The REspiratory Examination
Short Case
(if says examine chest, do Respiratory/Cardiac gen inspection then Respiratory/Cardiac Chest then come back to complete relevant system
Possible diagnoses:
Hypoplastic lung
Congenital lobar emphysema
Asthma
BPD
(Chronic hypoxia > hypoxic pulmonary vasoconstriction > T3PHTN > cor pulmonale (RV changes due to the HTN)
Suppurative lung disease (includes bronchiectasis, empyema, abscess, necrotising pneumonia)
Obstructive lung disease (includes bronchiectasis, asthma, rarely some DLD)
Restrictive lung disease (includes DLD,
Diffuse lung disease (previously Interstitial Lung Disease
Bronchiectasis
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"I have washed my hands"
"Good morning/afternoon, I'm Hadley. With your permission I will be examining you today. If I ask you to do something that you are uncomfortable with, or that you think might cause you pain please let me know"
Well / unwell (ask for obs)
Growth: HT/Wt/HC ?age appropriate ?proportional, ask for centiles to confirm
- FFT (Ex prem/CF/BPD/immunodeficiency)
Nutritional status (protein/fat) (as above)
Dysmorphism
- micrognathia (Pierre Robin sequence (retrognathia > glossoptosis > cleft palate)
- Down (OSA)
- Apert (craniosynostosis and maxillary hypoplasia)
- cleft lip
- Scaphocephaly (CLD)
- Cushingoid
(Shirt off, standing then sitting, unless infant)
Efficacy of breathing
cough (Bronchiectasis)
- if moist ask to inspect sputum
- haemoptysis (bronchiectasis)
Petechia (cough)
voice/cry (hoarse in laryngitis)
WOB
IV lines/infusions
Pulse oximetry/cardiac monitoring/Peakflow meter
O2 Rx and rate (CLD)
NGT
Nebuliser/spacer/inhaler/ventilator/
Sputum cup (bronchiectasis)
Chest deformity
- Barrel (hyperinflation) (CF, Asthma)
- Harrison's sulcus (Asthma, Ricket's)
- Pectus excavatum (normal, airway obstruction, corrected diaphragmatic hernia, SMA, connective tissue: Marf/OI/ElhDan, other: noonans/turners)
- pectus carinatum (normal, connective tissue: Marf, Other: Noonans
- rib flaring
- Scoliosis
- Kyphosis
Assymetry
- hypoplastic lung
- congenital lobar emphysema
Scars
- Midline sternotomy (CHD, lung transplant)
- Thoracotomy (lobectomy, pneumonectomy, lung transplant)
- VATS (empyema, lung biopsy)
- Intercostal drains
CVC (CF)
Hands
Clubbing
Finger prick marks (CFRD)
Palmar crease parlour (anaemia)
Dorsum PIVC scars (NICU grad)
Wrists for Hypertrophic Pulm OsteoArthropathy (CF..., Cyanotic HD, GIT)
Pulse
- Tachycardia (hypoxia, beta agonist, fever)
- Pulsus paradoxus (severe asthma)
Asterixis (CO2 retention)
Axillary lymphadenopathy (at end)
Head
E - chronic OM (ciliary dysfunction)
N
T - high arched palate (NICU grad)
Sinus tenderness (CF, ciliary dysfunction disorders, and immunodeficiencies)
Tracheal deviation
Neck
Tracheal tug
Cervical Lymphadenopathy (at end)
JVP: cor pulmonale from T3PHTN
Tracheal deviation
Chest
Chest Wall
Praecordium
apex beat (displaced in pneumothorax, congenital lobar emphysema, dextrocardia in Kartag)
parasternal heave (RVH /PHTN)
palpable P2 (second part of second sound ie pulmonary valve closure (PHTN)
loud P2 (PHTN)
Lungs
Inspection
Abdomen
Liver ptosis (hyperinflated)
Hepatomegaly (RHF)
Splenomegaly (Portal HTN in CF)
Ears
- OM
Nose
