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Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Lesson Plan
Tutors
 This is the first semester 2 session and as yet, the students have not been
through the structure of a systematic exam.
 They have covered the relevant surface anatomy and learnt expansion,
percussion and auscultation techniques in the APE 7 “Airways and the Lung”.
They have had a chance to practice and piece this together for the anterior chest
in APE 12 “Revision” session.
For All Sessions
 Please employ a 4 stage teach method unless otherwise asked – Stage 1 is
extremely important for role-modelling professionalism and communication
 You should not split into pairs unless otherwise asked – students have plenty of
opportunity to practice, what they do not have is someone to give feedback and
correct mistakes, therefore you should be supervising them all closely.
 Please do not say ‘you need to do it this way for the OSCEs’. Exams are
important and motivate people, but this is not the point of these sessions. Good
clinical skills are for life, not just for OSCEs!
General Rules
 Students should not be finishing more than 10 minutes before the end of the
session. If you finish early – please ensure you have covered all the material
fully. There is always more time for practicing clinical skills again.
 Phones and tablets are banned from the session – please enforce this rule.
Please send persistent rule-breakers to me.
 Students should be examining ‘bare-below-the elbows’. Please ensure
students are sticking to this. There are disposable sleeves available for any
students with issues regarding exposure.
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Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Suggested
Timing
1
13.3013.35
(5 mins)
Activity
Introduction
 Introductions, register
 Run through objectives, identify volunteers – male for chest
exposure, any for neck exam
Suggested
Timing
2
15.3015.35
(5 mins)
13.3513.45
(10 mins)
Activity 1 – Revision of Surface Anatomy
 Briefly run through anatomy questions
 Be facilitative
 Key points to emphasise
o How to palpate trachea
o Landmarks of where to percuss/auscultate on chest
13.3513.45
(10 mins)
13.4514.00
(15 mins)
Activity 2 – The Systematic Examination
 Work through the questions and structure considering both
o General examinations
o Respiratory Exam
 Show laminates of pathology
 Stage 2 demo TVF/VR and aegophony
15.4516.00
(15 mins)
14.0014.45
(45 mins)
Activity 3 – The Respiratory Examination
 Stage 1 – demo fully without explanation
 Stage 2 – demo whilst explaining, use laminates as appropriate
 Stage 3 – student(s) performs whilst rest of group recall steps
o This stage may be repeated
 Stage 4 – student(s) performs fully whilst recalling steps
o This stage should be repeated until all have examined
 Students should follow using workbook for Stages 1 and 2
 Please give feedback as appropriate throughout Stages 3 and 4
 Please do not break into pairs
16.0016.45
(45 mins)
14.4514.55
(10 mins)
14.5515.00
(5 mins)
Activity 4 – Cervical Lymph Node Examination
 Stage 2 demo, then Stage 4 in pairs.
16.4516.55
(10 mins)
16.5517.00
(5 mins)
Close and summarise
 Please spend a few minutes emphasizing the SDL given
 Highlight importance of practice including
presenting/communication skills
 Point out questions and clinical reasoning practice
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Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Preparation
You will get the most out of this session by reviewing the following PRIOR to the
session:


Lung anatomy from APE 7: Airways and the Lung and DR session
Practicing techniques of:
o Chest expansion
o Percussion
o Lung auscultation
Dress code
Male student volunteers need to be able to uncover the chest for this
session, so T-shirts/loose tops to be worn please.
PE
Learning objectives
During this session you will:
 Recall relevant respiratory system surface anatomical structures
 Discuss what is meant by systematic examination
 Replicate an examination of the respiratory system on a colleague
 Replicate an examination of the cervical lymph nodes on a colleague
By the end of this session and with deliberate repeated practice you should be able to:
 Perform a complete and systematic examination of the respiratory system using a
recognized approach on a peer
 Perform an examination of the cervical lymph nodes on a peer
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Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Exercise 1 - Revision of surface anatomy (10 mins max)
Tutors – This is revision – please be facilitative. Use skeleton as necessary.
Revise the relevant anatomy by answering the questions below:

