the respiratory system examination

8/14/2019 The Respiratory System Examination

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THE RESPIRATORYTHE RESPIRATORY

SYSTEM EXAMINATIONSYSTEM EXAMINATION

1.COUGH-1.COUGH- Coughing is a relativelyCoughing is a relatively

nonspecific symptom,resulting from irritationnonspecific symptom,resulting from irritation

anywhere from the pharynx to the lungs.Theanywhere from the pharynx to the lungs.Thecharacter of a patients cough may , however,character of a patients cough may , however,

give some clues to the underlaying cause.give some clues to the underlaying cause.

Ask for- DurationAsk for- Duration

e.g. chronic cough-e.g. chronic cough- think of pertussis, TB,think of pertussis, TB,foreign body, asthma.foreign body, asthma.


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DYSPNOEADYSPNOEA- Ask for Duration ,Steps climbed- Ask for Duration ,Steps climbed/Distance walked before onset./Distance walked before onset.

HOARSENESSHOARSENESS- e.g Due to Laryngitis,Singers- e.g Due to Laryngitis,SingersNodules or larengial tumourNodules or larengial tumour

FEVER/NIGHT SWEATS-FEVER/NIGHT SWEATS- Moderate nightModerate nightsweating is common in anxiety states, but severalsweating is common in anxiety states, but severalchanges of night clothes is a more ominouschanges of night clothes is a more ominoussymptom associated with infection. e.g. TB,symptom associated with infection. e.g. TB,lymphoproliferative disease or mesothelioma andlymphoproliferative disease or mesothelioma andpneumonia.pneumonia.

CHEST PAIN-CHEST PAIN- Pleuritic pain is exacerbated byPleuritic pain is exacerbated byinspiration implies inflammation of the pleurainspiration implies inflammation of the pleurasecondary to pulmonary infection, inflammationsecondary to pulmonary infection, inflammationor infarction.It causes the pt. to catch his breath.or infarction.It causes the pt. to catch his breath.


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WHEEZE- (RONCHI)-WHEEZE- (RONCHI)- are caused by air passingare caused by air passing

through narrowed airways.They may bethrough narrowed airways.They may be

monophonic(a single note, signify partialmonophonic(a single note, signify partial

obstruction) or polyphonic signify widespreadobstruction) or polyphonic signify widespread

narrowing of airways. Wheeze may also be heardnarrowing of airways. Wheeze may also be heardin LVF ( cardiac asthma).in LVF ( cardiac asthma).

STRIDOR-STRIDOR- is a term used to describe a snoringis a term used to describe a snoring

sound heard over extrathoracic airways.It ia ansound heard over extrathoracic airways.It ia an

inspiratory sound doe to partial obstruction of theinspiratory sound doe to partial obstruction of theupper airways.upper airways.


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PAST HISTORY- W/F-PAST HISTORY- W/F- Pneumonia, TB,Pneumonia, TB,bronchitis, Atopy(eczema, asthma, hay fever).bronchitis, Atopy(eczema, asthma, hay fever).

Previous CXR abnormalities, lung surgery.Previous CXR abnormalities, lung surgery.

FAMILY HISTORY-FAMILY HISTORY- Atopy, Emphysema, TB.Atopy, Emphysema, TB.

SOCIAL HISTORY-SOCIAL HISTORY- Ask for smoking andAsk for smoking andoccupational exposure.occupational exposure.

DRUG HISTORY-DRUG HISTORY- Ask for respiratory drugs(e.g.Ask for respiratory drugs(e.g.steroids, bronchdilators), any other drugssteroids, bronchdilators), any other drugsespecially those with respiratory side effects, e.g.especially those with respiratory side effects, e.g.

betablockers, ACE inhibitors.betablockers, ACE inhibitors.


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EXAMINATION-EXAMINATION-Assess general health.Assess general health.

( INSPECTION)( INSPECTION)

Is he diseased? Cachectic? Using accessoryIs he diseased? Cachectic? Using accessorymuscles in respiration? Are there signs of RDS?muscles in respiration? Are there signs of RDS?

Count the respiratory rate and breathing pattern.Count the respiratory rate and breathing pattern.Is there Kussmauls breathing?Is there Kussmauls breathing?

(Rapid, deep respirstion)(Rapid, deep respirstion)

It is deep, slow breathing that is principallyIt is deep, slow breathing that is principallyseen in metabolic acidosis and uraemia.seen in metabolic acidosis and uraemia.

Is there Chyne-stokes breathing?Is there Chyne-stokes breathing?(Apnoea alternating with hyperapnoea)(Apnoea alternating with hyperapnoea)

Breathing becomes progressively deeper and thenBreathing becomes progressively deeper and thenshallower.shallower.


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W/F- Chest wall deformities-W/F- Chest wall deformities-

1. Barrel chest-1. Barrel chest- AP diameter . seen in chronicAP diameter . seen in chronichyperinflation. e.g. asthma, COPD.hyperinflation. e.g. asthma, COPD.

2. Funnel chest-2. Funnel chest-(pectus excavatum)-(pectus excavatum)- it isit is

developmental defect involving local sternumdevelopmental defect involving local sternumdepression.depression.

3. Pigeon chest(pectus carinatum)-3. Pigeon chest(pectus carinatum)-prominent sternum with a flat chest seen inprominent sternum with a flat chest seen in

chronic childhood asthma and in ricketchronic childhood asthma and in ricket


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W/F- Chest wall movement-W/F- Chest wall movement- Is it symmetrical?Is it symmetrical?If not, pathology is on restricted side. Is thereIf not, pathology is on restricted side. Is thereparadoxical respiration?( abdomen sucked in withparadoxical respiration?( abdomen sucked in withrespiration, seen in diaphragmatic paralysis)respiration, seen in diaphragmatic paralysis)

W/F- Deformities of the spine.W/F- Deformities of the spine.1. Kyphosis-1. Kyphosis- Humpback from thoracic spineHumpback from thoracic spinecurvature.curvature.

