Matthew Yuyun (MD, MRCP, MRCGP, PhD)
Clinical Examination Workshops
Respiratory System
Introduction
Respiratory examination like most examinations is done with eyes, ears, hands and
the intellect (you can only see, feel or hear what you know).
Greet patient, introduce yourself and tell he/she what you want to do i.e. examine
him/her with more attention being paid to the chest.
Position patient: Head of bed at 45° to the rest of the bed
Always do a quick visual survey: Is patient in respiratory distress? (Tachypnoea,
nasal flaring, tracheal tug, use of accessory muscles of respiration, intercostals
recessions, unable to complete sentences). You cannot spend time trying to
examine a patient methodically when asphyxia is setting in. You might want to
initiate a crash call instead.
Temperature measurement
- Electronic (Digital) thermometer (oral cavity or axilla)
- Chemical dot thermometer (oral cavity or axilla)
- Infra-red tympanic thermometer (ear)
- LCD thermometers (forehead)
- Mercury thermometer (axilla, oral cavity or anus), now largely inexistent in
developed world
Fever: Temperature of ≥ 37.5 °C (≥ 99.5 °F).
Respiratory causes of fever: Infections (URTI, LRTI (pneumonia, bronchitis, TB);
connective tissue diseases; vasculitis; malignant neoplasms; drugs
Respiratory rate
Count number of inspirations for 30 seconds and multiply by 2.
Normal RR 12-18 in adults and children > 12 years old. In children 5g/dl of
deoxyhaemoglobin or SPO2 180°, increased curvature of the
nail bed, increased sponginess or fluctuation of the nail bed, thickening can
sometimes lead to fingers having drumstick appearance. Schamroth's sign (if you put
the finger nails of the same but opposing fingers against each other, you will see a
gap at their base. This gap may be lost when the angle is lost in finger clubbing.
Causes of clubbing include:
- Lung disease:
o Lung malignancy, mainly large-cell, usually not small cell
o Fibrosing alveolitis
o Suppurative lung disease: lung abscess, empyema, bronchiectasis,
cystic fibrosis
o Pulmonary hypertension
o Mesothelioma
Clubbing is not associated with COPD. Indeed, the presence of clubbing in a patient
with COPD should prompt a search for an underlying lung carcinoma.
- Heart disease:
o Cyanotic congenital heart disease
o Endocarditis
o Atrial myxoma
- Gastrointestinal and hepatobiliary:
o Malabsorption
o Crohn's disease and ulcerative colitis
o Cirrhosis
o GI lymphoma
- Others:
o Hyperthyroidism (thyroid acropachy)
o Axillary artery aneurysm (in unilateral clubbing)
- Wasting of intrinsic muscle of hand (Pancoast’s tumour impinging on
brachial plexus)
- Radial pulse (rate, volume, rhythym, character): Palpate for 15 seconds and
multiply by 4. Bounding in CO2 retention in COPD; tachycardia in severe
asthma, PE, COPD, pneumonia, decompensating lung fibrosis &
bronchiectasis; Bardycardia in life threatening asthma; AF in any severe lung
disease; pulsus paradoxus (drop in systolic blood pressure by more than
10mmHg during inspiration) seen in severe asthma, constrictive pericarditis
and pericardial effusion.
2) Head
Mouth
- Central cyanosis: Blue coloration of the skin and mucous membranes of lips
and tongue and buccal mucosa. Ask the patient to stick their tongue outwards
and upward towards their nose. Causes include:
o Lung disease: Asthma, COPD, pneumonia, PE, pulmonary oedema,
pulmonary hypertension, bronchiectasis, fibrosing alveolitis, ARDS,
acute large airway obstruction (e.g. foreign body or croup or
epiglottitis).
o Heart Disease: Cyanotic congenital heart disease (PDA, transposition
of great vessels, ASD, VSD, Tetralogy of Fallot, Eisenmenger
syndrome); congestive cardiac failure; cor pulmonale
o Polycythaemia
o Methaemoglobinaemia
o Sulphaemoglobinaemia
- Pursed lip breathing seen during expiration in COPD
Eyes
- Anaemia: Conjunctival pallor
- Horner’s Syndrome: Miosis, ptosis, enopthalmos, anhydrosis (Pancoast ‘s
tumour)
Nose
- Flaring of nasal alae: Enlargement of the opening of the nostrils during
breathing. Observed in:
o Asthma (acute)
o COPD
o Bronchiolitis
o Croup
o Epiglottitis
o Foreign body
3) Neck
- JVP: Patient at 45°, turn head slightly to the left, observe the right internal
jugular vein which can be found between the clavicular and sternal head of
the stenocloidomastoid muscle, by shinning touch light tangentially. Measure
the height and the waveform (a-atrial systole, c-closure of tricuspid valve, x
descent-ventricular systole, v- atrial filling against closed tricuspid, y descent-
opening of tricuspid valve). JVP is normally 80% predicted
is considered normal.
- PEFR variability: Use serial PEFRs to diagnosed asthma by checking for
diurnal variability. Take readings for a few days in the mornings and evenings
at approximating the same times.
Variability = [average amplitude of PEFR in serial measurements/ mean PEFR] x
100
≥ 20 % variability is significant and diagnostic of asthma.
- PEFR reversibility: Measure PEFR (PEFR1) - always best of three
measures. Then give salbutamol via spacer device or nebulizer. Re-measure
PEFR 15-20 minutes after this (PEFR2).
Reversibility = [PEFR2 – PEFR1/ PEFR1] x 100
≥ 15 % reversibility is significant and diagnostic of reversible airway obstruction
(asthma). This distinguishes asthma from COPD in which there negligible
reversibility. Reversibility can also be demonstrated during spirometry when FEV1 in
measured before and after beta-agonist administration. Other measures of
reversibility can be done after a six-week course of inhaled steroids (200mc g of
beclometasone or equivalent) or after two weeks of 30mg prednisolone in an adult.
Spirometry:
Measure functional lung volumes using a device called a spirometer. These are
FEV1 (forced expiratory volume in one second), FVC (tidal volume + inspiratory
reserve + expiratory reserve), RV (residual volume), and TLC (FVC + RV).
Obstructive defect: FEV1 < 80% predicted and FEV1/FVC ratio <70% (asthma or
COPD).
Restrictive defect: Decreased lung volumes with FEV1/FVC normal or increased
(lung fibrosis, kyphoscoliosis, neuromuscular disease)
Combined obstructive / restrictive defect: e.g. asthma and lung fibrosis.
Spirometry and PEFR measurement can only be done by children more than five
years old.
Distinction between heart failure and respiratory failure
Bibliography
1. Learning to Consult. Radcliffe Medical Press, Oxford. 2006. Chapter 4:
Physical Examination
2. Respiratory examination by Peter Tuteurin inClinical Methods: The History,
Physical and Laboratory Examinations by H.Kenneth Walker, W.Dallas Hall,
and J.Willis Hurst (30 April 1990). Butterworths
3. British Thoracic Society
4. NICE 2007: Feverish illness in young children
5. British Snoring & Sleep Apnoea Association
6. Oxford Hand book of Clinical Medicine (Longmore et el)
7. Oxford textbook of medicine
8. Harrison’s Principles of Internal Medicine
9. An Aid to the MRCP PACES, volume 1 (Ryder et al)
10. Clinical examination of the patient (Lumley & Bouloux)