Resp.system examination

Compiled by: Dr.Ankit Srivastav
B.H.M.S. (Gold Medalist), M.D. (PGR)
Gorakhpur, U.P., India
Email: ankitsrivastav183@Dr.Ankit Srivastav@copyright email:ankitsrivastav183@gmail.com 14/g12m/14 ail.c1om

Dr.Ankit Srivastav@copyright email:ankitsrivastav183@gmail.com 14/12/14 2

BREATHLESSNESS ; An unpleasant subjective
awareness of the sensation of breathing.

Cardiac diseases :
• pulmonary thromboembolism
• chronic cardiac failure,
• congenital heart diseases
Respiratory diseases:
•COPD
•Asthma
• bronchial carcinoma
• interstitial diseases
• pleural effusion
Also in Diabetic
Ketoacidosis ((kkuussssmmaauull
bbrreeaatthhiinngg))
severe Anemia

•COUGH :Dry or productive
How long has cough been present ?
Is the cough worse at any time of day or night?
Is the cough aggravated by anything for e.g. dust, pollen or cold air?

WHEEZING: Characterized by prolonged expiration
through an lower airways, bronchi, bronchioles.
E.g.. Asthma, COPD

• HAEMOPTYSIS: coughing of blood in the sputum.
Bronchial carcinoma-repeated small haemoptyses
Tuberculosis –chronic fever & wt. Loss
Pneumoccocal pneumonia- rusty colored sputum
Bronchiectasis-catastrophic bronchial hemorrhage with
previous history of T.B. & whooping cough
Pulmonary thromboemoblism- major risk factors include
immobilization, malignant disease,cardiac failure, pregnancy

CHEST PAIN :more common presentation of cardiac
disease but also signify diseases of the lungs , musculoskeletal
system.
Location
Radiation
Provocation
Character of the pain
Pattern of onset

1. PHYSIQUE
2. CLUBBING
3. CYANOSIS
4. NECK :THYROID SWELLING
5. PALLOR
6. LYMPHADENOPATHY
7. VENOUS PULSES
8. UPPER RESPIRATORY TRACT

• PHYSIQUE – Tall, short, thin or obese.

• CLUBBING –Bulbous enlargement of soft parts of the
terminal phalanges with both transverse and
longitudinal curving of the nails.
Bronchogenic carcinoma
Lung abscess
Bronchiectasis
Tuberculosis
Diffuse fibrosing alveolitis

• CYANOSIS :Bluish discoloration of the nails due to
increased amount of reduced Hb% (more than 5mg%)
in capillary blood.

Central –
•COPD
•Collapse and fibrosis of lung
•Marked pulmonary destruction
Peripheral –
•Cold
•Inc. viscosity of blood
•shock

• SHAPE OF THE CHEST:scar of previous surgery ,lumps visible beneath
the skin.
Normal chest –bilaterally symmetrical, ellipitical in cross section,
transverse :anteroposterior diameter = 7:5
Subcostal angle = 70
 Interspaces are broader anteriorly than posteriorly.

Shapes deformities
Pigeon chest or pectus carinatum: in severe asthma,
rickets.
Funnel chest or pectus excavatum : congenital,an
occupational deformity in cobblers (cobbler’s chest).
Barrel shaped chest: emphysema
Spinal deformities
Kyphosis
SDcr.Aonkitl Sirivoastasv@icsopyright email:ankitsrivastav183@gmail.com 14/12/14 24

• Depression on either side of the sternum
• A transverse groove passing Xiphistrenum to the
midaxillary line (Harrison sulcus)
• Sternum unduly prominent.

FFuunnnneell CChheesstt DDeeffoorrmmiittyy::--

• Depression in lower part
of sternum.
• Congenital, in rickets,
occupational deformity in
cobblers.

