RESPIRATORY EXAM

Introduction

Knock, enter the room, wash/sanitize hands and introduce yourself
Greet the patient, ask the patient’s name, explain the exam and ask for consent
Always ask for vitals
Advise and request patient to drape according to the exam being performed (mention what type of exposure is necessary)

Patient can sit on the examination table for the inspection exam

General	Inspect for assistive equipment in the room, such ventilatory support Inspect for increased work of breathing (look for pursed lips, nasal flaring, suprasternal indrawing, tracheal tug, intercostal indrawing, supraclavicular retraction, accessory muscle use, paradoxical breathing, tripod posture, grunting (pediatrics)) Inspect for rhythm of breathing: noting presence/absence of 1) Cheyne Stokes Breathing or 2) Kussmaul Breathing
Face	Inspect under tongue for central cyanosis
Hands	Inspect hands for peripheral cyanosis Inspect for signs of clubbing: noting presence/absence of Schamroth’s sign Inspect fingers for any tar staining
Chest	Inspect for any signs of scars or medical implants Inspect for pectus excavatum or carinatum Ask patient to breathe in and out to detect barrel chest or flail chest Look for signs of cachexia
Back	Inspect for scoliosis and kyphosis

Transition statement and consent to begin palpating
General
- Palpation anteriorly and posteriorly for masses and tenderness
Trachea
- Check for tracheal deviation (ensure trachea is midline on inspiration and mobile in 4 directions)
- Check for tracheal descent (ensuring tracheal descent is >4cm)
Posteriorly
- Bilateral Chest Expansion (ensuring symmetric expansion >5cm)
- Tactile Fremitus (ensuring bilateral resonance in all lung fields)

Intercostal percussion anteriorly and posteriorly
Diaphragmatic Excursion
- Checking for how much the diaphragm moves up and down during breathing
  - Ask the patient to breathe in, then percuss down the rib cage until dull, ask patient to breathe out, then continue percussing until dull again. The distance between dull sounds is of significance.
  - Repeat on the other side
  - Distance between inspiration and expiration should be equal and 4-5cm

Listen to sounds of breathing
- Ask patient to cross their arms to displace scapulae
- Diaphragm of the stethoscope:
  - Auscultate posteriorly, anteriorly and laterally on the right side (for the middle right lobe)
  - Comment on any other sounds heard: e.g., wheeze, stridor