Focused Respiratory Examination

Introduction

• Begin from the end of the bed to see the patient symmetrically.
• Observe the patient’s build: Average, cachectic (TB, cancer, COPD), or obese (OSA, COPD).
• Assess for respiratory distress indicators.

Visual Inspection

Breathing and Respiratory Distress

• Evaluate respiratory rate (>25 is tachypnea).
• Look for nasal flaring, pursed lip breathing, accessory muscle use, intercostal/subcostal recession, and tripod posture.

Adjuncts

• Look for oxygen supply, nebulizers, and IV lines.

Voice and Sounds

• Assess for stridor, wheezing, and hoarseness.
• Observe symmetric chest movement and any precordial deformities.

Examination of Hands

Tremors and Signs

• Fine tremor: Possible use of beta-2 agonists.
• Asterixis: Severe COPD, CO2 retention.

Muscle Wasting and Clubbing

• Check for muscle wasting (pancreas tumors) and clubbing (lung abscess, bronchogenic carcinoma, bronchiectasis).

Physical Signs

• Warm, clammy hands: CO2 retention.
• Absence of peripheral cyanosis.

Examination of Face

Signs of Medication and Conditions

• Cushingoid appearance (steroid use).
• Plethora (CO2 retention, SVC obstruction).
• Connective tissue disease signs (Lupus, Sarcoidosis).

Eyes and Mouth

• Look for conjunctival pallor (anemia, chronic illness).
• Horner's syndrome signs (ptosis, miosis, anhidrosis).

Neck Examination

• Lymph node examination from the back.
• Check for tracheal deviation and tracheal tug.
• Assess JVP for cor pulmonale.

Edema Check

• Check for ankle edema, typically around the medial malleolus.

Chest Inspection

Symmetry and Movement

• Symmetric vs. asymmetric chest rise.
• Consider differential diagnoses (fibrosis, pleural effusion, COPD, ILD).

Scars and Deformities

• Check for surgical scars (ICD, sternotomy, thoracotomy).
• Observe for precordial deformities (Marfan’s syndrome, pectus excavatum).
• Barrel chest in COPD and asthma.

Palpation

Chest and Trachea

• Check for costochondritis.
• Assess chest rise symmetry.

Tactile Fremitus

• Ask patient to say "99" while palpating.
• Increased fremitus suggests consolidation; decreased suggests pleural effusion.

Percussion

• Start supraclavicularly and move across the chest.
• Resonant: Normal
• Hyperresonant: Emphysema, pneumothorax
• Dull: Pleural effusion, consolidation

Auscultation

• Use bell for supraclavicular area, diaphragm for other areas.
• Listen for vesicular breath sounds and any added sounds (wheezes, crackles).
• Compare with bronchial breath sounds over the trachea.

Conclusion

• A thorough respiratory examination involves systematic observation, palpation, percussion, and auscultation.
• Important in identifying respiratory pathologies and guiding further investigation or management.