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Respiratory Examination

This is essentially an examination of the patient’s lungs; however it is a complex examination which
also includes examination of other parts of the body including the hands, face and neck.

The respiratory examination aims to pick up on any respiratory (breathing) pathology that may be
causing a patient’s symptoms e.g. shortness of breath, cough, wheeze etc. Common conditions
include chest infections, asthma and chronic obstructive pulmonary disease (COPD). This
examination is performed on every patient that is admitted to hospital and regularly in clinics and
general practice.

Like most major examination stations this follows the usual procedure of inspect, palpate, percuss,
auscultate (look, feel, tap, listen). It is an essential skill to master and is often examined in OSCEs.

Subject steps
1. Begin by washing your hands, introduce yourself and clarify the patient’s identity. Explain
what you would like to do and gain the patient’s consent.

Offer a chaperone for this examination

 Wash your hands

2. The patient should be sitting up and exposed from the waist up. Make a general
observation of the patient. Check whether they are comfortable at rest, do they
look tachypnoeic, are they using accessory muscles, are there any obvious abnormalities
of the chest. Also check for any clues around the bed such as inhalers, oxygen masks, or
cigarettes.
 Observe the patient from the end of the bed

3. Move to the hands. Hot, pink peripheries may be a sign of carbon dioxide retention. Look
for any signs of clubbing or nicotine staining. Ask the patient to extend their arms and
cock their wrists to 90 degrees. Observe the hands in this position for 30 seconds; a
coarse flap may also be a sign of carbon dioxide retention.

 Inspect the patient's hands

 Look for CO2 flap

4. At the wrist you should 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.

 Take the radial pulse


5. Move up to the face. Ask the patient to stick out their tongue and note its colour checking
for anaemia or central cyanosis. Remember to ask them to raise their tongue up and
check underneath.

 Inspect the mouth and tongue

6. Look for any use of accessory muscles such as the sternocleidomastoid muscle. Also
palpate for the left supraclavicular node (Virchow’s Node). This drains the thoracic duct
so an enlarged node (Troisier’s Sign) may suggest metastatic cancer e.g. lung or
abdominal.

 Palpate for the left supraclavicular node

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.

 Palpate the trachea

9. 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.

 Assess chest expansion

10. Perform percussion 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, effusion or a tumour. Be sure to perform this on the back as well.

 Percuss the lung fields

11. 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.

 Check for tactile vocal fremitus

12. Finally, 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, wheeze, pleural rub or rhonchi.
 Auscultate left lung

 Auscultate right lung

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.

 Palpate the submental lymph nodes

 Palpate the submandibular lymph nodes


 Palpate the occipital lymph nodes

 Palpate the pre-auricular lymph nodes

 Palpate the post-auricular lymph nodes

 Palpate the cervical lymph nodes

15. Thank your patient and allow them to dress. Wash your hands and report your findings to
your examiner.

- See more at: http://www.osceskills.com/e-learning/subjects/respiratory-


examination/#sthash.UMSIJYwd.dpuf

Inspection/Observation: A great deal of information can be gathered from simply


watching a patient breathe. Pay particular attention to:
1. General comfort and breathing pattern of the patient. Do they appear distressed,
diaphoretic, labored? Are the breaths regular and deep?
2. Use of accessory muscles of breathing (e.g. scalenes, sternocleidomastoids).
Their use signifies some element of respiratory difficulty.
3. Color of the patient, in particular around the lips and nail beds. Obviously, blue
is bad!
4. The position of the patient. Those with extreme pulmonary dysfunction will
often sit up-right. In cases of real distress, they will lean forward, resting their
hands on their knees in what is known as the tri-pod position.
5. Breathing through pursed lips, often seen in cases of emphysema.
6. Ability to speak. At times, respiratory rates can be so high and/or work of
breathing so great that patients are unable to speak in complete sentences. If
this occurs, note how many words they can speak (i.e. the fewer words per
breath, the worse the problem!).
7. Any audible noises associated with breathing as occasionally, wheezing or the
gurgling caused by secretions in large airways are audible to the "naked" ear.
8. The direction of abdominal wall movement during inspiration. Normally, the
descent of the diaphragm pushes intra-abdominal contents down and the wall
outward. In cases of severe diaphragmatic flattening (e.g. emphysema) or
paralysis, the abdominal wall may move inward during inspiration, referred to
as paradoxical breathing. If you suspect this to be the case, place your hand on
the patient's abdomen as they breathe, which should accentuate its movement.
9. Any obvious chest or spine deformities. These may arise as a result of chronic
lung disease (e.g. emphysema), occur congenitally, or be otherwise acquired. In
any case, they can impair a patient's ability to breathe normally. A few common
variants include:
1. Pectus excavatum: Congenital posterior displacement of lower aspect of
sternum. This gives the chest a somewhat "hollowed-out" appearance.
The x-ray shows a subtle concave appearance of the lower sternum.

Sample Lung Sounds (courtesy of Dr. Michael Wilkes, MD-- UC Davis and UCLA
Schools of Medicine)

 Bronchial Breath Sounds

 Vesicular Breath Sounds

 Crackles
 Wheeze

 Stridor

 Normal Voice E

 Egophony

BLOOD PRESSURE

Mean arterial pressure

where:

 is cardiac output
 is systemic vascular resistance
 is central venous pressure and usually small enough to be neglected in this formula
Equation: MAP = [(2 x diastolic)+systolic] / 3

Diastole counts twice as much as systole because 2/3 of the cardiac cycle is
spent in diastole. An MAP of about 60 is necessary to perfuse coronary
arteries, brain, kidneys.
Usual range: 70-110. 80 Y, IN CHILD 40-600t he blood pressure depends on cardiac
output (a strong heart leads to a high cardiac output) and total peripheral resistance (artherosclerosis and
stress increases the resistance). A high pressure leads to higher stresses of the arterial wall and increase
the risk of thrombosis, embolism and rupture. A high blood pressure is also an indication that the vessles
are unhealthy.

