Focused Respiratory Exam Notes

Introduction

• Performing a respiratory exam involves:
  • Observation: Look for symmetry and overall condition of the patient.
  • Palpation: Touching to assess for abnormalities.
  • Commands: Asking the patient to perform certain actions.

Initial Observations

• Patient Overview:
  • Examine the patient from the inside of the bed for symmetry.
  • Assess patient's build: normal weight, cachectic, or obese.
    • Cachexia: May indicate TB, malignancy, emphysema.
    • Obesity: Could suggest obstructive sleep apnea, COPD.
• Breathing Assessment:
  • Check for tachypnea (RR>25) suggesting respiratory distress.
  • Look for nasal flaring, pursed lips (COPD), tracheal tug, use of accessory muscles.

Signs of Respiratory Distress

• Patient may exhibit tripod posture (COPD).
• Observe for adjuncts like oxygen use, inhalers, or IV lines.

Voice and Chest Movement

• Listen for stridor, wheezing, or hoarse voice.
• Check symmetric chest rise and for any precordial deformities.

Hands Examination

• Fine Tremor: Indication of beta-2 agonist use.
• Asterexis: Indicates CO2 retention (severe COPD).
• Muscle Wasting: Suggests Pancoast tumors.
• Clubbing: Indicative of chronic lung conditions (e.g., lung abscess, bronchiectasis).
• Peripheral Cyanosis: Check for warm, clammy hands (CO2 retention).

Pulse and Face Examination

• Pulse: Tachycardia can occur in severe asthma.
• Cushingoid Features: Chronic steroid use.
• Plethora: CO2 retention or SVC obstruction.
• Connective Tissue Disease: Look for manifestations in the face.
• Conjunctival Pallor: Could suggest chronic illness (malignancy, TB).
• Horner's Syndrome: Meiosis, ptosis, anhidrosis (apical tumor).

Mouth and Neck Examination

• Check oral hygiene for signs predisposing to pneumonia.
• Lymph Nodes: Palpate submental, submandibular, cervical chains, supraclavicular.
• Tracheal Deviation: Assess for deviation, tracheal tug.

Additional Neck Checks

• Suprasternal to Cricoid Distance: Indicates hyperinflation if <3 fingers.
• Jugular Venous Pressure (JVP): Core pulmonale indicator.
• Edema: Check around the medial malleolus.

Chest Inspection and Palpation

• Chest Symmetry: Look for asymmetric rise.
• Scars: Indicate previous surgeries (CABG, pneumonectomy).
• Deformities: Barrel chest (COPD), pectus excavatum/carinatum.
• Radiation Tattoos: May indicate past malignancy treatment.
• Kyphoscoliosis: Check back for deformities.

Palpation Details

• Costal Chondritis: Palpate for pain along costal margins.
• Chest Rise Measurement: Should be 5 cm on inhalation.
• Tactile Fremitus: Useful to differentiate consolidation from pleural effusion.

Percussion Technique

• Supra Clavicular Area: Start percussion.
• Resonance: Normal chest should be resonant.
  • Hyper-resonance: Emphysema, bronchitis, pneumothorax.
  • Dullness: Pleural effusion, consolidation.
• Percuss Entire Chest: Note any deviations from expected resonance.

Auscultation

• Technique: Use diaphragm for chest, bell for supraclavicular.
• Breath Sounds: Vesicular is normal, check for wheezing, stridor.
• Bronchial Breath Sounds: Indicate consolidation if heard in chest.
• Crackles: Indicate fluid or fibrosis.

Conclusion

• Comprehensive respiratory exam includes detailed observation, palpation, percussion, and auscultation.
• Aim to identify any abnormalities that might indicate underlying respiratory conditions.