Ribs



How many pairs?
Where do they attach?
Which are true/false/floating?
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Attach:
- posteriorly to the corresponding thoracic vertebrae;
- anteriorly to their costal cartilage at the costochondral joint.
Clinical relevance – these can become inflamed and tender – cause of chest pain
‘costochrondritis’
Ribs 1-7 = “true ribs”; their costal cartilages are connected to the sternum
Ribs 8,9,10 = “false ribs”. They are attached to each other and to the seventh rib
Ribs 11&12 = “floating ribs”. Their costal cartilages have no anterior attachment

Suprasternal notch
 What structure can be palpated at this level?
 What does this bifurcate into?
Suprasternal notch is the superior border of the manubrium, felt between the medial ends of the
clavicles.
Trachea can be palpated at this level – get them to remember and demonstrate how – ring and
index fingers on clavicular heads whilst middle finger palpates trachea.
Trachea can be deviated to one side:
Can be caused by pathologies in 1 lung ‘pulling’ it towards: collapse, lobectomy/pneumonectomy
Or ‘pushed’ away from the other lung: large pleural effusion or pneumothorax
Trachea bifurcates into R and L bronchi – ask them how they are different/what’s the
significance?
Right bronchus is wider, shorter and more vertical than the left
Clinical relevance - foreign body inhalation/aspiration tend to go down right bronchus

Lungs
 Where are the superior and inferior borders?
 How many lobes?
 Where are the fissures?
Apex (2cm above clavicle to 6th rib (MCL); 8th rib (MAL) and 10th rib (scapula line)
Clinical relevance = Lungs start above clavicle and descend lower posteriorly. When percussing
and auscultating we must cover from apices to bases.
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Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Right lung = three lobes (upper, middle and lower).
Left lung = two lobes (upper and lower).
The oblique fissure runs from the spinous process of T3 posteriorly to the 6 th rib anteriorly.
The horizontal fissure (R lung only) runs along the 4th rib and costal cartilage anteriorly to meet
the oblique fissure.
This forms RML – in order to ensure we have assessed this we must also percuss and auscultate
laterally

Pleura
 What are the 2 layers called?
 Where are the superior and inferior borders?
Visceral pleura – adhered to lung surface and parietal pleura;
Parietal pleura – inferiorly 2 rib spaces below the lungs
Clinical relevance- ‘potential space’ where air/fluid can collect – what are these called?
- liver/renal biopsy can penetrate pleura at this level (costodiaphragmatic recess) to cause
pneumothorax/haemothorax
Exercise 2 – The Systematic Examination (15 mins)
When examining patients, we use a structured approach. Examinations can be focused on one
part of the body or you may be examining multiple systems. Here, we will be teaching you
examinations by systems (e.g. respiratory, cardiovascular…). This is something you will be
expected to be able to perform on placements, in OSCE exams and as a doctor.
To prepare for learning the Respiratory System examination today, please work through the
sections below with your tutor:
Discussion: Why do we have a structured approach to examination?



Routine – less likely to forget elements of exam, order and structure findings
Professionalism, formality – encroaching into another person’s personal space, often in
intimate proximity. A standardized approach marks this out a professional process (and
not misconstrued as anything else… - historical context: 18th century doctors caricatured
as sexual predators!)
Fluidity – minimizes inconvenience and discomfort to patient (e.g. not exposing/reexposing; not sitting up/lying down); also adds to professionalism – patient may feel more
confident with doctor who demonstrates proficiency in examination skills
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Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Examination introduction and preparation
What should we do before we begin the examination?
 Introduction – full name and role
 Ensure you have the correct patient (if required)
 Consent – “We are going to be examining the respiratory system today – What do you



