Respiratory Examination.

1. A respiratory examination is similar to all large system examinations in that you don’t jump in and start listening to the lungs straight away. The examination will include the hands, face, neck and then finally the chest. You should explain this to the patient prior to starting your examination. Stick to the familiar: Look, Feel, Listen.

2. Firstly, you should have a general look at the patient. You should be checking whether they are comfortable at rest, do they look tachypnoeic, are they using accessory muscles, are there any obvious abnormalities of the chest. Also you should check for any clues around the bed such as inhalers, oxygen masks or cigarettes.

3. Next you should move to the hands. Hot, pink peripheries may be a sign of carbon dioxide retention. Look for any signs of clubbing or nicotine staining. Also you should ask the patient to extend their arms and cock their wrists to 90º. Observe the hands in this position for 30 seconds, a coarse flap may also be a sign of carbon dioxide retention.

4. Whilst at the wrist you should also take the patient’s pulse. A bounding pulse may indicate carbon dioxide retention. After you have taken the pulse it is advisable to keep your hands in the same position and subtly count the patient’s respiration rate. This helps to keep it as natural as possible.

5. You should now move up to the face. Ask the patient to stick out their tongue and note its colour – checking for cyanosis. Also ask them to raise their tongue up and check there as well.

6. Look for any use of accessory muscles such as the sternocleidomastoid muscle. Also palpate for the left supraclavicular node (Virchow's Node) as an enlarged node (Troisier's Sign) may suggest metastatic lung cancer.

7. The examination now moves onto the chest. Take time to observe the chest looking for any abnormalities such as changes in rib cage shape, or scars – remember these may be in the axillae or on the back.

8. Now palpate the chest. Firstly feel between the heads of the two clavicles for the trachea. If it is deviated, it may suggest a tumour or pneumothorax.

9. Now feel for chest expansion. Place your hands firmly on the chest wall with your thumbs meeting in the midline. Ask the patient to take a deep breath in and note the distance your thumbs move apart. Normally this should be at least 5 centimetres. You should measure this at the top and bottom of the lungs as well as on the back.

10. Percussion should be performed on both sides, comparing similar areas on both sides. You should start by tapping on the clavicle which gives an indication of the resonance in the apex. Then percuss normally for the entire lung fields. Hyper-resonance may suggest a collapsed lung where as hypo-resonance or dullness suggests consolidation such as in infection or a tumour. Be sure to perform this on the back as well.

11. At this point you should check for tactile vocal fremitus. Place the medial edge of your hand on the chest and ask the patient to say ‘99’. Do this with your hand in the upper, middle and lower areas of both lungs. This again gives a suggestion of the constitution of the tissue deep to your hand.

12. Finally, you should auscultate. Do this in all areas of both lungs and on front and back comparing the sides to each other. Listen for any reduced breathe sounds, or added sounds such as crackles, wheezes or rhonchi.

13. Whilst using the stethoscope, ask the patient to again say ‘99’ whilst listening in all areas – this is a more reliable test than the one described earlier.

14. Finish by examining the lymph nodes in the head and neck. Start under the chin with the submental nodes, move along to the submandibular then to the back of the head at the occipital nodes. Next palpate the pre and post auricular nodes. Move down the cervical chain and onto the supraclavicular nodes.

15. Thank the patient.