Respiratory checklist

WIPPER and the intro

• Introduce yourself and shake hands
• Washing of hands and appropriate hand hygiene
• Asking for permission
• Ensuring the room’s privacy
• Ensuring the environmental warmth and good lighting conditions
• Asking for appropriate exposure (from the waist and above)
• Asking the patient to be in the appropriate position (simi-sitting at 45 degrees in bed)
• Relocating to the right side of the patient
• Asking for a chaperon
• “I have all of my equipment’s”

General look of the patient

• Consciousness, alertness and orientation of the patient to place, time and person (Asking the 3 questions) - in RS, disorientation is a sign for CO2 retention, it causes confusion (Hypercapnia)
• Commenting on the patient’s position and comfort
• Commenting on the patient’s external devices status (No oxygen masks, nebulizers etc.)
• Commenting on respiratory rate (Not tachypneic), respiratory distress (Mention these 2 signs)
  1. No apparent use of accessory muscles for breathing like sternocleidomastoid, trapezius and scalene)
     
  2. No Indrawing of intercostal spaces
• Commenting on cyanosis
• No abnormal sounds
• No abnormal odors

Vital signs

• Make sure you know the 6 vital signs

• What is pulsus paradoxus?

• Pulsus paradoxus is a more marked inspiratory decrease in arterial pressure exceeding 10 mmHg

• BMI is vital in respiratory system, obese patients may get obstructive sleep apnea

• Weight loss in COPD patients increases risk of morbidities (++inflammatory cytokines = ++metabolic rate)

Hands examination

Starting with the still hand

• No deformities / amputations
• No palmar erythema
• No pallor
• No scars, swellings and no visible masses
• No tar staining
• No muscle wasting (thenar and hypothenar)

Moving on to the nails

• No clubbing (May be asked to do the 3 tests, nail bed angle / schamroth’s window / fluctuations)
• No nail deformities like yellow nail syndrome

Hand palpation and radial pulse

• After doing the usual for palpation; check temperature + dryness/sweatiness
• Test for HPOA (Hypertrophic pulmonary osteoarthropathy) (Wrist tenderness)
• Test for Capillary refill (1 minute pressure on the nail, refill in <2 seconds)
• Check radial pulse

End this section by examining for tremor

• Test for fine tremor
• Test for asterixis (Flapping tremor) ~ (CO2 retention)

Face examination

• Comment on having no plethoric face
• Comment on having no face swelling

By examining the eye, make these 3 comments:

• No jaundice (Examining the sclera)
• No pallor (Examining the color of conjunctiva)
• No conjunctival edema
• Check for Horner syndrome (3 signs; ptosis, meiosis, anhidrosis)
• No nasal flaring
• No pursed lips
• Comment on cyanosis (Peripheral on lips, central under the tongue)
• Comment on good oral and dental hygiene

Neck examination

• No scars, swellings, visible masses
• No visible dilated veins
• Mention examining the JVP (SKIP)
• Mention examining the cervical lymph nodes (SKIP)

Chest Inspection

First, relocate to the foot of the bed

• Comment on symmetrical elliptical chest in cross section (Shape)
• Before chest expansion, ask the patient to **take a deep breath first**!
• Comment on bilaterally symmetrical chest expansion
• No chest deformities (kyphosis, scoliosis, pectus carinatum, pectus excavatum, barrel chest)
• Normal bilaterally symmetrical breathing pattern that’s Abdomeno-Thoracic
• Pemberton sign (raise both of your hands, wait for facial plethora) to check for SVC obstruction

From the right side of the patient

• No Scars, swellings, visible masses
• No skin lesions ~ Subcutaneous nodules (Malignancy)
• No visible dilated veins
• Normal hair distribution
• Check the axilla too!!!!

Chest Palpation

Do the usuals for any palpation and then;

1. General palpation:

• Palpate using the palm of the hand around the chest

Mention that you found:

• No tenderness
• No subcutaneous emphysema
• No palpable masses

2. Upper mediastinum palpation:

• Using 3 fingers, check for tracheal deviation (comment that it’s centralized)
• Ask the patient to take a deep inspiration, to check for tracheal tug
• Comment on no tracheal tug
• Measure the crico-sternal distance (Normally; 3 to 4 fingers)

3. Lower mediastinum palpation:

• Using palm of the hand at first, then two fingers; locate the Apex beat
• After locating it, start from the sternal angle, horizontal with 2nd intercostal space, count and mention the position of apex beat (Normal pos is in 5th intercostal space, mid clavicular line)
• Mention that it’s gently-tapping apex beat! / gently raises the pulsating finger!
• Using heel of the hand; putting it in the lower-left sternal angle; locate the right ventricular heave, should be negative (sign of severe pulmonary hypertension)

4. Last tests

• Test for tactile vocal fremitus by using palm of the hand on 4 points anteriorly, 4 points posteriorly, 3 points laterally. (SAY اربعة واربعين)
• Comment on normal bilaterally symmetrical tactile vocal fremitus
• Test for chest expansion, upper and lower anteriorly
• Test for chest expansion, only once posteriorly

Normal chest expansion is around 2.5cm on each side!

• Comment on normal bilaterally symmetrical chest expansion

Chest Percussion

Percuss bilaterally for each spot;

• Start percussing for the lung apex (left hand pointing posteriomedial)
• Percuss on the clavicle heads with only your right middle finger
• Percuss from the 2nd intercostal space and keep going space by space
• Anteriorly and on the right, find the liver’s level
• Percuss both lateral sides of the chest
• Percuss posteriorly (`Ask patient to hug a magical pillow!)
• Calculate diaphragmatic excursion on each side! (Remember what we ask the patient for ~ deep inspiration etc) - normal distance 5-8cm

Comment on having normal, bilaterally symmetrical resonant percussion note

Chest Auscultation

Get your stethoscope ready! set it to use the diaphragm (large one), test that by GENTLY tapping it, WARM it by rubbing it with your hand

• Ask the patient to face the other side (his left side; you’re on the right side right? wait right?!)
• Ask the patient to take a deep inspiration and expiration every time the stethoscope touches him (from the mouth and not the nose)
• Listen to chest sounds using diaphragm of stethoscope on the lung apex, anterior chest, lateral and posterior chest (again, bilaterally on each spot)
• Comment on normal bilaterally symmetrical vesicular breathing sound with inspiration phase longer than expiration
• Comment on good bilateral air entry
• Comment on having no added sounds (examples; wheeze, crackles, pleural rub)

Vocal resonance (Non-tactile)

• Listen to the chest again, same positions but instead of deep insp/exp ask the patient to say اربعة واربعين
• Comment on normal bilateral vocal resonance

Whispered pectoriloquy

• Listen to the chest again, same positions but instead of deep insp/exp ask the patient to WHISPER (يهمس اربعة واربعين)
• Comment on hearing no whispering pectoriloquy

Aeogophony

• Listen to the chest again, same positions but instead of deep insp/exp ask the patient to say E
• Comment on hearing no aeogophony

ENDING the station!

• I would like to request ENT examination for my patient to check his upper airways
• I would like to examine the abdomen for hepato-spleenomegaly and ascitis
• I would like to examine lower limbs for edema, erythema nodosum, signs of DVT