Respiratory System Examination

• Before conducting a respiratory physical examination, wash hands, introduce yourself, confirm patient details (name, date of birth), explain the examination, obtain consent, position the patient at a 45-degree angle, expose the chest, and ask about pain.

General Examinations

• Assess the patient's overall well-being, hydration, and nutritional status.
• Note the patient's mental status (e.g., well or unwell).

General Inspection

• Look for sputum pots, inhalers, nebulizers, or oxygen cylinders, which may indicate respiratory issues.
• Observe for cyanosis, pallor, and the use of accessory muscles.
• Identify any signs of respiratory distress or specific diseases.

Examination of the Hands

• Check temperature; coldness may indicate vasoconstriction or poor perfusion.
• Tar staining may suggest smoking, COPD, or lung cancer.
• Flapping tremors can indicate CO2 retention, COPD, or Type II respiratory failure and can be a side effect of beta agonists like salbutamol.
• Assess for clubbing and peripheral cyanosis.
• Peripheral cyanosis, a bluish discoloration of the nails, indicates oxygen saturations of ≤5 gm% of reduced hemoglobin.
• Pursed-lip breathing is a technique used in COPD to provide resistance to exhaled breath and prevent collapse.

Examination of Head and Neck

• Central cyanosis is a severe condition requiring oxygen and affects the lips, nose, ears, neck region, and tongue.
• Central cyanosis is more difficult to see in individuals with darker pigmentation; assess the palms of the hands, oral cavity, and tongue.
• Assess pupillary reflexes in neurological exams, looking for "PERRL" (pupils equal, round, reactive to light).
• Abnormal pupillary signs:
  • Mydriasis (dilated and fixed pupils) may indicate brain death or drug use.
  • Miosis (pinpoint pupils) may indicate opiate use or pontine hemorrhage.
  • Ptosis (drooping upper lid) may be due to congenital defects or neuromuscular disease.
  • Diplopia (double vision) may indicate neuromuscular disease, such as myasthenia gravis.

Neck Examination: Trachea

• Normally, the trachea is midline or slightly deviated to the right; palpate at the suprasternal notch.
• Tracheal shift can be caused by lung collapse, pneumothorax, effusion, or a tumor.

Neck Examination: JVP

• JVP (jugular venous pressure) reflects the volume and pressure of venous blood on the right side of the heart.
• In a supine position, JVP veins are full.
• At a 45º angle, the column of blood descends to a few cm above the clavicle; normal is 3-5 cm.
• High venous pressure is indicated if the column remains high even when the patient is sitting upright.
• Measure the distance the veins are distended above the sternal angle (5cm above the right atrium).
• JVP changes with breathing.
• The most common cause of elevated JVP is right heart failure (RHF), which can result from chronic left-sided heart failure or chronic hypoxemic lung disease (cor pulmonale).
• Other causes of elevated JVP include hypervolemia and obstruction of venous return to the right atrium.
• Assess the neck for lymph nodes.

Lower Limbs

• Check for lower limb pitting edema

Lung Topography: Imaginary Lines

• Anterior lines: midsternal, midclavicular, midaxillary, anterior axillary, and posterior axillary.
• Posterior lines: midspinal and midscapular.

Lung Topography: Thoracic Cage Landmarks

• Anterior landmarks: suprasternal notch, sternal angle (angle of Louis), and ribs (counted away from the sternum).
• Posterior landmarks: spinous processes of vertebrae (C7 is the most prominent spinous process at the base of the neck) and scapular borders.

Inter-lobar Fissures

• Oblique fissure: begins at the 6th rib mid-clavicular anteriorly, extends laterally and upward, crossing the 5th rib at the mid-axillary line, and continues posteriorly to T3.
• Horizontal fissure (right lung): separates the upper from the middle lobe, running from the 4th rib at the sternal border to the 5th rib at the mid-axillary line.

Landmarks

• Tracheal bifurcation: anterior- below the larynx; posterior- T4.
• Diaphragm (separates thoracic and abdominal cavities):
  • At the end of normal tidal volume expiration:
    • Right dome: 5th rib anteriorly, T9 posteriorly.
    • Left dome: 6th rib anteriorly, T10 posteriorly.
  • The resting position of the right side is higher than the left due to the liver.
• Diaphragm position at end exhalation:
  • Right dome: 5th rib anteriorly, T9 posteriorly.
  • Left dome: 6th rib anteriorly, T10 posteriorly.
• The right hemi-diaphragm is higher than the left due to the liver.

Steps for conducting a respiratory physical examination, including preparation, general inspections, and hand examination. Key indicators such as cyanosis, pallor, and accessory muscle use are noted. Examination of the hands includes checking temperature, tar staining, and flapping tremors.