SCHEME AND PROFORMA FOR RESPIRATORY SYSTEM EXAMINATION

General observation: Drowsiness

                                    Audible wheezes or stridor

All vitals + PILCyClOD

In head to toe examination : Neck: JVP (d/t cor pulmonale)

Head: Horner’s (d/t pancoast tumor)

Oral: candidiasis (immunosuppression or prolonged use of inhaled steroids)

Upper airway examination:

Nose:

            External: external nasal framework

            Vestibular: position of nasal septum

Polyps

Signs of inflammation over the skin

Congestion

Discharge

Paranasal sinuses:

Tenderness over sinuses

Oral cavity and oropharynx:

Oral hygiene, halitosis

Teeth (caries)

Tonsils

Post nasal drip

Polyps(antrochoanal)

Lower airway examination/ CHEST EXAMINATION (ASK THE PATIENT TO SIT ON THE EDGE OF BED AND EXAMINE BACK OF CHEST FRONT THEN THE FRONT)

Inspection: (look from front, back, sides & if possible top)

Position of trachea (central/ deviated to left or right side) &trail’s sign

Use of accessory muscles of respiration

Shape of chest (relation of AP diameter to lateral diameter) & any gross deformity (Bulging or swelling        or fullness or depression or intercostals indrawing) & symmetrical or not?

Movement of chest wall with respiration

Pulsations and apical impulse (in relation to nipple)

Venous prominences

Scar marks

Pigmentation

Swelling

Sinus

Signs of inflammation

Back: scoliosis, kyphosis, position of inferior angle of both scapula and its winging, skin of back)

Palpation:

Temperature

Tenderness (rib)

Position of trachea (?tracheal tug) & cricosternal distance (normal 3 fingers but decreased in COPD)

Position of Apex beat

Confirming the findings of inspection: e.g. measure AP and lateral diameter of chest, presence of scoliosis

Chest expansion and symmetry(by crossed tape method)- (upper and lower lobes)

Tactile Vocal fremitus (in 8 areas B/L: ANTERIORLY: infraclavicular, mammary and inframammary          LATERAL: axillary and infraaxillary POSTERIORLY: supra, inter and infrascapular areas)

Percussion B/L: (?+shifting dullness)

Per cussion over lung fields:

Anterior chest: Intercostal spaces sparing precordium and till liver dullness {2^nd -6^th ICS}

 Supraclavicular fossa(from back side)

Lateral chest: upper, middle and lower {3^rd -7^th ICS or 8^th}

Posterior chest:  suprascapular, upper and lower interscapular and upper and lower infrascapular

                        {ideally all ICS; upto 11th}

            Percussion over medial 3^rd of clavicle

            Delineate the upper border of hepatic dullness (?tidal percussion)

            [coin percussion, percussion myokymia, apex percussion, kronig’s isthmus, traube’s space]

Auscultation:

Ø  Breath sounds:(quality, intensity of breath sounds ){if crackles or decreased air entry, ask to cough and auscultate again}

@large number of equivalent positions but not within 3cm from midline

Anteriorly: from above the clavicle to the 6^th rib

Laterally: from axilla to eight rib

Posteriorly: from above down to the level of 11^th rib.

Ø  Added sounds (rhonchi, wheeze, crackles, pleural rub, bronchophony, whispering pectoriloquy)

Ø  Vocal resonance (areas include as that of tactile vocal fremitus)