Internal Medicine

🫁 Respiratory Examination (Part 2)

High-Yield Pulmonology

Amos Asamoah
November 2025
5 min read
Clinical Skills

Part 2 focuses on the systematic physical examination of the respiratory system, from initial inspection through advanced auscultation techniques. Master these hands-on skills to accurately detect pulmonary pathology and differentiate between common respiratory conditions.

🎯 Examination Setup & Initial Assessment

🎯 Patient Preparation

Optimal Positioning:

  • 45-degree elevation on bed/couch
  • Comfortable, relaxed position
  • Full chest exposure for comprehensive assessment

Step 1: Sputum Inspection:

🎯 Assessment Parameters

  • Amount: Cupful vs. bucket quantities
  • Color: White, yellow/green, rusty, bloody
  • Viscosity: Thick, stringy consistency
  • Odor: Offensive smell indicates anaerobic infection

👀 Step 2: General Inspection - Peripheral Signs

👀 Systemic Clues Assessment

Clubbing Evaluation:

🎯 Respiratory Causes

  • Suppurative lung disease (empyema, abscess, bronchiectasis)
  • Bronchial carcinoma
  • Fibrosing alveolitis, asbestosis
  • Pleural fibrosis
  • Congenital (non-pathological)

🎯 Examination Technique

  • Oppose middle fingers - should feel firm
  • Early clubbing: Sponginess at nail fold
  • Press with index fingers while supporting distal phalanx

Hypertrophic Pulmonary Osteoarthropathy:

  • Pain/swelling over long bone ends (wrists, ankles)
  • Almost always associated with squamous cell lung cancer
  • Often accompanies clubbing

Other Peripheral Signs:

🎯 Tar Staining

  • Yellow-brown finger/nail discoloration
  • Heavy smoker indicator
  • Major risk for COPD and lung cancer

🎯 Pallor Assessment

  • Check palms, nails, conjunctiva, tongue, buccal mucosa
  • Evert lower lip for mucosal inspection
  • Anemia suggests chronic disease or malignancy

🎯 Cyanosis Differentiation

  • Central: Bluish tongue (poor oxygenation)
  • Peripheral: Blue fingers/toes/lips (poor circulation)
  • Requires ≥5g reduced hemoglobin for visibility
  • Methemoglobinemia can mimic central cyanosis

Critical Respiratory Signs:

🎯 CO₂ Retention Flap (Asterixis)

  • Extended arms with dorsiflexed wrists ("stop traffic")
  • Flapping tremor indicates severe COPD/respiratory failure

🎯 Cachexia

  • Severe weight loss and muscle wasting
  • Chronic illness or malignancy indicator

🎯 Respiratory Distress Signs

  • Intercostal recession: Rib space sucking in
  • Accessory muscle use: Neck/shoulder muscle recruitment
  • Indicates severe obstruction or respiratory distress

👤 Step 3: Face and Neck Assessment

👤 Head & Neck Examination

Key Observations:

🎯 Pursed-Lip Breathing

  • Exhalation through nearly closed lips
  • Helps maintain airway patency in severe COPD
  • Compensatory mechanism for air trapping

🎯 Tracheal Tug

  • Trachea pulls downward with inspiration
  • Characteristic finding in COPD
  • Indicates increased respiratory effort

📏 Step 4: Chest Inspection

📏 Thoracic Configuration Assessment

Chest Shape Abnormalities:

🎯 Barrel Chest

  • Increased anteroposterior diameter
  • Horizontal rib orientation
  • Classic for: Emphysema

🎯 Congenital Deformities

  • Pectus excavatum: Sunken sternum
  • Pectus carinatum: Pigeon chest

🎯 Spinal Abnormalities

  • Kyphosis: Forward spinal curvature
  • Scoliosis: Lateral spinal curvature
  • Kyphoscoliosis: Combined - can restrict breathing

Surface Assessment:

🎯 Skin & Scars

  • Surgical scar documentation
  • Trauma evidence
  • Lumps, rashes, or other lesions

🎯 Vascular Patterns

  • SVC Obstruction: Dilated, non-pulsatile chest veins
  • Engorged, fixed jugular veins
  • Facial/neck swelling, conjunctival edema
  • Common cause: Bronchial carcinoma/mediastinal nodes

🌬️ Step 5: Respiratory Rate & Pattern

🌬️ Breathing Pattern Analysis

Respiratory Rate Norms:

🎯 Normal Range

  • 12-20 breaths/minute (average 16)
  • Tachypnea: >20/min - important early sign

Pathological Breathing Patterns:

