Cardiovascular and respiratory medicine
Station 17 Respiratory system examination 43
• Examine the lymph nodes from behind with the patient sitting up. Have a systematic routine
for examining all of the submental, submandibular, parotid, pre- and post-auricular, occipital,
anterior cervical, posterior cervical, supra- and infra-clavicular, and axillary lymph nodes (see
• Palpate for tracheal deviation by placing the index and middle fingers of one hand on either
side of the trachea in the suprasternal notch. Alternatively, place the index and annular fingers
of one hand on either clavicular head and use your middle finger (called the Vulgaris in Latin)
Ask the patient if he has any chest pain.
• Inspect the chest more carefully, looking for asymmetries, deformities, and scars.
• Inspect the precordium and palpate for the position of the cardiac apex. Difficulty palpating for
the position of the cardiac apex may indicate hyperexpansion, although this is not a specific
also the middle lobe (Figure 10).
• Palpate for equal chest expansion, comparing one side to the other. Reduced unilateral chest
expansion might be caused by pneumonia, pleural effusion, pneumothorax, and lung col lapse.
If there is a measuring tape, measure the chest expansion.
Figure 10. A right lateral view demonstrating lobar
anatomy. Posterior assessment gives information
about the lower lobes, whereas examination from
the front looks at the upper and middle lobes (the
44 Station 17 Respiratory system examination
• Percuss the chest. Start at the apex of one lung, and compare one side to the other. Do not
or pneumothorax, whereas a dull or stony dull note may indicate consolidation, fibrosis, fluid,
or lung collapse. If you uncover any variation in the percussion note, be sure to map out its
• Test for tactile fremitus by placing the flat of the hands on the chest and asking the patient to
lung, in the supraclavicular fossa, and compare one side to the other. Normal breath sounds
are described as ‘vesicular’ and have a low pitched and rustling quality. Reduced breath sounds
• Test for vocal resonance by asking the patient to say “ninety nine”. Both consolidation and
pleural effusions can lead to a dull percussion note, but in consolidation vocal resonance is
increased whereas in pleural effusion it is decreased. Both vocal resonance and tactile fremitus
(see above) provide the same sort of information.
Inspection and examination of the legs
• Inspect the legs for erythema and swelling. Palpate for tenderness and pitting oedema. A
unilateral red, swollen, and tender calf suggests a DVT, whereas bilateral swelling may indicate
Figure 11. Palpating for equal chest expansion: upper, middle and lower lobes.
Cardiovascular and respiratory medicine
Station 17 Respiratory system examination 45
• Indicate that you would look at the observations chart, examine a sputum sample, measure the
peak expiratory flow rate, and order some simple investigations such as a chest X-ray and a full
• Cover the patient up and ensure that he is comfortable.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a respiratory system examination station
Chronic obstructive pulmonary oedema (COPD):
• Signs may include breathlessness, breathing through pursed lips, cough, hyperinflated chest,
cyanosis, warm hands, tar staining, asterixis, bounding pulse, rhonchi, reduced breath sounds,
signs of right heart failure (cor pulmonale).
Cryptogenic fibrosing alveolitis:
• Signs may include breathlessness, dry cough, cyanosis, clubbing, reduced chest expansion,
fine late inspiratory crackles, signs of right heart failure (cor pulmonale).
• Look carefully for a scar and listen for reduced or absent breath sounds.
Read in conjunction with Station 116: Explaining skills.
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Check his understanding of asthma and of the PEFR meter.
• Explain the importance of using a PEFR (Peak Expiratory Flow Rate) meter and the importance
• Explain that the PEFR meter is to be used first thing in the morning and at any time he has
Explain the use of a PEFR meter
Demonstrate and ask the patient to:
• Attach a clean mouthpiece to the meter.
• Slide the marker to the bottom of the numbered scale.
• Hold the peak flow meter horizontal, keeping his fingers away from the marker.
• Take as deep a breath as possible and hold it.
• Insert the mouthpiece into his mouth, sealing his lips around the mouthpiece.
• Exhale as hard as possible into the meter.
• Read and record the meter reading.
• Repeat the procedure three to six times, recording only the highest score.
• Check this 21score against the peak flow chart or his previous readings.
• Check the patient’s understanding by asking him to carry out the procedure.
• Ask him if he has any questions or concerns.
Cardiovascular and respiratory medicine
Station 18 PEFR meter explanation 47
Figure 12. Expected peak flow rates in litres per minute according to age, sex, and height.
If the patient has been given a diary or chart to track PEFR variation:
• Explain that he must record a reading (best of three attempts) in the morning, afternoon, and
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