BBaarrrreell CChheesstt DDeeffoorrmmiittyy::--

• Anterior-posterior
diameter inc.,the sub
costal angle is wide
• Angle of Louis unduly
prominent, sternum more
arched
• IInn eemmpphhyysseemmaa

 KKyypphhoossiiss::

• Forward bending of spine
• Congenital, postural, neurological, pott’s spine,
rheumatoid arthritis.

 KKyypphhoossiiss::

 SSccoolliioossiiss

• Lateral bending of spine
• Congenital, postural, compensatory,
neurological-poliomyelitis, muscular dystrophy,
rickets

Bulging:
one side bulging
Pleural effusion, pneumothorax, tumors, aneurysm, emphysema
Localized bulging- aortic aneurysm, pericardial effusion, liver abscess,
chest wall tumors
Depression or flattening :one side affected in fibrosis, collapse, pleural
adhesions.
Flat chest: chronic nasal obstruction, bilateral T.B.

• RESPIRATORY RATE : normal 16-20 respiration per mins
Inc. rate (tachypnoea) –
Fevers e.g. pneumonia
Anoxaemia & acidosis
Pleurisy
Dec. rate (bradypnoea) –
Narcotic poisoning
Brain tumour

• RESPIRATORY RHYTHM
Cheyne stokes respiration: alteration of apnea and
hyperpnoea due to anoxemia.
LVF
Neurological
Uremia
Deep sleep
Cardio respiratory embarassement

Kussmaul’s respiration : deep and rapid respiration
Diabetes ketoacidosis
Uremia
Biot’s respiratory : irregularly irregular respiration
Meningitis
Raised intracranial pressure

• STRIDOR-prolonged inspiration through an obstructed
upper airways, which produced a characteristic sound.
Laryngeal or tracheal obstruction
Laryngeal diphtheria
Mediastinal growth

 WHEEZING-prolonged expiration through an obstructed
lower airways bronchi, bronchioles
 Cardiac & renal asthma
 STERTOR –occurs in coma or deep sleep or in dying
person (death rattles)

• THORACIC BREATHING-
 Diaphragmatic paralysis
 Peritonitis
Severe ascitis
• ABDOMINAL BREATHING-
Pleurisy
Collapse of lung

• NORMALLY, uniformly, no bulging or in drawing of interspaces
• Accessory muscles of respiration not required
• Diminished in fibrosis ,emphysema, pleural effusion etc.

• LYMPH NODES
• SWELLINGS & TENDERNESS
• CHEST EXPANSION
• TRACHEA & HEART

• Supraclavicular fossae, cervical regions and axillary's
region.
• Enlarged lymph nodes secondary to the spread of
malignant diseases from chest.
• Tuberculosis often affects the upper deep cervical
nodes.
• Normally on palpation surface is smooth but matted in
T.B. and irregular in malignancy.

• Palpate part of the chest presents an swelling or where the
patient complains of pain.
CAUSES OF PAIN &TENDERNESS
A recent injury or inflammatory conditions.
Intercostal muscular pain.
A painful costochondral junction.
Secondary malignant deposits in the rib.
Herpes zoster before the appearance of the rashes.

• The positions of cardiac impulse and trachea helps to assess mediastinum
position.
Tracheal palpation: Feel trachea in the suprasternal notch decide whether it is
central or deviated to one side by its relation to the suprasternal notch and
insertion of sternomastoids.

• APEX Beat: Is examined with palm of the hand and its
position is noted. Normally the apex beat is in 5th left
intercostal space just inside the mid clavicular line.It may be
shifted inward or outward depending upon the shift of the
mediastinum.
• Apex beat alone may be shifted in:
 Scoliosis
 Funnel shaped depression of the sternum in enlargement of L.V.

Pushed away from the affected side
• Pleural effusion
• Pneumothorax
Pulled towards the affected side
• Collapse
• Fibrosis
• Pleural thickening.