think that might involve in terms of consent?”
o Why exam necessary if not explicit
o What is involved - briefly
 Jargon-free – ask them exactly what they would say – ‘chest or lung
examination’ vs ‘respiratory’
o Exposure
 See below; again ask them exactly what they would say - avoid term
‘expose’
 Please be aware patient may need help dressing/undressing
o ‘Is a chaperone needed’? Maybe – see GMC guidelines – if they are unsure they
should ask (not classically considered “intimate” exam, the chest does need to be
uncovered and there may be some palpation necessary in the region of the
breasts)
o Ensure they have given consent and have not been coerced
Exposure – may be done at the beginning or during the exam, must ensure patient dignity
at all times e.g. offer blanket/gown if exposure not immediately required
Positioning – some exams require patients to be in a specific position, they should take
the time to do this
Wash hands – BEFORE they make contact with the patient
o Ensure this doesn’t impact on rapport i.e. wash hands as soon as they enter
cubicle without eye contact with patient
o Review when alcogel ok (i.e. not when visibly soiled, not with suspected c
diff/novovirus)
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Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
GMC guidance recommends that for all intimate exams (such as breast, rectal, pelvic
and external genitalia exam) and examinations that may involve close contact:
 All patients should be offered a chaperone (regardless of gender)
 The chaperone should be a health professional and familiar with the
procedure/examination being undertaken
 A relative/friend of the patient is not an appropriate chaperone (as they are
not impartial observers)
 If either the patient or doctor feel uncomfortable to go ahead with the
procedure/examination without a chaperone, they can delay it until a chaperone is
available (as long as the delay does not harm patient care)
 The use of a chaperone, or its refusal, should be documented in the patient
notes. If a chaperone is used, their name and identity should be recorded.
Please review the guidance regarding chaperones and related issues, by the General
Medical Council (GMC) under “Intimate examination and chaperones (2013)”
(http://www.gmc-uk.org/guidance/ethical_guidance/21168.asp)
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Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Components of a standard systematic examination
The standard order of approach for Respiratory, Cardiovascular, and Abdominal examinations
follow the format of:




Inspection
Palpation
Percussion
Auscultation
Inspection is an essential component of ALL systems examination. It can be easy to forget
when you are practicing on your peers, but can provide a wealth of clues about the patient.
There are times you can make a diagnosis without ever even touching a patient…
We start with a general inspection;
 Observing a patient from the end of the bed and,
 Looking around the bed/patient surroundings
With the help of your tutor, think of some things you may pick up on:
Tutors -Keep this brief and relevant.
Focus on useful global findings, and focus them onto respiratory things
 Patient –
o Alert
o Comfortable/in pain
o Posture/Position
o Respiratory distress – struggling to breathe
o Blue? ‘Cyanosis’
o Auditory – cough/wheeze
o Occasionally even use smell as well…
 Surroundings
o Oxygen
o Medications – e.g. inhalers
o Observation chart/drug chart
o Walking aids – neuromuscular breathing problem?
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Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Peripheral Examination
We start with the hands (why?) and ‘work our way up’ the arm to the face and neck.
Tutors – as above – encroaching on personal space – starts conservatively; always start at the
same place – helps routine
We are mostly inspecting, but sometimes will want to perform other aspects of examination –
you do not have to complete all the inspection first! (e.g. if you identify a lump on examination,
you may wish to then palpate it +/- percuss/auscultate)
Get your tutor to show you some signs we will be looking for in the peripheral Respiratory
Examination.
Tutors - Please use laminate provided to demonstrate clubbing, cyanosis and tar staining in the
hands; and anaemia, horner’s and cyanosis in the face.
Please explain how to assess for clubbing – initially should look from the side, then doing
‘window’ test if uncertain. Causes is a question in their SDL – refer them to this, the one they
should be aware of is lung cancer.
Peripheral cyanosis is due to reduced local circulation and increased extraction of oxygen by the
tissues.
Central cyanosis represents dangerously low oxygen level – it is most likely peripheral cyanosis
is also present. This is due to desaturation of central arterial blood resulting from the shunting
of deoxygenated venous blood into the systemic circulation from cardiac or respiratory
pathology
Horner’s can be caused by a tumour in the apex of the lung (‘Pancoast’ tumour) which invades
the sympathetic chain. This is a triad of ptosis, miosis and anhydrosis of the same side a tumour.
There are other causes. Note also: anhydrosis not really seen.
Central Examination
We then move onto the main system of examination and progress through the steps IPPA.
Let’s think about what this might involve for the Respiratory Examination
 Inspection - Closer inspection of chest: Scars (laminate), movement chest wall,
deformities (See SDL)

Palpation - Expansion, New test – tactile vocal fremitus

Percussion - Percussion over all zones of lungs – get them to recall where on anterior
chest – they did this in the revision session: clavicle, upper chest and laterally;
Posteriorly – upper-mid-lower. 3 points is the minimum number – more can be done

Auscultation – Auscultation over all zones lungs (as percussion), New test - vocal
resonance
Tutors – briefly demo TVF, VR and aegophony
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Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Vocal resonance (VR) and tactile vocal fremitus (TVF)
VR and TVF test the same thing (transmission of low frequency vibrations) so it is not
necessary to do both. The patient says ‘ninety-nine’ while the clinician examines the patient.
For VR the clinician auscultates the lung and listens to how loudly the noise is heard. For
TVF the clinician places the ulnar aspect of their hand on the chest and ‘feels’ the vibrations
on the chest against the hand.


