Position/Lighting/Draping
Position
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Patient should sit upright on the examination table.
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The patient’s hands should remain at their sides.
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When the back is examined, the patient is usually asked to move their arms forward(hug themselves)
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Lighting
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Adjusted so that it is ideal.
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The chest should be fully exposed. Exposure time should be minimized.
Clinical examination
- General Appearance
- General Examination
- Chest Examination
General Appearance
General Inspection:
- Evidence of respiratory distress at rest or when walking - eg, obvious breathlessness, talking in short phrases rather than full sentences, use of accessory muscles, exhalation with pursed lips. - Evidence of other respiratory symptoms - eg, cough, audible wheeze. - Note whether the patient appears to be pyrexial (check their temperature). - Note whether there are any indicators of recent weight loss - eg, sunken cheeks.
Hands:
- Finger clubbing. - Cyanosis. - Tobacco staining. - Radial pulse: tachycardia suggests significant respiratory difficulty or marked overuse of a beta agonist.
- Lung cancer can cause atrial fibrillation.
- A large pneumothorax or a tension pneumothorax can cause pulsus paradoxus. - A tremor may indicate carbon dioxide retention.
- Weakness of hand’s small muscles.
Wrist:
- Pulse: rate & character
- Flapping tremors (asterixis)
Neck:
- JVP: increase in corpulmonale & SVC obstruction. eg, cor pulmonale.
- LN: enlargement in CA bronchus or metastasis; Lymphadenopathy
- Goitre (any possible tracheal obstruction). - Evidence of superior vena cava obstruction (may be caused by lung cancer).
Face:
- General appearance - eg, Cushingoid as a result of long-term use of steroids. - Tongue: central cyanosis - Anaemia (conjunctivae). - Eye: Horner’s syndrome (possible apical lung cancer). in CA bronchus
- SVC obstruction: plethoric & cyanosed, injected
eyes.
Respiratory distress
- Can not complete sentence
- RR (14-20) per min (Tachypnea)
- Use of accessory muscles, paradox movement and intercostal drawing
- Cyanosis
- Lip breathing
Chest Inspection
1- Tracheal.
2- Chest wall deformities:
- Kyphosis - curvature of the spine - anterior-posterior
- Scoliosis - curvature of the spine - lateral
- Barrel chest - chest wall increased anterior-posterior diameter (normal in children) typical of hyperinflation
- Pectus excavatum
- Pectus carinatum
Overinflated (may indicate chronic obstructive pulmonary disease
(COPD)or severe acute asthma).
Asymmetry (the abnormality is on the side that moves less - eg,
pneumothorax, collapse, consolidation or effusion).
Other abnormalities include pigeon chest (pectus carinatum), funnel chest (pectus excavatum). Kyphosis and/ or scoliosis.
Abdomen and lower limbs: - Hepatomegaly may indicate right heart failure. - Swollen calf (possible deep vein thrombosis). - Peripheral oedema may be noted (lower legs if ambulant or sacral if bed-bound).
Respiration Inspection
Respiratory rate (normal for an adult is about in between 12-18 with an average14/minute). - Note any indication of respiratory distress.
Nature of breathing, including:
- Kussmaul’s breathing: deep and laboured breathing, often associated with severe metabolic acidosis.
- Cheyne-Stokes’ breathing: progressively deeper breathing followed by temporary apnoea, which may occur with heart failure, cerebrovascular disease, head injury, carbon monoxide poisoning or brain tumours, or be a normal variant during sleep or at high altitude.
- Respiratory movement
- Abdominal breathing: male adult and child
- Thoracic breathing: female adult.
- Symmetry: posteriorly and anteriorly looking for decrease or delayed chest movement during moderate respiration
- Respiratory rate: 16-18 b/min
- Tachypnea: >20 b/min
- Bradypnea: <12 b/min
- Shallow and fast
- respiratory muscular paralysis, elevated intraabdominal pressure, pneumonia, pleurisy
- Deep and fast
- Agitation, intension
- Deep and slow
- Severe metabolic acidosis (Kussmaul’s breathing)
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Respiratory rhythm Cheyne-Stokes’ breathing
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Inhibited breathing
- Sudden cessation of breathing due to chest pain
- Pleurisy, thoracic trauma
- Sighing breathing
- Depression, intension
- Scars:
- From previous operation or chest drains or cautery marks or radiotherapy markings.
- Paradoxical chest movement may indicate a fractured rib
- Prominent veins:
- in case of SVC obstruction