Overview
This lecture outlines the systematic approach to the adult respiratory system examination, highlighting essential techniques, normal and abnormal findings, and common respiratory pathologies relevant for OSCEs.
Introduction & Preparation
- Wash hands and wear PPE if appropriate.
- Introduce yourself, confirm patient identity, explain the exam, and obtain consent.
- Position patient at 45°, expose chest and lower legs as needed, and ask about pain.
General Inspection
- Observe for signs: cyanosis, shortness of breath, cough, wheeze, stridor, pallor, oedema, cachexia.
- Note equipment (e.g. oxygen devices, inhalers), mobility aids, vital signs charts, prescriptions.
Examination of the Hands
- Inspect for colour changes, tar staining, skin changes, joint abnormalities.
- Assess for finger clubbing (loss of Schamroth’s window), fine tremor, and asterixis.
- Palpate for temperature, check radial pulse (rate, rhythm), and measure respiratory rate.
- Note pulse and respiratory rate abnormalities.
Jugular Venous Pressure (JVP)
- Position patient at 45°, turn head to left, inspect and measure JVP (normal <3 cm above sternal angle).
- A raised JVP suggests pulmonary hypertension or right-sided heart failure.
Facial Examination
- Inspect for plethoric complexion, conjunctival pallor, ptosis, miosis, enophthalmos (Horner’s syndrome), central cyanosis, and oral candidiasis.
Chest Inspection
- Look for scars: median sternotomy, thoracotomy, pacemaker, radiotherapy changes.
- Note chest wall deformities: asymmetry, pectus excavatum/carinatum, barrel chest.
Trachea & Cricosternal Distance
- Palpate trachea for deviation (indicates tension pneumothorax, effusion, collapse).
- Measure cricosternal distance (normal: 3-4 fingers); short distance indicates hyperinflation.
Chest Palpation & Expansion
- Palpate the apex beat (normal: 5th intercostal space, midclavicular line).
- Assess chest expansion; asymmetry suggests local pathology.
Percussion
- Percuss symmetrical areas of chest; compare sides.
- Note percussion sounds: resonant (normal), dull (consolidation), stony dull (effusion), hyper-resonant (pneumothorax).
Fremitus & Vocal Resonance
- Assess tactile vocal fremitus or vocal resonance (increased = consolidation; decreased = effusion/pneumothorax).
Auscultation
- Auscultate all lung fields for vesicular/brochial sounds and added sounds: wheeze, stridor, crackles.
- Assess and compare vocal resonance between sides.
Lymph Node Examination
- Palpate submental, submandibular, auricular, cervical, and supraclavicular nodes for lymphadenopathy.
Posterior Chest Assessment
- Inspect, assess expansion, percuss, and auscultate posterior chest, with arms folded.
Final Steps
- Examine for sacral/pedal oedema (heart failure), DVT signs in calves, and erythema nodosum.
To Complete the Examination
- Thank the patient and wash hands.
- Summarize findings and suggest further assessments/investigations.
Key Terms & Definitions
- Cyanosis — Bluish discoloration of skin due to low oxygen.
- Finger clubbing — Bulbous swelling of fingertips; loss of Schamroth’s window.
- Asterixis — Flapping tremor due to CO₂ retention.
- JVP — Jugular venous pressure, reflects right atrial pressure.
- Vesicular breath sounds — Normal lung sounds.
- Bronchial breath sounds — Harsh sound, suggests consolidation.
- Crackles — Discontinuous sounds; coarse (pneumonia/oedema), fine (fibrosis).
- Wheeze — Continuous whistling, indicates narrowed airways.
- Stridor — High-pitched inspiratory sound from upper airway obstruction.
Action Items / Next Steps
- Review the respiratory examination checklist PDF or interactive version.
- Practice examination steps, focusing on technique and sequence.
- Study further assessments: oxygen saturation, vital signs, sputum sampling, peak flow, chest X-ray, ABG, and cardiovascular exam.