2. Dr Sana Kauser Ateeque Ahmed
Assistant Professor
Dept. of Mahiyatul Amraz
Al-Ameen Unani Medical College & Hospital, Malegaon
Exam. of RS...Dr Sana Kauser (Pathology) 2
3. Contents
▰ History taking
Bio data of the patient
Chief/ Presenting complaints
History of presenting complaints
Cardinal symptoms
▰ Examination of respiratory System
o Inspection
o Palpation
o Percussion
o Auscultation
Exam. of RS...Dr Sana Kauser (Pathology) 3
4. 4
Structures present in the chest cavity
• Diseases of the RS
accounts for third of
deaths
• Major cause of patients
visit to the doctor
• An important part of
systemic examination
Introduction
Exam. of RS...Dr Sana Kauser (Pathology)
6. “
”
Basically with history, from
each point you ask the
patient and each answer
you get from the patient,
you understood that yes,
these are probable
diagnosis .
6
7. Bio data of the patient
Name
Age
Sex
Occupation
Address
Religion
Marital status
7
Exam. of RS...Dr Sana Kauser (Pathology)
8. Presenting complaints
RESPIRATORY SYSTEM
• History of presenting complaints
• Chronological order (complaints with duration)
• Pain (SOCRATES)
• Cough: Dry or productive
• If productive: Quantity, Color, Nature, Odor, Haemoptysis,
relation to posture, diurnal variation.
• Breathlessness: duration, grade, postural variation, diurnal
variation, seasonal variation,
• History of wheezing
• History of Orthopnea
8
Exam. of RS...Dr Sana Kauser (Pathology)
9. Others
• History of past illness: Hypertension, DM, TB, HIV,
Exathematous fevers.
• Personal history:
food/appetite, B/B, sleep
addiction-smoking, alcohol, drug addictions
• Family history
• Menstrual and obstetric history
• Treatment history (anaphylaxis, urticaria)
• H/O Fever
• H/o allergies, swelling of feet, palpitations, seizures,
• Surgery under general anesthesia
9
Exam. of RS...Dr Sana Kauser (Pathology)
10. Cardinal symptoms
The primary or major symptom by which a diagnosis is made
• Cough
• Expectoration/ Sputum
• Haemoptysis
• Breathlessness/ dyspnoea
• Wheezing
• Pain in the chest
Exam. of RS...Dr Sana Kauser (Pathology) 10
11. Cough اھکیسن
Definition: A sudden expulsion of air through the large breathing passages
that can help clear them of fluids, irritants, foreign particles and microbes.
• Acute/ short lived or chronic
• Dry or productive
• Episodic? Time?
• Related to any posture
• Aggravated by Allergens? Pollens? Cold air?
Acute
(lasting <3 weeks)
Recent infections (viral/ bacterial)
Chronic
(lasting > 8 weeks)
Should be Sent for CXR, spirometry
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12. Causes of cough
Causes Examples
Respiratory Viral or bacterial infections
Bronchospasm
COPD
Asthma
Aspiration
Brochiolitis (infection and inflam. of bronchioles in children
and infants)
Malignancy
Parenchymal disease e.g. ILD (progressive scarring)
Cystic fibrosis (inherited, affect mucus and sweat producing
cell, thick & sticky fluids, plug)
Upper airways diseases Post nasal drip
Sinusitis
Inhaled foreign bodies
Tonsillar enlargement
Cardiovascular diseases LVF, Mitral stenosis
Gastro-oesophageal disease GORD
Drugs and irritation ACE inhibitors (prils-antihypertensive), cigarette smoking
Exam. of RS...Dr Sana Kauser (Pathology)
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14. Sputum/ Expectorationثنفنت
• Definition: An act of bringing up and spitting out sputum.
• Is sputum produced? In cough
• Looks like? Colour? Consistency?
• Yellow or green: usually purulent
• Odour? Foul smelling- Bronchiectasis
• Amount? Bronchiectasis: a cupful amount
• Asthma: small amount of thick jelly like sputum
Exam. of RS...Dr Sana Kauser (Pathology) 14
15. Haemoptysisادلمن
• Definition: Coughing up blood from the lungs or
bronchial tubes in the sputum. It can range from small
flecks of blood to a lot of blood.
• Amount?
• Fresh or altered blood
• D/D from hematemesis, bleeding from gums
• Whether associated with epistaxis or melena
• Suspected T.B., malignancy
Exam. of RS...Dr Sana Kauser (Pathology) 15
16. Breathlessness سفنترسع
• Definition: Shortness of breath is also known as dyspnea.
It is a feeling that one cannot breath enough air into the
lungs. It may be associated with tightness in the chest.
• Dyspnea on exertion or at rest?
• Episodic/ paroxysmal?....asthma
• Nocturnal? ……pulmonary oedema
• In sitting position or on lying down
Exam. of RS...Dr Sana Kauser (Pathology) 16
18. Wheezing
• Definition: The shrill whistle or coarse rattle heard due to partial
or complete blockage in the airway.
