Respiratory Examination

Positioning

• 45 degrees (if sick)/sitting upright
• Ensure adequate exposure

Inspection

Surface anatomy (identify at landmarks)

• nasal passages and sinuses
• trachea
• major bronchi
• diaphragm
• lobes of both lungs

General appearance (actually done the moment patient enters room!!!)

• Build and posture (for cachexia)
• Observe for puffers
• Observe for stridor (harsh vibrating noise when breathing, caused by larynx obstruction)
• Listen for hoarseness
• Observe for dyspnea, cyanosis (peripheral and central), debility (weakness due to illness)

Inspection of hands

• Clubbing, peripheral cyanosis (finger nail beds)
• Nicotine/tar staining (sides and tips of fingers)
• Wasting and weakness (finger abduction and adduction)
• Wrist tenderness (hypertrophic pulmonary osteoarthropathy)
• Radial pulse (rate and rhythm)
• Flapping tremor (CO2 retention)

Inspection of face

• Plethora (excess of bodily fluid, particularly blood)
• Eyes (pallor, jaundice)
• Pupils ( constricted pupil, ptosis)
• Ear, nose (polyps, engorged turbinates, deviated septum) and sinuses (frontal and maxillary)

Inspection of mouth

• Lips, tongue - central cyanosis
• Throat
• Teeth

Inspection of neck

• Lymph nodes (cervical, supraclavicular, axillary)
• Trachea

Inspection of chest (anterior, lateral then posterior)

• Abnormal shape (barrel, pigeon, funnel)
• Scars (thoracotomy)
• Skin changes (radiotherapy scars)
• Asymmetrical chest wall movement (anteriorly and posteriorly)
• Use of accessory muscles and indrawing of intercostal muscles

Palpation

• Trachea (should be in midline of neck anteriorly, felt with thumb and forefinger)
• Cervical and supraclavicular nodes
• Apex beat
• Chest expansion (tape measure)
• Vocal fremitus* (test for chest resonance)

* not done by many physicians as vocal resonance (below) is better

Percussion

• Clavicles (examine lung apices)
• Front of chest (move percussed finger down 6-8 cm at a time)
• Identify upper border of liver, area of cardiac dullness
• Back of chest (move scapula out of the way)
• Lateral chest wall

Auscultation

• All areas (with diaphragm, except clavicle with bell)
• Pemberton's sign (development of facial flushing, distented neck and head superficial veins, inspiratory stridor and elevation of JVP upon raising patient's both hands simultaneously above head as high as possible

Consider following 4 aspects

• Quality of breath sounds
• Intensity of breath sounds
• Added or abnormal breath sounds
• Vocal resonance