Respiratory Clinical Examination Dr Mazen Qusaibaty MD DIS

Respiratory Clinical Examination Dr Mazen Qusaibaty MD, DIS / Head Pulmonary and Internist Department Ibnalnafisse Hospital Ministry of Syrian health – Email: Qusaibaty@gmail. com 1

• Dr Mazen Qusaibaty • pulmedsyr • Syrian Thoracic Group • 0944320024 • Qusaibaty@gmail. com 2

4 The respiratory examination should include the following • Examination of the chest – repeated on the anterior and then the posterior chest wall. ¶Inspection ¶Palpation ¶Percussion ¶Auscultation

Preparation

Wash your hands 6

7 • Introduce yourself and clarify the patient’s identity • Explain what you would like to do • Gain the patient’s consent

8 • Equipment ¶Stethoscope ¶Peak Flow meter

9 Patient position

10 • The patient should be sitting up and exposed from the waist up at 45 degrees

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General Observations 12

13 General Observations • Look at the patient from the end of the bed 1. Hands 2. Face 3. Neck

Observe the patient from the end of the bed 14

15 • Check whether they are comfortable at rest / pain • Do they look tachypnoeic • Are they using accessory muscles • Are there any obvious abnormalities of the chest

16 • Audible breathing ¶Wheezing ¶Stridor

17 Also check for any Items around the bed such as: o Inhalers o Oxygen masks o Chest tube o Sputum pot o Cigarettes

Inspect the patient's hands 18

19 Patient's Hands • Hot, pink peripheries ¶A sign of carbon dioxide retention

Patient's Hands 20 Clubbing

Clubbing 21

Patient's Hands 22 Nicotine staining

Patient's Hands 23

24 Patient's Hands • A coarse flap may be a sign of carbon dioxide retention

Patient's Hands Take the radial pulse 25

26 Patient's Hands • A bounding pulse may indicate carbon dioxide retention

27 General Observations • Look at the patient from the end of the bed 1. Hands 2. Face

28 • Gently pull down lower eyelids and ask patient to look up • Inspect for pale conjunctiva of anaemia

Inspect the mouth and tongue 29

30 • Ask the patient to stick out their tongue and note its colour checking for anaemia or central cyanosis

31 • Remember to ask them to raise their tongue up and check underneath

32 General Observations • Look at the patient from the end of the bed 1. Hands 2. Face 3. Neck

Palpate for the left supraclavicular node 33

34 • Look for any use of accessory muscles such as the sternocleidomastoid muscle

35 • Also palpate for the left supraclavicular node ¶(Virchow’s Node)

Palpate the submental lymph nodes 36

Palpate the submandibular lymph nodes 37

Palpate the occipital lymph nodes 38

Palpate the pre-auricular lymph nodes 39

Palpate the post-auricular lymph nodes 40

Palpate the cervical lymph nodes 41

The Chest 42

The Chest • The chest wall must be examined completely (inspection, palpation, percussion, auscultation ) • First the whole of the front and then the whole of the back. • Examine from side to side and not top to bottom so that you can make comparisons.

44 Inspection - Anterior

With the chest exposed look carefully for • Chest wall abnormalities ¶Barrel Chest ¶Pectus Carinatum ¶Pectus Excavatum ¶Harrison’s Sulci ¶Kyphosis And Scoliosis

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47 Pectus Excavatum

48 Pectus Carinatum

49 Scoliosis Rib Cage Deformity

50 Scoliosis Rib Cage Deformity

51 Harrison’s Sulci

With the chest exposed look carefully for • Breathing pattern and asymmetry of movement

53 Palpation –Anterior

Palpate the trachea 54

Assess chest expansion 55

Percussion 56

Percuss the lung fields 57

Auscultation 58

Auscultate left lung 59

Auscultate right lung 60

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Characteristics of Breath Sounds

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Adventitious Lung Sounds

71 Adventitious Lung Sounds • Discontinuous Sounds ¶Crackles • Continuous Sounds ¶Wheezes ¶Rhonchi

Discontinuous Sounds Crackles Fine crackles Intensity Soft Pitch High Duration Very brief (5– 10 msec) 72

Discontinuous Sounds Crackles Fine crackles Coarse crackles Intensity Soft Some what louder Pitch High Lower Duration Very brief (5– 10 msec) Not quite so brief (20– 30 msec) 73

Continuous Sounds Rales Wheezes Pitch Quality Relatively high Have a hissing (around 400 or shrill quality Hz or higher) 74

Continuous Sounds Rales Wheezes Rhonchi Pitch Relatively high (around 400 Hz or higher) Relatively low Quality Have a hissing or shrill quality Have a snoring (around 200 Hz quality or lower) 75

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