Consolidation of the lungs causes an increase in TVF/VR
Pleural effusions cause a decrease in TVF/VR.
Aegophony
This is an optional test that could be done in addition to TVF and VR. It also tests
transmission of voice. Whilst auscultating, the patient is asked to say the letter "eee”. Over
consolidation you should hear a higher pitched sound that sounds like the letter "a". Over an
effusion it will sound like “eee”
Aegophony comes from the Greek word for "goat," referring to the bleating quality of the
noise goats make.
We need to examine both the anterior and posterior chest. In order to minimize discomfort
to the patient, complete IPPA for one side first, then the other.
It is worth noting the posterior chest often yields the most information.
We will then complete the examination by moving on from the trunk, down to the legs.
Concluding the examination

Thank the patient and ensure that they are comfortable. They may need to be
helped back into their previous position or assisted in putting their clothes back on.

Wash your hands to ensure that you do not carry infection to your next patient.

Inform the patient what will happen next (for example explaining that you will report
findings to supervisor/will be seen be the doctor shortly…)

Or, if supervised, summarize your findings to your supervisor at end of your exam.
10
Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Exercise 3 - The Respiratory Examination (45 minutes)
Your tutor will now demonstrate the full Respiratory Examination. Then, have a go yourselves…
Your patient today will be Mr. Coffey, who has been referred to the Respiratory clinic with a
persistent cough. Your Consultant has asked you to examine him, she will be in to see the
patient in 15 minutes and will repeat some of the examination again.
Tutors- 4 stage teach of Resp Exam. Please for teaching purposes only, do both TVF and VR,
though make it clear they ultimately only need to do one of these. They should practice both
today. Leave the cervical lymph node exam – we will cover this at the end of the session, just
state where you would do it in the exam. HR and RR do not need to be calculated as will have a
‘vital signs’ session to practice this is but still must be stated/modelled. JVP should also be done,
but this will get more coverage next week, so don’t spend long discussing/giving feedback
Ask them to follow what you are doing during stage 1 and 2 by using the structure given.
Then get them to put books away and run through stage 3 with a volunteer. Continue at stage 3
until they are getting familiar. Then stage 4. Due to constraints on time you may need to split ‘1
exam’ between students, so all have some practical task. This must be done as a group, do not
split into pairs.
Introduction





Introduce yourself and check you have the correct patient Tutors – note you have been
given this info
Explain procedure and obtain informed consent
Offer chaperone as appropriate
Expose/Position patient ensuring they are comfortable and dignity is maintained
Wash your hands +/- clean stethoscope
General Inspection
From the end of the bed:
 Patient
o Alert? Comfortable?
o Colour – cyanosis?
o Breathless?
 Tachypnoea
 Accessory muscle use, tracheal tug
 Posture – ‘fixing chest wall’
o Pursed lip breathing
o Cough/wheeze
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Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller

