Respiratory
Examination
3rd years early bird
Clinical Teaching Fellows 
Dr G. Aidoo-Micah
Learning outcomes
• Describe an initial approach to all patients
• Identify the relevant components in a
respiratory examination
• Know how to demonstrate a fluent and
professional respiratory examination
• Recognise abnormal signs, in the hands, face
neck and chest.
Respiratory Examination
• Things to think about before you start
• SOB/distress…
• Exposure/dignity…
Things to do before you start…
1) Wash hands
2) Introduce yourself and ask patient’s name
3) Permission/Pain - explain exam and gain
consent
4) Expose patient
5) Re-position to 45⁰
“WIPER”
Inspection – “end-of-the-bedogram”
•
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1. Patient:
What can you see/hear/smell?
General appearance
Chest deformities and operative scars.
Respiratory rate, regularity and depth.
Asymmetry of chest expansion.
Use of accessory muscles and positioning.
• 2. Around bed:
- Oxygen, drugs chart, inhalers, nebs, peak flow meters,
IV lines, chest drains (and contents), sputum pots (mmm).
Systematic 3. HANDS
•
-
Inspect for:
Colour - ?peripheral cyanosis
Tremor
Tar staining
Clubbing
Asterixis
Thenar wasting
•
-
Feel for:
Capillary refill - ?how many seconds
Radial pulse – rate, rhythm, character (sneakily check RR)
Temperature
Ask for BP
Take the hands of the person next to
you…
Respiratory causes of clubbing
4. Face/neck
a) Face:
-Plethora
-Moon face
-Anhidrosis
b) Eyes:
-Partial ptosis
-Miosis
-Conjunctival pallor
c) Mouth:
-Central cyanosis – underside of
tongue
-Pursed lip breathing
-Tar staining of teeth
d) Neck:
-JVP
-Trachea
-LN’s
-Tracheostomy scar
5. Chest – anterior then posterior (IPPA)
• Inspection (for any system)
– DWARFS
• Deformity, Wasting, Asymmetry, Redness,
Fasciculations, Scars.
• Palpation
- Apex beat
- Chest expansion
- Tactile vocal fremitus
Chest percussion
• Percussion
-
Start at apex of one lung, compare each side. Clavicles.
Resonant = normal
Dull = consolidation, collapse, pleural thickening
Stony dull = pleural effusion
Hyper-resonant = pneumothrax
• Tips
Don’t forget over clavicles and axillae!
Practise, practise, practise – on selves, doors, each other!
Trim nails!!
• Auscultation
• Ask patient to take slow, deep breaths through
mouth.
• Breath sounds:
- Normal = vesicular
- Diminished = obesity, effusion, pneumothorax, COPD
• Added sounds = crackles wheeze (expiratory, high pitched – e.g.
asthma), stridor (airway obstruction).
• (Vocal resonance: “ninety-nine”)
• DON’T FORGET TO EXAMINE THE BACK (IPPA)
6. Completion
• (Legs): If time
- Inspect for erythema and swelling
- Palpate for tenderness and pitting oedema
a) Unilateral red, swollen, tender calf – think DVT
b) Bilateral pitting oedema - ? R-sided heart failure
• To patient:
- Thank, cover, comfort. Wash hands!!
•
-
To examiner: To complete my examination I would like to…
Take a full history
Ask for O2 sats (obs chart), sputum sample, PEFR, CXR.
Relevant bloods and ABG
Summarise findings and differential diagnosis.
Watch the experts in action…
http://geekymedics.com/respiratory-examination-2/
Respiratory exam mark sheet
Task
Introduce self, task and exposure
Consent
Ask about pain
Inspection
End of the bed – makes obvious they look!
Notes nebs, inhalers, oxygen, sputum pots
Inspect Hands for … tar staining, clubbing, cyanosis, muscle
wasting
Check for tremor (salbutamol or CO2 retention)
Check radial pulse – comment on rate rhythm and character
Face – plethora, moon face
Eyes – inspect for pallor, signs of Horners
Mouth – inspect for central cyanosis under tongue
Neck – raised JVP, use of SCM? Check trachea is central. LNs.
Chest – use of accessory muscles, shape deformities, scars,
drains, bandages
Count RR
Look for pursed lip breathing
Palpation
*Check trachea central if not done already.
Apex beat if trachea is deviated
Expansion – anterior and posterior
Vocal fremitus (unless doing vocal resonance)- 1 will do!
Percussion
Anterior, posterior and axillae
Auscultation
Anterior, posterior and axillae
Vocal resonance anterior, posterior and axillae
To conclude – ask for 02 sats/obs and CXR/PEFR if appropriate
Thank the patient and cover them up
Adequate?
Y
N
Comments
Practise, practise, practise
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On patients
Colleagues
Unsuspecting friends and family
Teddy bears
Doors
Practice makes perfect! 
Any questions?
• Thank you!
• Have a go…
• Good luck!
Special thanks to Dr Emma Figures (CTF 2015)