Chest expansion- As well as by simple inspection possible
asymmetrical expansion of the chest may be further explored by
palpation.
Unilateral diminished movements
• Obstruction to the main bronchus
• Consolidation
• Fibrosis
• Collapse
• Hydropneumothorax
• Pleural effusion.
Bilateral diminished movements
• Emphysema
• Bilateral fibrosis,
collapse,consolidation,
hydropneumothorax.
• Bronchial asthma

• Auenbrugger applied percussion to the chest first.
• Points to be noted on percussion of the chest:
Resonance
Dullness
Pain & tenderness.
• Normally resonance present below clavicle anteriorly , below scapula posteriorly.
• Normally dullness present right side inferiorly as the liver encountered left side
stomach.

Reduce resonance
 Consolidation
 Pleural effusion
 Fibrosis
 Infiltration
 Collapse
 Pleural thickening
Hyper resonance
 Pneumothorax
 Emphysema
 Large cavity
 Congenital cyst
 Emphysematous bullae.

 Liver dullness: right 5th intercostal space in the mid
clavicular line, in 7th space in the anterior axillary line
and in 9th space in the scapular line.
 Abnormally in 4th space in the mid clavicular line in :
Amoebic or pyogenic abscess of liver.
Diaphragmatic paralysis
or collapse of the lower lobe of the lung

 It may be pushed down to the 6th space in the
mid clavicular line:
 Emphysema
 Right sided pneumothorax
 air in the peritoneal cavity
 Terminal cirrhosis

Cardiac dullness:
 This area of dullness decreasing in emphysema and left
pneumothorax.
 Increase in cardiomegaly and push of the heart to the left
side.
Shifting dullness
 In hydro pneumothorax in sitting position hyper resonant
note above followed by dullness below.

• Vesicular breath sounds
• Bronchial breath sounds

• Vocal fremitus &resonance
Bronchophony
Whispering pectoriloquy
egophony

• Added sounds
Pleural rub
Wheezes
Crackles

• VESICULAR BREATH SOUNDS : normal lung tissue make the sound quieter & selectively filter out some of the higher
frequency this result vesicular sounds. No distinct pause between the end of inspiration and the beginning of expiration.
• BRONCHIAL BREATH SOUNDS :In consolidation, the sounds generated in the large airways are transmitted more
efficiently/so they are louder & less filtering of the high frequency.

 TACTILE VOCAL FREMITUS – Perception of vibration communicated to the
chest wall from the larynx via the bronchi and lungs during the act of phonation
 TVF inc. in-consolidation, pulmonary infraction, malignant lesion.
 TVF dec. in-pleural effusion, pneumothorax, hydrothorax, bronchial asthma,
emphysema, fibrosis, collapse

• Vocal resonance: Resonance in the chest made by the voice when
testing vocal resonance you are detecting vibration transmitted to the
chest from the vocal cord as the patient repeats a phrase “ninety
nine”.
Inc. In consolidation
Dec . in pneumothorax

BRONCHOPHONY: Inc vocal resonance where the sounds are loud & clear but the
words are not distinguished. Found in consolidation
EGOPHONY: When spoken voices are auscultated over the chest, nasal quality is imparted
to the sound which resembles the bleating goat.
WHISPERING PECTORILOQUY- When the patient whispers a phrase (eg. One
,two, three) the sounds may be heard clearly. Found in consolidation

• WHEEZES/RHONCHI- Musical sounds associated with
airways narrowing
Widespread POLYPHONIC– Heard in expiratory eg.Asthma,
COPD.
Fixed MONOPHONIC- May be inspiratory or expiratory eg.
Tumors foreign bodies.

