A presentation on general physical examination specially pertaining to the respiratory system

1. GENERAL PHYSICAL
EXAMINATION OF THE
RESPIRATORY SYSTEM
DR.BERMIO.V.S

2. GENERAL EXAMINATION
• HEAD TO FOOT EXAMINATION
• ANTHROPOMETRY
• VITAL SIGNS

3. HEAD TO FOOT EXAMINATION
• GENERAL APPEARANCE
• POSTURE, GAIT, STANCE
• NUTRITION AND HYDRATION INCLUDING EDEMA
• SKIN – PALLOR, ICTERUS, CYANOSIS, SCARS, SWELLINGS,LESIONS ETC
• EYES – PALLOR, ICTERUS, SUBCONJUNCTIVAL EDEMA
• FACE – EDEMA, PLETHORA
• NECK – THYROID SWELLING, TRACHEAL TUG

4. • CHEST - GYNAECOMASTIA
• HANDS – FINE TREMOR (INHALED BETA AGONISTS), FLAPS (HYPERCAPNIA),
SMALL MUSCLE WASTING (DUE TO T1 INVOLVEMENT IN PANCOAST TUMOUR)
• NAILS – CLUBBING, PALLOR, CYANOSIS, COLOUR, NICOTINE STAINS, ETC
• LYMPH NODES
• FEET
• SPECIAL CONSIDERATION:
• STIGMATA OF TUBERCULOSIS
• FEATURES OF HORNERS SYNDROME

5. • EXAMINATION SHOULD BE DONE IN 45 DEG POSITION

6. GENERAL APPEARANCE
• CONSCIOUSNESS LEVEL (CO2 NARCOSIS, METASTATIC MALIGNANCY)
• COMFORTABLE/DISTRESSED
• INABILITY TO COMPLETE A SENTENCE
• USE OF ACCESSORY MUSCLES OF RESPIRATION (STERNOCLEIDOMASTOID, TRAPEZIUS, SCALENES,
ALAE NASI)
• INTERCOSTAL INDRAWING
• PURSED LIP BREATHING (SEVERE COPD)
• AUDIBLE WHEEZE (INSPIRATORY NOISE)/STRIDOR (EXPIRATORY NOISE)
• HOARSENESS OF VOICE/ WEAKNESS OF VOICE
• SURROUNDINGS (INHALERS, PEAK FLOW METERS, TISSUES, SPUTUM POT, OXYGEN MASK)

8. POSTURE
• SITTING FORWARD WITH ARMS BRACED ON THE TABLE (SO THAT THEY CAN USE
PECTORALIS MAJOR TO PULL THE RIBS OUTWARD)
• LYING TOWARDS THE AFFECTED SIDE IN PNEUMONIA AND PLEURITIS (AUTO
SPLINTING)

10. NUTRITION
• MALNOURISHMENT
• OBESITY
• OBSTRUCTIVE SLEEP APNEA
• CUSHINGOID HABITUS
• CHRONIC STEROID USE
• PARANEOPLASTIC

11. EDEMA IN RESPIRATORY SYSTEM
• COR PULMONALE – B/L EDEMA
• DEEP VEIN THROMBOSIS- U/L EDEMA

12. SKIN
• A LIST OF PULMONARY CUTANEOUS SYNDROMES
• DISTINCT SWELLING – METASTATIC NODULES IN LUNG CANCER
• ERYTHEMA NODOSUM – SARCOIDOSIS, TB, HISTOPLASMOSIS,
COCCIDIOIDOMYCOSIS
• SKIN ABSCESS, IV MARKS – SOURCE OF LUNG ABSCESS
• VASCULITIC CHANGES – PULMONARY RENAL SYNDROMES
• PARANEOPLASTIC SKIN MANIFESTATIONS – ACANTHOSIS NIGRICANS,
PEMPHIGOID, POLYMYOSITIS-DERMATOMYOSITIS, RAYNAUD PHENOMENON
• ATOPIC DERMATITIS – SUGGESTS A COEXISTING BRONCHIAL ASTHMA
• DAHL’S SIGN - COPD

13. SKIN

14. FACE – PLETHORA IN SVC OBSTRUCTION

15. NECK
• TRACHEAL TUG (OLLIVERS SIGN) – SYSTOLIC DOWNWARD MOVEMENT OF THE
TRACHEA IN AORTIC ANEURYSM

16. PALLOR IN RESPIRATORY DISEASES
• HEMOPTYSIS
• EXCESSIVE SPUTUM PRODUCTION CAUSING PROTEIN LOSS
• LOSS OF APPETITE

17. ICTERUS
• PULMONARY INFARCTION
• DRUG INDUCED LIVER INJURY (ATT)
• LIVER SECONDARIES

18. CYANOSIS
• BLUISH DISCOLOURATION OF THE SKIN THAT IS CAUSED BY INCREASED
AMOUNTS OF REDUCED HEMOGLOBIN IN THE SUBCAPILLARY VENOUS PLEXUS
(MORE THAN 5 G%)
• OR DUE TO ABNORMAL PIGMENTS IN BLOOD (METHB >1.5, SULFHB >0.5 G%)
• CYANOSIS IS ABSENT IN SEVERE ANEMIA AND CO POISONING

20. CYANOSIS IN RESPIRATORY DISEASES
• COPD
• INTERSTITIAL LUNG DISEASE – CYANOSIS ON EXERTION
• ALVEOLAR HYPOVENTILATION