• It could go away on its own, or it could be a sign of a serious
condition.
• Wheez- Present on examination or noticed sometime by any
individual
• Respiratory:
bronchitis
Asthma
Pneumonia
• Others
an allergic reaction, cold or allergies
Heart failure and more
D/D with
stridor
Rubbing/
gurgling sound-
pneumothorax
Exam. of RS...Dr Sana Kauser (Pathology)
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19. Cont…
• Some wheezes can only be heard with a stethoscope, but
often they can be heard with the human ear.
• Wheezing is more obvious at the time of exhalation, but can
also be heard during inhalation.
• The tone of the wheeze can vary depending on which part of
the respiratory system is blocked or narrowed.
• Narrowing in the upper respiratory system may make for a
hoarser wheeze.
• Lower obstructions may have a more musical tone, similar to
a how a wind instrument like a clarinet might sound.
Exam. of RS...Dr Sana Kauser (Pathology) 19
20. Pain in the chestادصلروعج
• Chest pain-------site, duration, nature, relation with
respiration aggravating & releiving factors.
• Causes:
• Pleuritic pain- sharp, stabbing, aggravated in deep breath
or coughing………pleurisy
• Musculoskeletal
• Prolonged coughing
• Invasion of chest wall by lug tumour
• Pulmonary embolism
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36. OEDEMA
General:
• Right ventricular failure
• Cor pulmonale
• Renal failure
Local:
• Lymphatic obstruction
• Inflammation
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37. HANDS
• Nails
• Clubbing
• Koilonychia
• Leuconychia
• Palmar erythema
• Dupuytren’s contractures
Exam. of RS...Dr Sana Kauser (Pathology) 38
38. Clubbing
Bulbous enlargement of soft parts of the terminal phalanges with both
transverse and longitudinal curving of the nails.
CA bronchus
TB
Empyema
Abscess
Fibrosing alveolitis
Bronchiectasis
Exam. of RS...Dr Sana Kauser (Pathology)
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39. Schamroth’s sign
Exam. of RS...Dr Sana Kauser (Pathology)
40
When the nails of two
normal fingers are
opposed each other,
there is a diamond
shaped gap.
In clubbing this gap
disappears known as
Schamroth’s sign
49. Cont…
• Drooping of shoulder
• Widening of intercostal spaces
• Indrawing of intercostal spaces, crowding of ribs
• Increased hollowness or fullness of supra and infra
clavicular fossae
• Mediastinum: Trails sign, apex impulse
Exam. of RS...Dr Sana Kauser (Pathology) 51
50. SHAPE OF THE CHEST
Normal: transverse diam> AP
A-P diameter
Pectus excavatum---funnel chest
Pectus carinatum---pigeon chest
Kyphoscoliosis
Exam. of RS...Dr Sana Kauser (Pathology) 52
53. Respiratory rate and Rhythm
• Rate:
• Normal Respiratory Rate-{14-16/min}
• Hyperventilation-DKA, PE
• Hypoventilation-type 2 resp. failure
• Bradypnea: rate under 12: coma, medications, deep sleep
• Tachypnea: rate over 20: anxiety, heart or lung disease, pain
• Respiratory rhythm:
Chyne stokes breathing: Cyclical variation in the depth of respiration
with period of apnoea. drugs, CNS damage, stroke
Kussmaul: rapid, deep
Labored: metabolic acidosis
Exam. of RS...Dr Sana Kauser (Pathology) 55
58. PALPATION
• Tracheal position
• Apex beat
• Movements of chest
• Measurements—AP & transverse diameter,
• Chest-inspiration, expiration
• Hemi thorax measurement
• Palpation of inter costal spaces
• Vocal fremitus
• Tenderness, local rise of temp
Exam. of RS...Dr Sana Kauser (Pathology) 60
59. Tracheal position
4-5 cm of the upper trachea can be felt in the neck between the cricoid
cartilage and the sternal notch.
Pushed –pneumothorax
-pleural effusion
Pulled—fibrosis
--collapse
Exam. of RS...Dr Sana Kauser (Pathology)
61
60. Apex beat
• Lowermost & outermost point where cardiac impulse is
felt.
• Normally- 5th ICS within midclavicular line.
• Heaving apex: LVH (sustained throghout systole,
exaggerated )
• Tapping apex: mitral stenosis (loud first heart sound)
• Parasternal heave: left parasternal region, RV enlargement
62
Exam. of RS...Dr Sana Kauser (Pathology)
61. Movements of chest
Chest expansion– normal up to 5 cm
-abnormal < 2 cm
• Movements of chest
Use of accessory muscles- Status Asthmaticus
Tenderness: Fractured ribs, metastasis , neuralgia
Exam. of RS...Dr Sana Kauser (Pathology) 63
62. Palpation of respiratory movements
Anterior, Apical, Posterior
Exam. of RS...Dr Sana Kauser (Pathology) 64
63. Palpation of inter costal spaces
Exam. of RS...Dr Sana Kauser (Pathology) 65
64. Tactile Vocal Fremitus
Vocal fremitus is a vibration transmitted through the body.