• CRACKLES/RALES- Short,explosive as bubbling or
clicking. Produced by sudden change of gas pressure related
to sudden opening of previously closed small airways.
COPD
Bronchiectasis
Pulmonary edema
Diffuse Dr.Ankit Srivastav@copyright eminail:atnkeitsrrivsasttavi1t83i@aglm aifl.ciombrosis 14/12/14 83

 Pleural infflammation with pleuritic pain.
 More prominent in lateral & posterior bases of the lung and dec.
Superiorly
 Best heard at the bases in the axillary lines

 SPUTUM EXAMINATION
 LUNG FUNCTION TEST
 X-RAYS
 CT –SCAN
 RADIOISOTOPES IMAGING
 MAGNETIC RESONANCE
IMAGING(MRI)
 ULTRASOUND (USG)
 FIBRE OPTIC BRONCHOSCOPY
 PLEURAL ASPIRATION &
BIOPSY
 LUNG BIOPSY
 IMMUNOLOGICAL TESTS

Measuring the size of the lungs.
Measuring how easily air flows into & out of the airways.
Measuring how efficient the lungs are in the process of gas
exchange.
• VITAL CAPACITIES (VC): How much air can be exhaled
after a maximal inspiration.
• TOTAL LUNG CAPACITY(TLC): Amount of air can be
exhaled after a maximal inspiration.

• Residual vol.(RV)- Air still remain in the lungs after full
expiration.
• Forced vital capacity (fvc)-Vital capacity is measured after the
patient has blown as hard and fast as possible into the spiro meter
• FORCED EXPIRATORY VOLUME (fev)-Vol. Of the air
expired in the first second
normally, FEV is 70% of FVC.
-In copd fev/fvc is reduced
-In pulmonary fibrosis FFEV/FVC is normal but absolute value
reduced

NORMAL X -RAY DESCRIBED AS
 View
 Centralization
 Exposure
 Sex
Diaphragm
 Cardiophrenic & costophrenic angles
 Rib cage
 Cardiac shadow
 Lung shadow

NORMAL X- RAY
 Clavicle should be at same level .
 If breast shadows are visualized the plate is of a female
patient.
 Rt. Diaphragm slightly higher than the left ,with clear
costophrenic & cardiophrenic angles.

 Cardiac shadow consists of
 Smooth right border-superior vena cava,right atrium
&inferior vena cava
 Left border-aortic knuckles,pulmonary artery, left
arterial appendage, right ventricle &left ventricle from
above downwards

• Aortic knuckle prominent: in aortitis, atherosclerosis, aneurysm.
• Pulmonary artery prominent: in pulmonary hypertension
• Pulmonary artery shadow absent: in pulmonary stenosis. or pulmonary
atresia

Ratio of chest wall and cardiac shadow is 2:1.
Cardiac enlargement it dec.
Emphysema it inc.
LUNGS SHADOWS
Normally: TRANSLUCENT
Abnormally: OPAQUE HYPER TRANSLUCENT

Opaque
 Pneumothorax
 Pleural thickening
 Bullae
 Emphysema
 Bronchial asthma
 Pulmonary hypertension
Hyper translucent
 Pleural effusion
 Calcification
 Lung carcinoma
 Collapse
 Lung abscess

PPlleeuurraall EEffffuussiioonn::

CCoollllaappsseedd LLeefftt SSiiddee

• A thoracic CT scan comprises a series of the cross sectional slices through the
thorax at various levels.
• Help in diagnosing
• Carcinoma lung
• Bronchiectasis
• Diffuse pulmonary fibrosis

Radio-isotope Imaging:
• Ventilation & perfusion scanning
• Helpful in case of pulmonary embolism
Magnetic resonance imaging (MRI)
• Mediastinal abnormalities
• Chest wall tumors

Ultra-Sonography:-
• Reveals less details than CT scan.
• Used in diaphragmatic movements
• Help to distinguished between pleural thickening from
pleural fluid.

Fiber optic bronchoscopy
• For carcinoma of bronchus & for biopsy
LUNG BIOPSY
IMMUNOLOGICAL TESTS

Pleural Effusion & Biopsy:-
• In pleural effusion
• Middle aged or old aged present in carcinoma
• Young aged in tuberculosis

Resp.system examination

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