22. CLUBBING
• BULBOUS ENLARGEMENT OF THE DISTAL SEGMENTS OF THE DIGITS DUE TO
INCREASE IN SOFT TISSUE
• IT TAKES 2 TO 3 WEEKS FOR CLUBBING TO MANIFEST
• CLUBBING FIRST APPEARS IN THE INDEX FINGER
• CLUBBING IS SEEN IN 1% OF HOSPITAL ADMISSIONS BUT IS ASSOCIATED WITH A
SERIOUS DIAGNOSIS IN 40% INDIVIDUALS

25. THEORIES OF CLUBBING
• NEUROGENIC
• HUMORAL
• FERRITIN
• HYPOXIC
• PDGF THEORY

27. RESPIRATORY CAUSES OF CLUBBING
• CLUBBING DOES NOT OCCUR IN COPD
• HYPERTROPHIC OSTEO ARTHROPATHY – LUNG CANCER, CYSTIC
FIBROSIS,SUPPURATIVE LUNG DISEASES
• CLUBBING, TENDERNESS OF WRISTS AND ANKLES
• SUBPERIOSTEAL NEW BONE FORMATION

28. UNILATERAL CLUBBING IN RESPIRATORY
SYSTEM
• PANCOAST TUMOUR

30. LYMPH NODES IN RESPIRATORY SYSTEM

31. EXTERNAL MARKERS OF TUBERCULOSIS
• TINEA VERSICOLOR
• PHLYCTENULAR CONJUNCTIVITIS/KERATITIS
• LUPUS VULGARIS
• ERYTHEMA NODOSUM
• SCROFULODERMA
• EPIDIDYMO-ORCHITIS
• THICKENED SPERMATIC CORD

34. PULSE
• BOUNDING PULSE IN CO2 RETENTION
• NARROW IN MASSIVE HEMOPTYSIS

35. BLOOD PRESSURE
• PULSUS PARADOXUS
• INSPIRATORY FALL OF SBP >10 MM HG
• OMINOUS SIGN IN OBSTRUCTIVE LUNG DISEASE

36. RESPIRATION
• RATE (12 – 16/MIN)
• TACHYPNEA (RATE MORE THAN 20 IS ABNORMAL IN ADULTS)
• 15 TO 20 BREATHS PER MIN MAYBE DUE TO ANXIETY
• DIFFERENT FROM DYSPNEA
• BRADYPNEA
• APNEA (CENTRAL APNEA/ OBSTRUCTIVE APNEA)
• TYPE OF RESPIRATION
• ABDOMINOTHORACIC
• THORACOABDOMINAL
• THORACIC – DIAPHRAGMATIC PARALYSIS, PERITONITIS, ASCITES
• ABDOMINAL – PLEURITIS, LUNG COLLAPSE
• PATTERN OF RESPIRATION
• PARADOXICAL RESPIRATION AND THORACO-ABDOMINAL ASYNCHRONY

39. • CHEYNE STOKES BREATHING
• SEVERELY ILL PATIENTS
• SEVERE HEART FAILURE
• NARCOTIC DRUG POISONING
• NEUROLOGICAL DISORDERS
• SLEEP, HEALTHY ADULTS IN ALTITUDE
• DUE TO ABNORMAL FEEDBACK FROM CAROTID CHEMORECEPTORS TO
RESPIRATORY CENTRE

40. NEUROLOGICAL CAUSES OF ABNORMAL
BREATHING PATTERNS

41. JVP
• NON PULSATILE ELEVATION IN JVP – SVC OBSTRUCTION
• COR PULMONALE – PULSATILE ELEVATION IN JVP
• PULMONARY HYPERTENSION
• COPD
• INTERSTITIAL LUNG DISEASE
• BRONCHIECTASIS
• ACUTE
• TENSION PNEUMOTHORAX
• LARGE PULMONARY EMBOLISM
• DIFFICULT TO SEE JVP IN A BREATHLESS PATIENT
• A RELAXED STERNOCLEIDOMASTOID IS ESSENTIAL FOR JVP

42. PULSE OXIMETRY
• IN REST
• IN EXERTION

43. EXAMINATION OF THE UPPER RESPIRATORY
TRACT
• NASAL POLYPS
• WEGENERS GRANULOMATOSIS
• ASTHMA (SAMPTERS TRIAD)
• ABPA
• CYSTIC FIBROSIS
• SINUS TENDERNESS
• ORAL HYGIENE
• DENTAL CARIES, BITTEN TONGUE
• TONSILS
• POST NASAL DRIP
• ORAL CANDIDIASIS (USE OF INHALED CORTICOSTEROIDS)

44. OTHER SYSTEM EXAMINATION
• MUSCULOSKELETAL SYSTEM (TO R/O CONNECTIVE TISSUE DISEASES)
• CARDIOVASCULAR SYSTEM (TO R/O PULMONARY HYPERTENSION AND COR
PULMONALE)
• ABDOMEN (ASCITES CAN CAUSE HEPATIC HYDROTHORAX)

45. REFERENCES
• MACLEOD’S CLINICAL EXAMINATION 14TH ED.
• HUTCHISON’S CLINICAL METHODS 24TH ED.
• ALAGAPPAN MANUAL OF PRACTICAL MEDICINE, 5TH ED.
• P.J.MEHTA’S PRACTICAL MEDICINE
• HARRISON PRINCIPLES OF INTERNAL MEDICINE 20TH ED.
• FISHMAN’S PULMONARY DISEASES AND DISORDERS, 5TH ED.
• MURRAY & NADEL TEXTBOOK OF RESPIRATORY MEDICINE 6TH ED.