Environment
o Oxygen
o Medications
o Sputum pot
o Walking aids
o Observation/drug chart – esp. Oxygen saturations
Peripheral Examination
Hands
• Clubbing
• Tar Staining
• Peripheral cyanosis
• Small muscle wasting
Tremor
Asterixis (CO2 retention flap)
Heart rate
Respiratory rate
Face
 Eyes
o Anaemia
o Horner’s syndrome
 Mouth
o Central cyanosis
Neck
 Scars, visible masses
 JVP
 Tracheal deviation
Anterior and Lateral Chest Examination
Inspection
 Scars e.g. thoracotomy
 Chest wall movement
 Chest wall deformities
 Flail chest
 Prominent chest wall veins
12
Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Palpation
 Expansion
o Pump handle movement – upper chest
o Bucket handle movement – lower chest
 Tactile Vocal Fremitus (can be omitted if performing Vocal Resonance)
 If patient has pain – you may also wish to palpate over this area
Is this symmetrical? Is expansion normal or reduced?
Percussion
 Percuss over minimum 3 positions comparing sides
o Clavicle
o Upper anterior chest
o Lateral chest in nipple line
Is this resonant? Dull? (or ‘Stony dull’) Hyperresonant?
Auscultation
 Auscultate over landmark points as above comparing sides
 Vocal Resonance (can be omitted if performing Tactile Vocal Fremitus)
 Aegophony if appropriate
Are the breath sounds vesicular? Reduced or absent?
Are there any added sounds?
 Crepitations (‘crackles’)
 Wheeze
 Bronchial breathing
 Rhonchi
 Pleural rub
Posterior Chest Examination
Inspection
 Scars
 Kyphosis
Palpation
 Expansion
 Tactile Vocal Fremitus*
Is this symmetrical? Is expansion normal or reduced?
Percussion
 At least 3 points comparing side to side
o Upper/Mid/Lower
Is this resonant? Dull? (or ‘Stony dull’) Hyperresonant?
13
Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Auscultation
 At landmark points comparing side to side
 Vocal Resonance*
 Aegophony if appropriate
Are the breath sounds vescicular? Reduced or absent?
Are there any added sounds?
Completing the Examination
Cervical lymph node examination (see below)
Inspection/Palpation of lower limbs
 DVT
 Pitting oedema
Concluding the examination




Thank patient
Ensure comfortable
Wash hands
Explain next steps to patient/Summarise to supervisor
Exercise 4- Cervical lymph node examination (10 mins)
Tutors - the student will cover this again during their Life Maintenance module. Perform a stage 2
demonstration of a cervical lymph node examination (3-4 mins). Spend the remaining time
circulating whilst student practice examining in pairs and provide feedback.
Upper respiratory tract pathology drains to cervical neck lymph nodes; lower respiratory tract
pathology may lead to enlargement of supraclavicular lymph nodes, as well as axillary and
mediastinal lymph nodes.
Examination:
It is usual to examine the neck standing behind the patient, so sit patient upright. Be aware
this may create communication difficulties.
Palpate both sides of the neck simultaneously apart from lateral to the thyroid cartilage
(carotids arteries). All areas should be covered: the order doesn’t matter, but the process
should be fluent and systematic. We suggest palpating in the order below – watch your tutor
demonstrate:
14
Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller











