An example of a perfect respiratory examination for OSCE/ISCEs for medical students, or in clinical practice for junior doctors. Step-by-step guide covering an examination from hands-neck-face-chest, including signs, symptoms and their relevance in forming a clinical differential diagnosis. Covers ...
Examination
May present with:
Haemoptysis = coughing up blood, coryza = bunged up/runny nose Face/mouth/eyes
W.I.P.E.E - Pallor – anaemia in conjunctiva
- 45 degrees lying down - Central cyanosis – under tongue
- Exposure = waist up, ideally no bra - Droopy eyelid/constricted pupil = Horner’s
syndrome, compression of sympathetic chain
- URTI signs = tonsil enlargement/exudate
General inspection: (upper respiratory tract infection)
- Oxygen/CPAP/nebuliser masks
- Saturations probe
Chest inspection
- Sputum pot
- Cigarettes - Closer inspection for scars, under bra band/strap
- Inhalers - Chest shape – barrel, pectus excavatum, carinatum
- IV breathing aids
- Walking aid?
Palpation
- Breathless? Sat forward to help breathe?
- Respiratory rate? - Feel for apex beat
- Cyanotic? - Chest expansion – front + back – symmetrical?
- In pain? - Feel for right ventricular heave
- Any scars?
- Using accessory muscles to breathe?
- Bruises – from steroids Percussion
- Snake across front, starting at clavicle and going
under armpits – comparing sides
Hands o Do the same on the back
- Clubbing – bronchiectasis (CF), pulmonary fibrosis, - Dullness = consolidation, collapse, effusion
cancer. Also sarcoidosis/TB
- Peripheral cyanosis Auscultation – front and back too
- Small muscle wasting – cancer; brachial plexus
impingement - Ask patient to breathe in and out of mouth
- Cigarette/tar staining - Same snake pattern as percussion
- CO2 retention flap – asterixis Listen for breath sounds; vesicular, bronchial?
o Added sounds? Crackles, wheezes, rubs?
- Vocal resonance, ask patient to say ‘99’
Wrists/arm o Follow same pattern
- Pulse – rate, rhythm, bounding? – sepsis, CO2 retention
- Respiratory rate Peripheral examination
- Blood pressure
- Tremor – beta-agonist use; salbutamol (hold hands - Pitting oedema – press top of shin for 5 seconds
out in front) - Calves swelling/pain/red = signs of DVT
Further investigations:
Neck
- Sputum
- JVP – patient at 45degrees, look to left, relax! - Peak flow
o Normal <4cm above sternal angle - Oxygen saturations
o Hepatojugular pressure reflex? - Temperature
sign of right heart strain, pulmonary hypertension, cor pulmonale - X-ray
- Spirometry
- Tracheal deviation?
Remember SPOT XS
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