Clinical skills - respiratory examination

WIPPE

General inspection: LAAPE

What objects can you see?
Oxygen/CPAP/nebuliser masks
Sats probe
Sputum pots
Cigarettes
Inhalers

Is the patient breathless? Cyanotic? In pain? Have any scars? On O2? Using accessory muscles?

Hands
Clubbing (bronchiectasis, cancer, fibrosis)
Cyanosis
Cancer - small muscle wasting (brachial plexus impingement)
Cigarette stains
CO2 retention (asterixis)

Wrists/arm
Pulse (rate, rhythm, bounding (in sepsis/CO2 retention)
Resp rate
BP (general indication of how well someone is)
o Say that you would do it
Tremor (B-agonist use)

Neck
JVP (right heart strain, pulmonary HTN, cor pulmonale) (~4cm)
o Tension pneumothorax + PE can give raised JVP
Tracheal deviation
Cricosternal distance (3 or 4 fingers)
Lymph nodes

Face/mouth
Pale conjunctiva (anaemia)
Horner's syndrome (compression of sympathetic chain)
Peripheral cyanosis/central cyanosis
URTI signs (red, swollen tonsils)

Chest
Inspect (remember to inspect all the way around the chest, sides + back)
Scars (thoracotomy)
Chest shape (barrel, pectus excavatum, pectus carinatum)
Chest expansion (for asymmetry)

Palpate
Expansion
Apex beat (lower mediastinal shift)

Percuss
 Both sides
Resonant (normal), hyper-resonant, dull or stony dull (effusion)

Auscultate - ask patient to take deep breaths through their mouth

Breath sounds - present? Vesicular? Bronchial?
Added sounds: wheeze, crackles, rubs
Vocal resonance - "say 99" - is there asymmetry?
NB: if short of time in ISCEs, you are more likely to hear better breath sounds on the back

Peripheral
Pitting oedema (ankles, sacrum)
Calves - swelling/pain (signs of DVT)

Thank the patient, wash hands, summarise + synthesise

Appropriate investigations: SPOT XS

Sputum
Peak flow
Oxygen sats
Temp

X-ray
Spirometry

Clinical skills - history notes

SOB questioning
o Trigger/reliever
o Chronology
o Any other sounds?
o Any other symptoms? e.g. weight loss, fever, tiredness, cough
Stridor = more common in children
o URT, occurs on inhalation
PMH, FH, DH, SH: risk factors
PMH:
J - jaundice
A - anaemia
M - MI

T - thyroid/TB
H - HTN
R - rheumatological
E - epilepsy
A - asthma/COPD
D - diabetes
S - stroke
Atopy - hypersensitivity to various allergens e.g. (atopic) asthma, hayfever, eczema, allergies
Drugs associated with respiratory symptoms
o ACE inhibitors - cough
o B blockers - breathless?
o Cannabis - pneumothorax