Video


Exam Summary


1. Introduction

  • Introduce yourself and the examination
  • Hand Hygiene

2. Observations

  • Temperature
  • Oxygen Saturations
  • Respiratory Rate
  • Heart Rate

2. General Inspection

  • Alertness - Orientated, confused or drowsy
  • Breathing - use of accessory muscles, laboured breathing, rate, use of oxygen (see dyspnoea)
  • Cough - lack of explosive start (vocal cord paralysis), wheezy (obstructive disease), productive (infection), dry (infection, asthma, bronchal carcinoma, ACE Inhibitors), barking cough (upper respiratory tract infection)
  • Stridor - croaking noise on inspiration. May be due to Foreign body, tumour or epiglottitis
  • Hoarseness - or dysphonia, may be due to recurrent laryngeal palsy, Pancoast tumour or laryngeal carcinoma.
  • Sputum cup - colour, volume, type (purulent, mucousy, mucopurulent)
  • Cachexia - cancer
  • Deformity - spinal scoliosis may affect breathing
  • Scars - past surgery or trauma
  • Signs of Right Heart Failure - May be due to cor pulmonale - peripheral oedema, ascites.

3. Hands

a. Nails

b. Fingers

  • Peripheral cyanosis - Blue or purplish colouration of the hands due to low oxygen saturation.
  • Nicotine stains - yellow stains on fingers due to chronic smoking.
Cyanosis.JPG
Peripheral cyanoisis
Nicotine_stains10.JPG
Nicotine Stains

c. Palms

  • Muscle Wasting and Weakness - If the Brachial plexus is impinged by a Pancoast's tumour finger abduction and adduction may be affected.
  • Palmar crease Pallor
  • Palmar Erythema - may be due to polycythaemia secondary to chronic hypoxia

4. Arms

a. Metabolic Flap (Asterixis)

  • Ask the patient to hold their hands up and spread their fingers for 15 seconds. A flap is a result of hypercapnia.

b. Radial Pulse

radialpulse.jpg
Radial Pulse

  • The radial pulse is taken on the flexor side of the forearm, just below the wrist on the radial side. Check for regularity and rate. A normal heart rate is between 60 and 100 beats per minute. A fast rate is called a tachycardia and a slow rate is called a bradycardia.

c. Respiratory Rate

  • After measuring the heart rate, leave the hands on the patient's wrist and measure the respiratory rate. It is important to ensure the patient is unaware that respiratory rate is being measured so that conscious drive doesn't affect the rate of breathing. A normal respiratory rate at rest in adults is 16-20 breaths per minute.

5. Face

a. Eyes

  • Horner's Syndrome - A Pancoast Tumour may affect sympathetic nerves leading to ipsilateral pupil constriction, partial ptosis, possible anhydrosis and possible iris discoloration.
  • Conjunctival Pallor
Horner's.jpg
Horner's Syndrome
conjunctivapallor.jpg
Conjunctival Pallor

b. Mouth and Tongue

cyanosistongue.jpg
Cyanotic Tongue
















c. Voice

  • A Pancoast Tumour may affect the recurrent laryngeal nerve causing hoarseness.

d. Skin

  • Palpate the maxilary sinuses and ask the patient if they experience any facial pain.

6. Neck

  • Tracheal Deviation - Gently feel the trachea above the jugular notch, feeling both sides. A deviation may be due to lobe collapse, pneumonectomy, tension pneumothorax or massive pleural effusion.
  • Sternocleidomastoids - Check for use of sternocleidomastoids in breathing.
  • Look for raised Jugular Venous Pressure which may be due to cor pulmonale leading to right-sided heart failure or SVC obstruction.
  • Pemberton's Sign- If the JVP is raised, get the patient to stand and hold their arms above their head for one minute. Engorgement of the face may be due to SVC obstruction from lung cancer.