CONSCIOUSNESS

Modified Glasgow Coma Scale


Motor Response The patient obeys commands 6
The patient responds to a painful stimulus by moving toward the site of the stimulus 5
The patient moves away from a painful stimulus 4
The patient flexes his or her joints in response to a painful stimuli 3
The patient extends his or her joints in response to a painful stimuli 2
The patient has no response to a painful stimuli 1
The patient is able to respond appropriately to questions regarding who he or she
Verbal Response 5
is and where he or she is
The patient responds to questions, but is confused 4
The patient responds to questioning using inappropriate words. There is no
3
conversation
The patient makes incomprehensible sounds, but no actual words 2
No response to questioning 1
Eye opening The patient spontaneously opens his or her eyes 4
The patient opens his or her eyes to speech 3
The patient opens his or her eyes to painful stimulus 2
The patient does not open his or her eyes, despite painful stimulus 1
Total possible
15
score

Read more: http://www.momsteam.com/health-safety/glasgow-coma-scale-used-in-evaluating-level-


consciousness-not-concussion-severity#ixzz2qxfFg47q

The GCS measures the following functions:

Eye Opening (E)

 4 = spontaneous
 3 = to voice
 2 = to pain
 1 = none

Verbal Response (V)

 5 = normal conversation
 4 = disoriented conversation
 3 = words, but not coherent
 2 = no words, only sounds
 1 = none

Motor Response (M)

 6 = normal
 5 = localized to pain
 4 = withdraws to pain
 3 = decorticate posture (an abnormal posture that can include rigidity, clenched
fists, legs held straight out, and arms bent inward toward the body with the wrists
and fingers bend and held on the chest)
 2 = decerebrate (an abnormal posture that can include rigidity, arms and legs held
straight out, toes pointed downward, head and neck arched backwards)
 1 = none

Clinicians use this scale to rate the best eye opening response, the best verbal response,
and the best motor response an individual makes. The final GCS score or grade is the sum
of these numbers.

Using the Glasgow Coma Scale

Every brain injury is different, but generally, brain injury is classified as:

 Severe: GCS 3-8 (You cannot score lower than a 3.)


 Moderate: GCS 9-12
 Mild: GCS 13-15

Mild brain injuries can result in temporary or permanent neurological symptoms and a
neuro-imaging tests such as CT scan or MRI may or may not show evidence of any damage.

Moderate and severe brain injuries often result in long-term impairments


in cognition(thinking skills), physical skills, and/or emotional/behavioral functioning.
Levels of Consciousness
• Alert and Oriented
• Disoriented
• Obtunded
– Drowsy/somnolent
– Clouded consciousness
– Slow thought, movement, and speech
• Stuporous
– Marked reduction in mental and physical activity
– Vigorous stimuli needed to provoke a response
• Comatose
– Completely unconscious
– Cannot be aroused by painful stimuli
– Absence of voluntary movement
– +/- reflexes

Suhu manusia yang sehat, yang diukur di ketiak, berkisar 36-37 derajat
Celsius pada siang hari.

Suhu di bawah normal lebih rendah dari 36,2 ° C dan berhubungan dengan
metabolisme terkendali. Hal ini dapat diamati pada orang tua, pada penyakit
cachexia penyebab kronis (tumor), dihipopituitarisme, hipotiroidisme, setelah
perdarahan yang berlebihan, dan shock.
Suhu Subfebrile tidak melebihi 38 ° C, melainkan menyertai infeksi fokal (tonsillitis
kronis atau sinusitis, infeksi saluran kencing, adnexitis).
Demam (piretik, state demam) ditandai dengan peningkatan suhu tubuh di atas 38 °
C. Kondisi dengan suhu berkisar 40-41 ° C disebuthiperpireksia .

Demam terjadi pada radang, penyakit menular, penyakit sistemik, dan pada
tumor tertentu (limfoma, tumor Grawitz s). Bentuk kurva suhu beruang fitur
khas pada penyakit tertentu. Sebelumnya, fitur tersebut seharusnya cukup
penting. Pengenalan antibiotik ke dalam praktek klinis telah berubah
beberapa mantan fitur khas. Hanya untuk kelengkapan, kita menambahkan
gambaran dari jenis suhu.
consciousness

Continua Febris ditandai dengan fluktuasi suhu dalam kisaran 1 ° C selama periode
24 jam (typhus abdominalis, paratifoid, pneumonia croupous,erisipelas).
Febris remittens - fluktuasi harian melebihi rentang 1 ° C, suhu tidak kembali ke nilai
normal (penyakit menular).
Intermittens Febris (suhu septik) - suhu cepat menimbulkan sampai 39 ° C,
dengan cepat turun di bawah 37 ° C, dalam 24 jam perbedaan maksimum dan suhu
minimum lebih besar dari 1 ° C (sepsis, misalnya kolangitis, urosepsis, infeksi
endokarditis).
Febris recurrens - pergantian demam dan periode apyretic berbagai durasi.
Febris undulans - periode membesarkan dan jatuh suhu bergantian dengan periode
apyretic (limfoma perut, brucellosis).
Efemera Febris - demam satu hari ini disebabkan oleh kemajuan ringan infeksi
pernafasan, melalui transfusi darah, atau oleh aplikasi intravena obat-obatan tertentu.
Febris hectica - tahan lama suhu intermiten, sering terjadi pada TB
Appearance rhythm

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