Makindo Medical Notes

Respiratory Exam: Overall Plan

Wash hands, introduce yourself, and obtain consent. Inspect head to toe and the environment from the end of the bed. Examine hands and check pulse. Examine the neck (JVP, hepatojugular reflux). Inspect the chest for thoracotomy scars, pulsations, deformities, or pacemaker. Detect the position of the trachea and apex beat. Percuss and auscultate anteriorly (upper, middle, lower zones) on both sides. Percuss and auscultate posteriorly (upper, middle, lower zones) on both sides. Thank the patient, wash hands, and present your findings.

Introduction (WIPER Preparation)

• W - Wash your hands.
• I - Introduce yourself and confirm patient details.
• P - Obtain permission (consent) to proceed with the exam and explain the process.
• E - Expose the patient appropriately and gather necessary equipment.
• R - Position the patient at 45 degrees.

Ask the patient to cough first to clear any phlegm that might affect auscultation. Ask the patient to breathe through an open mouth, as this allows more air movement, making normal breath sounds easier to hear. In normal respiration, expiration is more prolonged than inspiration (2:1 ratio).

Inspection

• End-of-bed Inspection:
  • Bedside Environment:
    • Sputum pots (suggests bronchiectasis, COPD).
    • Oxygen cylinder (suggests hypoxia: COPD, pneumonia).
    • Inhalers (COPD, asthma).
    • Chest drain (check if swinging).
    • Nebulizers (COPD, asthma).
    • Peak flow charts (asthma).
  • Patient:
    • Respiratory rate (normal: 12–15 breaths/min) and effort.
    • Signs of respiratory distress: intercostal retractions, tripod position, pursed lips (COPD).
    • Audible wheeze (COPD, asthma).
    • Hoarse voice (recurrent laryngeal nerve palsy from bronchogenic carcinoma).
    • Cachexia (malignancy, end-stage COPD).
    • Visible chest scars.
    • Signs of Cushingoid appearance (steroid use, Cushing's disease).
    • Kyphosis or scoliosis (e.g., Ankylosing spondylitis).

Hand Examination

• Look for signs in the hands:
  • Clubbing (lung cancer, bronchiectasis, pulmonary fibrosis).
  • Nicotine staining (suggests smoking).
  • Tremor (CO₂ retention).
  • Cyanosis (peripheral or central if lips are blue).
• Radial pulse:
  • Bounding pulse (CO₂ retention).
  • Irregularly irregular pulse (atrial fibrillation).
  • Tachycardia (fever, distress).

Neck Examination

• Check the jugular venous pressure (JVP) for signs of cor pulmonale or heart failure.
• Palpate for cervical lymph nodes.
• Assess for tracheal deviation (suggests lung collapse or tension pneumothorax).

Chest Examination

• Inspect for chest wall deformities (e.g., kyphosis, scoliosis).
• Palpate the chest:
  • Palpate the apex beat and assess for mediastinal shift.
  • Measure chest expansion.
• Percuss and auscultate the chest:
  • Percuss and auscultate both anterior and posterior lung fields (upper, middle, and lower zones).
  • Listen for normal breath sounds and abnormal findings such as bronchial breathing, crackles, or wheezes.
  • Assess vocal fremitus and resonance (e.g., ask the patient to say "99").

Peripheral Examination

• Check for peripheral oedema (sign of heart failure).

Finishing the Exam

• Thank the patient and help them get dressed if necessary.
• Wash your hands.
• Present your findings and offer a differential diagnosis.
• Suggest appropriate investigations (e.g., chest X-ray, ABG, peak flow).

Pathological Conditions and Exam Findings

Pathology	Aetiology	History/Inspection	Mediastinum	Palpation/Percussion	Auscultation
Consolidation	Lobar Pneumonia	Dyspnoea, Cough, Fever, Pleuritic Chest Pain	Central	Dull, Increased Tactile Fremitus	Bronchial Breathing, Crackles, Increased Vocal Resonance
Collapse	Obstructed Bronchus	Dyspnoea, Reduced Chest Expansion	Towards Affected Side	Dull	Absent Breath Sounds
Pleural Effusion	Fluid in Pleural Space	Progressive Breathlessness, Fever	Away from Pathology	Stony Dull	Reduced Breath Sounds, Pleural Rub
Asthma	Bronchospasm	Wheeze, Dyspnoea, Cough	Central	Resonant	Expiratory Wheeze
COPD	Chronic Bronchitis or Emphysema	Cough, Dyspnoea, Cyanosis	Central	Hyperresonant	Wheeze, Reduced Breath Sounds
Pneumothorax	Air in Pleural Space	Sudden Dyspnoea, Chest Pain	Towards Affected Side	Hyperresonant	Absent Breath Sounds
Tension Pneumothorax	Air under Pressure in Pleural Space	Dyspnoea, Hypotension, Distressed	Away from Affected Side	Hyperresonant	Absent Breath Sounds
Pulmonary Fibrosis	Chronic Interstitial Lung Disease	Progressive Dyspnoea, Clubbing	Central	Dull	Fine Crackles