7. Chest

a. Inspection

  • Shape - The chest may be barrel-shaped - a sign of hyperinflation in severe asthma or severe emphysema, be pigeon-chested (having a local outward prominence - pectus carinatum) which could be a sign of long-term childhood respiratory disease or rickets, or funnel-chested (having a local inward depression - pectus excavatum). Look for exaggerated kyphosis and scoliosis.
  • Scars - past surgery or trauma
Pectus_carinatum.jpg
Pigeon Chest
Pectus1.jpg
Funnel Chest

b. Palpation

  • Chest Expansion
    • Measure chest expansion at the base of the lungs by wrapping hands tightly around the chest, thumbs pointing together. Ask the patient to take a deep breath and observe movement between your thumbs.
    • Measure chest expansion at the top of the lungs by placing two open palms on the top of the chest, thumbs pointing together. Again observe movement between thumbs
    • Ensure that both sides of the chest expansion is the same on both sides.

c. Percussion

  • Percuss the anterior and lateral chest wall.

d. Auscultation

  • Listen to the anterior and lateral chest wall, getting the patient to breathe to listen to breath sounds listening for intensity and quality and then ask them to say 'ninety-nine' to listen for vocal resonance.

8. Heart

a. Palpation

  • Apex Beat - Feel for the apex beat may be displaced towards (lower lobe collapse) or away (tension pneumothorax, pleural effusion) from a lung lesion.
  • Right Ventricular Heave - Place a hand on the right parasternal edge to feel a heave.

b. Auscultation

  • Listen to the Pulmonary and Aortic Valves. If the Pulmonary 2nd heart sound is louder than the Aortic 2nd heart sound then Pulmonary Hypertension should be suspected. Look again for signs of Right Heart Failure.

9. Back

  • Ask the patient to sit on the edge of the bed

a. Inspection

  • Scars - past surgery or trauma
  • Spine Curvature - look for abnormalities in the spinal shape. Significant abnormalities may impact on breathing (particularly scoliosis).
  • Sacral Oedema
Spine curvature.jpg
Spine curvature

b. Palpation

  • Chest Expansion - Ensure that both sides of the chest expansion is the same on both sides by wrapping hands around the base of the lungs, thumbs pointing together..
  • Supraclavicular Fossae - Palpate the supraclavicular fossae for enlarged lymph nodes indicating potential lung cancer. Also check for use of scalene muscles respiration which can be felt in the supraclavicular fossae when they contract.
  • Ask the patient to hug themselves

c. Percussion

  • Percuss the lung fields of the back.

d. Auscultation

  • Listen to the posterior lung fields, getting the patient to breath to listen to breath sounds and then say 'ninety-nine' to listen for vocal resonance.

10. Liver

  • Palpate the liver for inferior displacement due to COPD hyperinflation or lung cancer metastases.

11. Legs

Assess legs for:
Piting_Oedema wiki.jpg
Pitting Oedema

12. Peak Flow

  • Request a peak flow - Using a peak flow meter get the patient to stand up, hold the peak flow meter horizontally, wrap their lips around the device, take a deep breath and breath out as fast as they can. Record the best of 3.

13. Conclude

  • Thank the patient and offer assistance

Citation

Talley and O'Connor - Clinical Examination 7th edition pp 138-151, 161-162 (summary)

Pigeon chest photo: By Tolson411 (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons
Funnel chest photo: The number c (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons
Pitting Oedema image:
By James Heilman, MD (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons
Capillary refill image: By Alex Miles - pager Author (Own work)
Clubbing image: "Acopaquia" by Desherinka - Own work. Licensed under GFDL via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Acopaquia.jpg#/media/File:Acopaquia.jpg
Radial Pulse image: "Radial pulse". Licensed under Public Domain via Wikimedia Commons -https://commons.wikimedia.org/wiki/File:Radial_pulse.jpg#/media/File:Radial_pulse.jpg
Cyanosis image: "Cynosis" by James Heilman, MD - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Cynosis.JPG#/media/File:Cynosis.JPG
Peripheral Cyanosis image: http://imgbucket.com/pages/c/chronic-bronchitis-blue-bloater/
Lumbar curvature image: From http://www.quora.com/What-kind-of-training-should-I-do-to-become-taller
Conjunctival Pallor image: http://image.frompo.com/4f21b9b2c559bfd71fc1c2f6c49d4c08