- Polyps (CF)
Throat
- Tonsillitis/megaly
Lymph nodes
- Cervical
- Axillary
Lower limbs
- Inguinal hernia scar (NICU grad)
- Clubbing
- Oedema (Cor Pulmonale from T3PHTN)
Fundi
- venous dilation (CO2 retention)
Skin
- eczema (asthma)
Neuro
- Bulbar palsy
- SMA (diaphragmatic breathing)
Obs (fever)
Ix
Sputum, BAL
PEFR (5 x ht in cm -450 = 3rd centile)
PFTs
Chest Xray
Pleural fluid MCS, AFBs, Protein (>25g/L = exudate (Pneumonia/Ca/TB), <25g/L = transudate (Nephrotic syndrome, Liver failure, heart failure), cytology
- Polymorph (bacterial, Lymphocytes (TB, Lymphoma)
ECG looking for signs of RVH or right heart strain
CT chest (cygnet ring sign, tram tracking, brochoarterial ration >0.76 = bronchiectasis. main pulmonary artery diameter of 3cm ?T3PHTN
Biopsy (Primary ciliary dyskinesia)
If loud / palpable P2 > ECG: R-axis deviation, RA enlargement, RVH
?ECHO if ?T3PHTN / cor pulmonale
?Immunodeficiency: Ig levels and subclasses, lymphocyte subsets, complement levels, pneumococcal titre
(if says examine chest, do Respiratory/Cardiac gen inspection then Respiratory/Cardiac Chest then come back to complete relevant system
Possible diagnoses:
Hypoplastic lung
Congenital lobar emphysema
Asthma
BPD
(Chronic hypoxia > hypoxic pulmonary vasoconstriction > T3PHTN > cor pulmonale (RV changes due to the HTN)
Suppurative lung disease (includes bronchiectasis, empyema, abscess, necrotising pneumonia)
Obstructive lung disease (includes bronchiectasis, asthma, rarely some DLD)
Restrictive lung disease (includes DLD,
Diffuse lung disease (previously Interstitial Lung Disease
Bronchiectasis
- Congenital
- Williams-Campbell Syndrome > tracheobronchomalacia
- Bronchial obstruction
- Congenital (CCAM, pulmonary sequestration)
- foreign body
- mucous impaction (asthma, ABPA)
- hilar adenopathy (TB)
- tumour
- Immunodeficiencies (SCID, complement deficiency, HIV)
- Secretion clearance
- CF
- Primary Ciliary Dyskinesia (Kartagener if with situs inversus and chronic sinusitis)
- neurological (poor cough in NM)
- Infection (staph, pseudomonas, adenovirus, TB, recurrent aspiration)
- Environmental (talc, smoke)
- Autoimmune (scleroderma,
- Genetic (Yellow nail syndrome, Alpha-1 antitrypsin deficiency)
------------
"I have washed my hands"
"Good morning/afternoon, I'm Hadley. With your permission I will be examining you today. If I ask you to do something that you are uncomfortable with, or that you think might cause you pain please let me know"
Well / unwell (ask for obs)
Growth: HT/Wt/HC ?age appropriate ?proportional, ask for centiles to confirm
- FFT (Ex prem/CF/BPD/immunodeficiency)
Nutritional status (protein/fat) (as above)
Dysmorphism
- micrognathia (Pierre Robin sequence (retrognathia > glossoptosis > cleft palate)
- Down (OSA)
- Apert (craniosynostosis and maxillary hypoplasia)
- cleft lip
- Scaphocephaly (CLD)
- Cushingoid
(Shirt off, standing then sitting, unless infant)
Efficacy of breathing
- Cynosis/plethoric
- Mentation
cough (Bronchiectasis)
- if moist ask to inspect sputum
- haemoptysis (bronchiectasis)
Petechia (cough)
voice/cry (hoarse in laryngitis)
WOB
IV lines/infusions
Pulse oximetry/cardiac monitoring/Peakflow meter
O2 Rx and rate (CLD)
NGT
Nebuliser/spacer/inhaler/ventilator/
