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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

Station 9).

• 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)

to palpate the trachea.

Palpation of the chest

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

sign.

[Note] Carry out all subsequent steps on the front of the chest and, once finished, repeat them on the back of the chest.

This is far more elegant than to keep asking the patient to bend forwards and backwards like a Jack-in-the-box.

Pulmonary anatomy is such that examination of the back of the chest yields information about the lower lobes,

whereas examination of the front of the chest yields information about the upper lobes and, on the right-side,

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

latter only on the right).

Upper lobe

Lower lobe

Middle lobe

Clinical Skills for OSCEs

44 Station 17 Respiratory system examination

Percussion of the chest

• Percuss the chest. Start at the apex of one lung, and compare one side to the other. Do not

forget to percuss over the clavicles and on the sides of the chest. For any one area, is the resonance increased or decreased? A hyper-resonant or tympanic note may indicate emphysema

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

geographical extent.

• Test for tactile fremitus by placing the flat of the hands on the chest and asking the patient to

say “ninety nine”.

Auscultation of the chest

• Ask the patient to take deep breathsthrough the mouth and, using the diaphragm of the stethoscope, auscultate the chest in the same locations as for percussion. Start at the apex of one

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

may indicate consolidation. Listen carefully for added sounds such as wheezes (rhonchi), crackles (crepitations), bronchial breathing, and pleural friction rubs.

• 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

right-sided heart failure.

Figure 11. Palpating for equal chest expansion: upper, middle and lower lobes.

Cardiovascular and respiratory medicine

Station 17 Respiratory system examination 45

After the examination

• 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

blood count.

• Cover the patient up and ensure that he is comfortable.

• Thank the patient.

• Wash your hands.

• 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).

Lobectomy

• Look carefully for a scar and listen for reduced or absent breath sounds.

Clinical Skills for OSCEs

46 Station 18

PEFR meter explanation

Read in conjunction with Station 116: Explaining skills.

Before starting

• 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

of using it correctly.

• Explain that the PEFR meter is to be used first thing in the morning and at any time he has

symptoms of asthma.

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.

• Stand or sit up straight.

• 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

Interpret a PEFR reading

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

evening.

• Show him how to plot readings on the chart.

Height

Men

190 cm

183 cm

175 cm