the respiratory system examination dr mike henry dr claire bowker dept of respiratory medicine leeds...
TRANSCRIPT
The Respiratory System Examination
Dr Mike HenryDr Claire Bowker
Dept of Respiratory MedicineLeeds General Infirmary
Major Symptoms of Respiratory Disease
• Cough
• Sputum production
• Dyspnoea
• Haemoptysis
• Wheeze
• Chest pain - pleuritic
Cough• Larynx / Pharynx – harsh and painful• Trachea – harsh, dry and painful / productive• Bronchitis - paroxysmal / productive
AcuteChronic
• Carcinoma – short / dry - haemoptysis• Bronchiectasis – productive purulent sputum• Pneumonia – painful and productive• Pulmonary Oedema – dyspnoea/ orthopnoea/ PND• Fibrosing alveolitis – dry / short / persistent
Sputum
• Amount
• Character
• Viscosity
• Taste or odour
Dyspnoea
• Dyspnoea associated with increased work of breathing
• Dyspnoea associated with increased pulmonary ventilation
• Dyspnoea associated with weakness of muscles of respiration
• Dyspnoea associated with multiple factors
Acute Onset Dyspnoea
Sudden Rapid(minutes) (hours – days)
Pneumothorax Acute asthmaSevere acute asthma Pulmonary oedemaPulmonary embolism PneumoniaLaryngeal oedema Acute bronchitisForeign body Allergic alveolitisPulmonary oedema (orthopnoea / PND)
Gradual Onset Dyspnoea
• Onset days – weeks – months
Pleural effusion
Chronic asthma
Fibrosing alveolitis
Tuberculosis
Chronic bronchitis
Bronchial carcinoma
Slow Onset Dyspnoea
• Onset months – years
Pleural fibrosis
Emphysema
Pneumoniconiosis
SarcoidosisChronic broncitis
Ankylosing spondylosis
Haemoptysis
Type and degree
• Frank – whole blood / clots Carcinoma / PE / Bronchiectasis / TB
• Blood Stained – blood/sputum mixedSuppurative pneumonia / Carcinoma
• Blood Streaked – streaks or flecksCarcinoma / chronic bronchitis
• Rusty – degraded HbPneumococcal pneumonia
Aetiology of Wheeze
Chest PainSite CharacterRadiation SeverityDuration Frequency and
periodicityAggravating factors Relieving factors
Associated phenomena
• Upper reterosternal – tracheitis
• Reterosternal – oppressive similar to cardiac pain / not related to exertion
• Pleuritic – stretching of inflammed parietal pleura
The Physical Examinationfrom the end of the bed - Inspection
• Patient comfortable ? / Supine 45• Look around the bed• Measures of respiratory compromise
RESPIRATORY RATE Use of accessory muscles
• Audible sounds• Patient in pain• Cyanosis• Oedema• SVCO
Palpation• Hands
Finger clubbingCyanosis
Signs of CO2 retention• Eyes
Signs of CO2 retentionAnaemiaHorners syndromePapilloedema
The Laying on of HandsPalpation
• The NeckScalene lymph nodesJVP – jugular venous pressureTrachea
CentralTracheal tug
Thyroid• Skin
Erythema nodosumMetastatic carcinoma nodulesLupus pernio
Chest wall• Symmetry of chest wall movements during
tidal and deep breathing• Chest expansion (2-4 cms) Two levels ?• Significance of reduced chest wall
movements• Anteropostero:lateral diameter = 5:7• Pectus excavatum / Carinatum /
kyphoscholiosis• Thoracic operations / thoracoplasty
Chest wall
• Significance of reduced chest wall movements
• Pleural Effusion: reduced unilateral• Consolidation : reduced unilateral• Collapse of lobe: reduced unilateral• Pneumothorax: reduced unilateral• COPD:reduced bilateral• Asthma: reduced bilateral• Pulmonary fibrosis: reduced bilateral
PercussionWhere to percuss
How to percuss - technique
• Normal: Resonant• Impaired: consolidation / collapse / fibrosis• Dull: consolidation / collapse / pleural thickening• Stony dull: fluid = pleural effusion• Hyperresonant : pneumothorax• Typanic: hollow viscus
• Vocal tactile fremitus• Vocal resonance
Percussion
Auscultation
• Normal breath sounds produced by air through larynx / vocal cords vibrations
• Vibrations transmitted through airways to the chest wall rustling sound = Vesicular
• Diminished: airflow obstruction / pneumothorax / pleural effusion
• Bronchial breath sounds: consolidation, fibrosis or collapse: resemble breath sounds heard over larynx
Auscultation
Added sounds
Wheezes – passage of air through narrow bronchi
Usually expiratoryIf inspiratory – mucosal oedema clear with coughDescribe siteFixed low pitch – STRIDOR – upper
airflow obstruction
Added soundsCrackles
Explosive reopening of small airways occluded during expiration
Fine crackles: pulmonary oedema / consolidation – usually inspiratory
Course crackles: pulmonary fibrosis / bronchiectasis
Plueral rub / pleural click
Interstitial Lung Disease – CFA Bilateral course / velcro bibasal crackles
Pleural Effusion
• Chest expansion - reduced
• Percussion - stony dull
• Breath sounds - absent or decreased
• Added sounds - none
• Vocal resonance - absent or decreased
Consolidation
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Consolidation
• Chest expansion - reduced
• Percussion - dull
• Breath sounds - bronchial
• Added sounds - crackles
• Vocal resonance - increased (whispering pectorilouy)
ATAELECTASIS - Total right lung collapse
Collapse left lower lobe – The Sail Sign
Collapse / Atelectasis lobe or lung
• Chest expansion - reduced
• Percussion note - dull
• Breath sounds - absent or diminished
• Added sounds - none / crackles or wheeze
• Vocal resonance - absent / decreased
Pneumothorax
• Chest expansion - reduced
• Percussion - hyperresonant
• Breath sounds - absent or decreased
• Added sounds - none, occasionally click
• Vocal resonance - decreased