🎯 Shallow Breathing

  • Pain limitation
  • Pulmonary fibrosis
  • Chest wall restriction

🎯 Kussmaul's Breathing

  • Deep, labored respirations
  • Metabolic acidosis (DKA, renal failure)

🎯 Cheyne-Stokes Breathing

  • Cyclical pattern: apnea → increasing depth/rate → decreasing → apnea
  • ~2-minute cycles
  • Significance: Serious brainstem dysfunction

🎯 Frequent Sighing

  • Suggests psychogenic component
  • Anxiety-related breathing pattern

👐 Steps 6-10: Hands-On Chest Examination

👐 Palpation, Percussion & More

Step 6: Chest Wall Movement:

🎯 Inspection & Palpation

  • Assess symmetry of expansion
  • Asymmetric: Local pathology (consolidation, effusion, pneumothorax)
  • Normal expansion: ~5cm at nipple level
  • Flail chest: Paradoxical inward movement during inspiration

🎯 Subcutaneous Emphysema

  • Crackling sensation under skin
  • Air in subcutaneous tissues
  • Pneumothorax or chest trauma indicator

Step 7: Tracheal Position:

🎯 Assessment Technique

  • Middle, index, ring fingers in suprasternal notch
  • Normal: Central position

🎯 Pathological Deviations

  • Away from affected side: Pneumothorax, massive effusion
  • Toward affected side: Lung collapse, fibrosis

Step 8: Lymph Node Examination:

🎯 Cervical Nodes

  • Examine from behind patient
  • Relaxed neck position
  • Systematic palpation
  • Causes: Carcinoma, lymphoma, TB, sarcoidosis

🎯 Axillary Nodes

  • Support arm on forearm
  • Palpate apical, central, medial groups
  • Switch hands for lateral group assessment

Step 9: Tactile Fremitus:

🎯 Technique

  • Hand on chest, patient says "ninety-nine" or "ko ko"
  • Compare vibration transmission bilaterally

🎯 Interpretation

  • Normal/Increased: Normal lung, consolidation
  • Reduced/Absent: Effusion, thickening, pneumothorax
  • Clinical use: Differentiates dull percussion causes

Step 10: Percussion Technique:

🎯 Proper Method

  • Percuss directly on clavicle first
  • Left middle finger flat on chest
  • Strike middle phalanx with right middle finger
  • Wrist action only (hammering motion)
  • Move ~1 inch, always compare sides

🎯 Percussion Locations

  • Anterior: Mid-clavicular and anterior axillary lines
  • Axilla: Hands on head for exposure
  • Posterior: Medial scapula border and posterior axillary line

🎯 Percussion Notes

  • Resonant: Normal lung tissue
  • Hyper-resonant: Pneumothorax
  • Impaired/Dull: Consolidation, collapse, fibrosis
  • Stony dull: Pleural effusion, empyema

🎵 Step 11: Auscultation - Breath Sounds

🎵 Advanced Listening Techniques

Equipment & Technique:

🎯 Stethoscope Selection

  • Use BELL (not diaphragm)
  • Diaphragm causes hair friction → artificial crackles
  • Hard to flatten diaphragm on thin patients

🎯 Proper Method

  • "Take deep breaths in/out with mouth open"
  • Listen >2-3 cm from midline (lung tissue, not airways)
  • Always compare corresponding areas bilaterally
  • Gentle approach for pleuritic pain patients

Auscultation Assessment Parameters:

🎯 Three Key Elements

  • Air entry: Normal, reduced, or absent
  • Breath sound type: Vesicular vs. bronchial
  • Added sounds: Crackles, wheeze, rub

Breath Sound Types:

🎯 Vesicular (Normal)

  • Soft, rustling quality
  • "Wind through leaves"
  • Inspiratory phase longer than expiratory

🎯 Bronchial (Abnormal)

  • Harsh, high-pitched
  • "Blowing through tube" quality
  • Clear inspiratory-expiratory pause
  • Expiration heard throughout
  • Locations: Consolidation, collapse, fibrosis
  • Normal over: Larynx/trachea only

🎯 Other Terminology

  • Tubular: Synonym for bronchial
  • Broncho-vesicular: Mixed normal/bronchial
  • Cavernous/Amphoteric: Cavity-originating sounds

Reduced/Absent Breath Sound Causes:

🎯 Transmission Barriers

  • Pleural effusion
  • Pneumothorax
  • Lung collapse

🎯 Reduced Airflow

  • Obesity
  • Hyperinflation
  • Depressed ventilation (unconscious state)
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