Sputum cup (bronchiectasis)
Chest deformity
- Barrel (hyperinflation) (CF, Asthma)
- Harrison's sulcus (Asthma, Ricket's)
- Pectus excavatum (normal, airway obstruction, corrected diaphragmatic hernia, SMA, connective tissue: Marf/OI/ElhDan, other: noonans/turners)
- pectus carinatum (normal, connective tissue: Marf, Other: Noonans
- rib flaring
- Scoliosis
- Kyphosis
Assymetry
- hypoplastic lung
- congenital lobar emphysema
Scars
- Midline sternotomy (CHD, lung transplant)
- Thoracotomy (lobectomy, pneumonectomy, lung transplant)
- VATS (empyema, lung biopsy)
- Intercostal drains
CVC (CF)
Hands
Clubbing
Finger prick marks (CFRD)
Palmar crease parlour (anaemia)
Dorsum PIVC scars (NICU grad)
Wrists for Hypertrophic Pulm OsteoArthropathy (CF..., Cyanotic HD, GIT)
Pulse
- Tachycardia (hypoxia, beta agonist, fever)
- Pulsus paradoxus (severe asthma)
Asterixis (CO2 retention)
Axillary lymphadenopathy (at end)
Head
E - chronic OM (ciliary dysfunction)
N
T - high arched palate (NICU grad)
Sinus tenderness (CF, ciliary dysfunction disorders, and immunodeficiencies)
Tracheal deviation
Neck
Tracheal tug
Cervical Lymphadenopathy (at end)
JVP: cor pulmonale from T3PHTN
Tracheal deviation
Chest
Chest Wall
Praecordium
apex beat (displaced in pneumothorax, congenital lobar emphysema, dextrocardia in Kartag)
parasternal heave (RVH /PHTN)
palpable P2 (second part of second sound ie pulmonary valve closure (PHTN)
loud P2 (PHTN)
Lungs
Inspection
- WOB (Effort)
- RR
- Flare, grunt, gasp, Supraclav, TT (aka Suprasternal), IC, SC, Sternal, accessory muscle use
- Chest expansion (Efficacy)
- Reduced: congenital lobar emphysema,?any resp/neuromuscular/fatigue
- Vocal Fremitus "99" (or resonance)
- increased in consolidation
- decreased in pneumothorax and effusion
- Tympanic: Pneumothorax
- hyperresonant: congenital lobar emphysema, asthma
- dull: consolidation
- Stoney dull: effusion
- reduced: congenital lobar emphysema, asthma
- wheeze: congenital lobar emphysema, asthma
- Bronchial: consolidation
- Creps (infection, atelectasis, CHF)
- Vocal resonance
- increase: consolidation
- decreased: pneumothorax and effusion
Abdomen
Liver ptosis (hyperinflated)
Hepatomegaly (RHF)
Splenomegaly (Portal HTN in CF)
Ears
- OM
Nose
- Polyps (CF)
Throat
- Tonsillitis/megaly
Lymph nodes
- Cervical
- Axillary
Lower limbs
- Inguinal hernia scar (NICU grad)
- Clubbing
- Oedema (Cor Pulmonale from T3PHTN)
Fundi
- venous dilation (CO2 retention)
Skin
- eczema (asthma)
Neuro
- Bulbar palsy
- SMA (diaphragmatic breathing)
Obs (fever)
Ix
Sputum, BAL
PEFR (5 x ht in cm -450 = 3rd centile)
PFTs
Chest Xray
Pleural fluid MCS, AFBs, Protein (>25g/L = exudate (Pneumonia/Ca/TB), <25g/L = transudate (Nephrotic syndrome, Liver failure, heart failure), cytology
- Polymorph (bacterial, Lymphocytes (TB, Lymphoma)
ECG looking for signs of RVH or right heart strain
CT chest (cygnet ring sign, tram tracking, brochoarterial ration >0.76 = bronchiectasis. main pulmonary artery diameter of 3cm ?T3PHTN
Biopsy (Primary ciliary dyskinesia)
If loud / palpable P2 > ECG: R-axis deviation, RA enlargement, RVH
?ECHO if ?T3PHTN / cor pulmonale
?Immunodeficiency: Ig levels and subclasses, lymphocyte subsets, complement levels, pneumococcal titre