Start on the mastoid process
Anterior border of the trapezius muscle
Posterior triangle (flat of your fingers)
Posterior border of the sternocleidomastoid muscle
Anterior border of the sternocleidomastoid
Midline including thyroid and larynx
Submental group of lymph nodes
Inferior border of the horizontal ramus of the mandible (submandibular nodes)
Pre-auricular
Post-auricular
Occipital lymph nodes
Source:
meded.ucsd.edu/clinicalmed/head.htm
photographs by Charlie Goldberg,
M.D., UCSD School of Medicine, USA
accessed 11.1.13
15
Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Self Directed Learning
The only way to learn a skill is deliberate and repeated practice. You will also become
confident with ‘normal’ findings, which then makes it easier to identify pathological signs.
You must spend sufficient time practicing these examinations before your exams and
commencing your clinical placements.
You should:
1. Practice the Respiratory Examination on peers, friends and family
2. When you are feeling more confident, practice ‘presenting your findings’ i.e. saying what
you find to a ‘supervisor’ as you go along.
Top Tip:
Remember: You do not need to tell the supervisor what you are doing only what you have or
have not found.
You do need to tell the patient what you are doing.
Be careful with your communication here: Can you recall the different ways you
described movements in APE1?
 Use jargon free language to explain what you are doing to the patient.
 Use specific and succinct terminology when presenting your findings to your
supervisor.
In T-year and on your clinical attachments, you will be examining real patients with clinical signs
due to underlying pathology.
You should:
1. Complete the following questions to help familiarise yourself with pathological signs
2. Have a go at working out the diagnoses from the clinical signs given below
Questions
1. Name the pulmonary causes of clubbing.
2. What are the following?
a. Barrel chest
b. Pectus excavatum
c. Pectus carinatum
3.
a. What conditions can cause crepitations?
b. What other information about the crepitations is useful to know to help determine
the cause?
4.
a. What causes a wheeze?
16
Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
b. What conditions might this be seen in?
5.
a. Name a condition which causes kyphoscoliosis
b. How might this affect breathing?
6.
a. What is stridor?
b. What should you do if hear this in a patient?
7.
a. Name some signs of respiratory distress.
b. Are their any additional signs you should look for, if your patient is a child?
Clinical Reasoning
The following patients have been examined and pertinent findings are documented below.
 What is the diagnosis or are the differential diagnoses based on the findings given?
1. 25-year old gentleman with sudden onset chest pain and shortness of breath:
• Asymmetrical chest expansion, with expansion reduced on the right
• Hyperresonant percussion on the right compared with the left
• Reduced air entry throughout the whole right lung
• Reduced vocal resonance throughout the right lung
2. 56-year old gentleman with a cough productive of green sputum for the past 5
days
• Temperature of 37.9 oC
• Bilateral equal chest expansion
• Resonant percussion throughout
• Course crepitations at the left base (left lower zone)
• Increased vocal resonance at the left base
3. 75-year old lady with a 3-week history of worsening shortness of breath especially
when lying flat.
• No evidence of clubbing
• Raised JVP - 5cm above the manubriosternal angle
• Reduced but symmetrical chest expansion
• Resonant percussion
• Bibasal fine crepitations
• Pitting oedema bilaterally to the knee
17
Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
4. 66-year old gentleman with shortness of breath that is worse than usual, ex
smoker
• Barrel chest
• Reduced symmetrical expansion
• Resonant percussion bilaterally
• Expiratory wheeze throughout
• No crepitations
5. 45-year old lady with a history of breast cancer with shortness of breath
• Tracheal deviation to right
• Mastectomy scar on left anterior chest wall noted
• Reduced chest expansion on the left
• Dull to percussion whole left chest
• Reduced air entry and vocal resonance throughout left side
18
Life Support: Introduction to Systematic Examination &
Respiratory System Examination – Tutor notes 2016-17
Clinical Skills Lecturer: Dr Claire Spiller
Additional technical info sheet for Tutors:
You will notice some signs are written in bold/others not. This is to try and de-emphasise some of
the more obscure signs we ask you to look for, therefore please don’t dwell too long on these.
Some extra information for your reference is provided below.
Techniques will be demonstrated at the briefing.
Peripheral examination


Tremor – hold hands out: b2 agonists such as salbutamol
Asterixis with cocked wrists – held for 15 secs (looking for more of a flapping jerk vs tremor)

RR should be demonstrated by laying the patients arm across their chest

Pursed lip breathing – prolonged exhalation through pursed lips, helps keep airways open
longer and reduce the work of breathing
Accessory muscles: Scalenes, Sternocleidomastoid
Fixing of chest wall = ‘Tripod’ position: allows pectoralis +/- neck muscles to be accessory
muscles of respiration by fixing upper limb (like after intense exercise)
Tracheal tug – suprasternal recession/indrawing associated with increased work of breathing




Pitting oedema – please hold for a few seconds, not just cursory; will leave finger impression
(important as with JVP – R heart failure can accompany chronic lung diseases: ‘cor
pulmonale’ which is pulmonary hypertension secondary to lung disease)
Chest wall
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Scars – Thoracotomy: seen laterally and posteriorly. ‘Hands on hips’
Dilated veins on chest wall – Superior Vena Cava Obstruction
Flail chest – paradoxical movement of broken ribs during respiration – ‘sucked’ in during
inspiration (need multiple breaks)
Kyphosis – please check from the side
Additional sounds
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Bronchial breathing – harsh breath sounds mimicked by listening over the trachea (they have
done this before). There is an audible gap between inspiration and expiration and the
expiratory phase is equal to or longer than inspiration, unlike vesicular breathing. Suggests
underlying consolidation.
Rhonchi – noisy ‘snoring’ breath sounds on auscultation – suggestive of secretions in
bronchi
Pleural rub – squeak, like’ walking on fresh snow’ – sign of pleural inflammation
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