- Respiratory rate (<14/min = normal). It is often easiest to count this whilstmeasuring the patient's pulse. With practice, you should be able to estimate thepulse (the examiner will not usually be bothered about the exact figure), so take this quiet opportunity to glance over and count the respiratory rate. You can alsouse this 'quiet time' of pulse taking to think about what comes next!
- Cough
- Hoarse voice (tumour pressing on recurrent laryngeal nerve) / stridor
Peripheral Signs of Respiratory Disease
Hands:
- Clubbing - bronchial carcninoma / chronic suppurative disease (bronchiectasis / empyema / cystic fibrosis) / fibrosing alveolitis / mesothelioma / hypertrophic pulmonary osteoarthropathy (HPOA)
- Peripheral cyanosis
-Wasted thenar eminence indicates apical lung tumour pressing on brachial plexus (Pancoast's tumour)
-Tar stains (smoking)
-Flap (or asterixis - caused by CO2 retention)
Arms:
Pulse:
- Tachycardia (eg. moderate-severe asthma).
- Pulsus paradoxus (eg. severe asthma).
Face:
- Eyes (conjunctival pallor (anaemia), Horner's syndrome (meiosis - constricted & non-reactive pupil, ptosis, anhydrosis))
- Tongue (central cyanosis)
- Lips (peripheral cyanosis)
- Pharynx (red - infection)
Neck:
- Lymph nodes
- Trachea (deviation can be caused by tension pneumothorax or pneumonectomy/tug caused by overexpansion of chest)
- JVP (raised due to cor pulmonale)
Chest Examination
Chest (Anteriorly):
1. Inspection
- Symmetry
- Scars / chest drains
- Deformity (hyperexpansion, barrel chest, scoliosis)
- Inwards movement of abdomen on inspiration
2. Palpation
- Always ask: DO YOU HAVE ANY PAIN?
- Chest expansion (normal = 5cm)
- Tactile fremitus (ask patient to say 99 whilst the palm and edge of your hand rests on chest wall, repeat in all 4 quadrants). Increased in consolidation (eg. pneumonia), decreased with fluid (pleural effusion).
- Apex beat (displaced in lung pathology such as tension pneumothorax)
3. Percussion
- Tap on clavicle bilaterally, then move diagonally downwards in 6 places. Always compareleft to right (DON'T just go all the way down one side then the other)
- Resonant (normal)/hyper-resonant (pneumothorax, ie. with increased air)/dull (consolidation or fluid)/'stony dull' (pleural effusions).
4. Auscultation
- Ask patient to take slow deep breaths through their open mouth.
- Auscultate at the same 6 locations as percussed.
- Listen for normal vesicular breath sounds (insp longer than exp, with no discernable gapbetween the two).
- Is there any bronchial breathing? (insp length=exp length) eg. pneumonia or at the top borderof a pleural effusion.
- Other added sounds: wheeze (mono or polyphonic), crackles/rales/crepitations (all of these wordsmean the same thing). Causes of crackles include: Left Ventricular Failure, pulmonary oedema, fibrosis, pneumonia, bronchiectasis, etc.)
- Pleural rub (sounds like 'walking on fresh snow'). Found in any inflammation of the pleura.
- Which area of lung are the signs in? Are they found during inspiration or expiration?
- Vocal resonance (ask patient to say '99' as for fremitus, but whilst auscultating - clearer & increased over consolidation, quieter over air and fluid).
- Whispering pectoriloquy (ask patient to say '1, 2, 3, 4' whilst auscultating - if the numbers are heard clearly, this suggests consolidation, i.e. an increase in vocal resonance).
Chest (Posteriorly):
- Inspect / Palpate / Percuss / Auscultate (as before)
- Remember to palpate for lymphadenopathy.
Final Points to Consider
Also...
If appropriate examine or tell the examiner that you would briefly examine the legs (for swelling of ankles for signs of a DVT, as this maybe the initial cause of the respiratory pathology, eg. if there was a pulmonary embolus secondary to this).
To complete your examination:
- Cover-up and thank the patient.
- Tell the examiner you would like to order the following to complete your examination:
Sputum
Peak flow
Oxygen
Temperature
X-ray (chest)
Presenting Your Findings
What do you say?
Whilst this obviously depends on what signs you have elicited, it is useful to have a set framework of what to say planned. Sounding confident (whether you actually are or not) is one of the most important aspects of your presentation. Never useabbreviations (always say 'myocardial infarction' rather than 'MI').
Examiners may well not give you the chance to formally present your findings due to time limitations in examinations and mayjust ask you to recall your salient findings. Use the 'quiet' parts of the examination such as auscultation to gather your thoughtsand to prepare what you have found so far. An example presentation might be:
"On general examination, Mr Smith appeared short of breath at rest. He was sat forwards and was breathing through pursed lips. Beside his bed was a used packet of antibiotic tablets and a pot filled with green sputum. There were no peripheral stigmata of respiratory disease, in particularthere was no cyanosis. On inspection, his chest had a barrel-shaped appearance. The right lower zone had increasedtactile and vocal fremitus. On auscultation, crackles and bronchial breathing were also heard at the right lower zone. Thesefindings suggest consolidation."
For a nice finishing touch, you can add: "In summary, these findings are consistent with a diagnosis of right lower lobe pneumonia, suggesting aninfective exacerbation of this gentleman's underlying chronic obstructive airways disease".
Then prepare yourself for some questions!