2. Scoliosis-2. Scoliosis- Lateral curvatureLateral curvature

Both may cause restrictive ventilatory defect.Both may cause restrictive ventilatory defect.3. Harrisons sulcus-3. Harrisons sulcus- is a groove deformity ofis a groove deformity oflower ribs at the diaphragm attachment sitelower ribs at the diaphragm attachment sitesuggesting chronic childhood asthma and rickets.suggesting chronic childhood asthma and rickets.


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Examine the hands-Examine the hands-W/F-W/F-1. Clubbing-1. Clubbing- Finger nails haveFinger nails have

exaggerated longitudinal curvature + loss ofexaggerated longitudinal curvature + loss of

angle between nail and nail folds and the nail foldangle between nail and nail folds and the nail foldfeels boggy.feels boggy.

W/F- 2.W/F- 2.Peripheral cyanosis.Peripheral cyanosis.

Inspect the face-Inspect the face- check for ptosis andcheck for ptosis and

constricted pupil.constricted pupil.W/F W/F Tongue and lips for central cyanosis.Tongue and lips for central cyanosis.


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Palpation-Palpation-1. W/F-1. W/F- Lymphadenopathy-Lymphadenopathy- Check for cervicalCheck for cervicalLymphadenopathy from behind with the pt.Lymphadenopathy from behind with the pt.sitting forwardsitting forward

2. W/F- Tracheal position-2. W/F- Tracheal position- Is it central orIs it central ordisplaced to one side?displaced to one side?

If deviated, concentrate to upper lobe forIf deviated, concentrate to upper lobe forpathology.pathology.

3. W/F- Chest exapansion-3. W/F- Chest exapansion- Use both hands toUse both hands to

compare chest exapansion on bothcompare chest exapansion on bothsides.Exapansion < 5 cm on deep inspiration issides.Exapansion < 5 cm on deep inspiration isabnormal.Reduced exapansion implies pathologyabnormal.Reduced exapansion implies pathologyon that side.on that side.


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4. W/F- Tactile vocal fremitus-4. W/F- Tactile vocal fremitus- By asking theBy asking the

pt. to repeat 99 while palpating chest wall overpt. to repeat 99 while palpating chest wall over

different respiratory segments comparing similardifferent respiratory segments comparing similar

positions over each lung in turn.Increased vocalpositions over each lung in turn.Increased vocal

fremitus implies consolidation.fremitus implies consolidation.

5.W/F- Vocal resonance-5.W/F- Vocal resonance- is sound vibration ofis sound vibration of

the pts. Spoken or whispered voice transmittedthe pts. Spoken or whispered voice transmitted

to the stethoscope.to the stethoscope.


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Percussion-Percussion- Percuss symmetrical areas of thePercuss symmetrical areas of theAnterior, Posterior and Axillary regions of theAnterior, Posterior and Axillary regions of the

chest wall and note down the percussion note.chest wall and note down the percussion note.

For the percussion of the chest, put the indexFor the percussion of the chest, put the indexfinger of the left hand in the intercostals apacefinger of the left hand in the intercostals apace

and stroke the index finger of the right hand onand stroke the index finger of the right hand on

this left index finger.The movement of the rightthis left index finger.The movement of the right

hand should be from the wrist joint.hand should be from the wrist joint.


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Percussion note-Percussion note-1. Resonant note-1. Resonant note- is the normal.is the normal.

2. Hyper resonant -2. Hyper resonant - suspect pneumothorax orsuspect pneumothorax orhyperinflation.hyperinflation.

3. Stony dull-3. Stony dull- suspect lobe collapse.suspect lobe collapse.Consolidation, fibrosis, pleural thickening, orConsolidation, fibrosis, pleural thickening, orpleural effusion.pleural effusion.

TheThecardiac dullnesscardiac dullness is usuallydetectable overis usuallydetectable overthe left side of the chest.the left side of the chest.

The liver dullnessThe liver dullness usually extends up to theusually extends up to thefifth rib, right mid clavicular line, if the chest isfifth rib, right mid clavicular line, if the chest isresonant below this level, it is a sign of lungresonant below this level, it is a sign of lunghyperexapansion.hyperexapansion.


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4. Vesicular breathing-4. Vesicular breathing- Normally heard allNormally heard allover the lungs.It is a normal breath soundsover the lungs.It is a normal breath soundshaving a rustling quality.having a rustling quality.

5. Bronchial breathing-5. Bronchial breathing- Normally heard overNormally heard over

the trachea and bronchus. It has hollow qualitythe trachea and bronchus. It has hollow qualityand occur where lung tissue become firm , solidand occur where lung tissue become firm , soliddue to consolidatuion, localized fibrosis etc.due to consolidatuion, localized fibrosis etc.

6. Pleural rubs-6. Pleural rubs- are caused by movement of theare caused by movement of thevisceral pleura over the parietal pleural, whenvisceral pleura over the parietal pleural, when

both surfaces are roughened. E.g. by anboth surfaces are roughened. E.g. by aninflammatory exudate(pneumonia, pulmonaryinflammatory exudate(pneumonia, pulmonaryinfarction)infarction)


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Further Examination-Further Examination- Look at the JVP.Look at the JVP.

the respiratory system examination

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