It refers to the assessment of the lungs by either the vibration intensity felt on the
chest wall (tactile fremitus) and/or heard by a stethoscope on the chest wall with
certain spoken words (vocal resonance).
Exam. of RS...Dr Sana Kauser (Pathology)
66
67. “
”
The percussion note loses its normal
resonance when ever aerated lung tissue is
separated from the chest wall by fluid or
pleural thickening .
OR
When lung tissue is separated from chest
wall by collapse or consolidation or
fibrosis
Exam. of RS...Dr Sana Kauser (Pathology) 69
68. PERCUSSION
Direct percussion
Over clavicles
Indirect percussion
Anterior
KRONIGS
ISTHMUS
Supra clavicular
Infra clavicular
Mammary
Infra mammary
Lateral
Axillary
Infra axillary
Posterior
Supra scapular
Inter scapular
Infra scapular area
Exam. of RS...Dr Sana Kauser (Pathology)
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69. Cont…
Tidal percussion
Kronig isthmus
Traube’s space
S-shifting dullness
S –succusion splash
Skodaic resonance
Coin test above the fluid level
Liver dullness
Exam. of RS...Dr Sana Kauser (Pathology) 71
71. Cont…
• Traube's (semilunar) space is an anatomic space of some clinical
importance. It is a crescent-shaped space, encompassed by the lower
edge of the left lung, the anterior border of the spleen, the left costal
margin and the inferior margin of the left lobe of the liver. Thus, its
surface markings are respectively the left sixth rib superiorly, the left
mid axillary line laterally, and the left costal margin inferiorly.
• A succussion splash, also known as a gastric splash, is
a sloshing sound heard through a stethoscope during sudden movement
of the patient on abdominal auscultation. It reflects the presence of gas
and fluid in an obstructed organ, as in gastric outlet obstruction.
• A coin test (or a bell metal resonance) is a medical diagnostic
test used to test for a punctured lung. A punctured lung can cause air
or fluid to leak into the pleural cavity, leading to, for
example, pneumothorax or hydrothorax.
Exam. of RS...Dr Sana Kauser (Pathology) 73
72. Cont…
• Kronig isthmus is a band of resonance representing
the apex of lung,[1] also it's described as the narrow strap-
like portion of the resonant field that extends over
the shoulder, that connect the larger areas of resonance
over the pulmonary apex in front and behind.[2
• Skodaic resonance - a peculiar, high-pitched sound, less
musical than that obtained over a cavity, elicited by
percussion just above the level of a pleuritic effusion.
• Shifting dullness and fluid thrill (wave) are clinical signs
that confirm ascites. Free fluid will flow to the dependent
part of the abdominal cavity, while the gut filled with air
will float in the middle. If the child is supine, the fluid
collects posteriorly and in the flanks.
Exam. of RS...Dr Sana Kauser (Pathology)
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73. Cont…
• Liver dullness: The purpose of liver percussion is to
measure the liver size. Starting in the midclavicular line at
about the 3rd intercostal space, lightly percuss and move
down. Percuss inferiorly until dullness denotes the liver's
upper border (usually at 5th intercostal space in MCL).
Exam. of RS...Dr Sana Kauser (Pathology) 75
76. BREATH SOUNDS
• Breath sounds come from the
lungs when you breathe in and
out. A person can hear these
sounds using a stethoscope or
simply when breathing.
• A typical breath sound is similar
to the sound of air.
Check for Intensity
Character:
Vesicular-
https://www.google.com/search?q=vesicular+sound&rlz=1C1LOQA
Bronchial-
https://www.google.com/search?q=bronchial+spund&rlz
Vesicular
Normal
Insp. twice
that of
expiration
No pause
Bronchial
Inspiration is
shorter than
expiration
Gap between
insp. and
exp.
Exam. of RS...Dr Sana Kauser (Pathology)
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77. ADDED SOUNDS
• However, it may include some irregular breath sounds.
Added/ adventitious sounds:
Exam. of RS...Dr Sana Kauser (Pathology) 79
78. Cont…
• Rhonchi: https://www.google.com/search?q=rhonchi+sound&rlz
Low pitched breath sounds that are similar to snoring.
These sounds occur when air tries to pass through bronchial
tubes that contain fluid or mucus.
Wheezing: https://www.google.com/search?q=wheezing+sound&rlz
• Wheezing, is a high pitched whistling sound that occurs
due to the narrowing of the bronchial tubes
• This sound occurs when the bronchial tubes become
inflamed and narrowed.
Wheezes or rhonchi---COPD
--bronchial asthma
Exam. of RS...Dr Sana Kauser (Pathology) 80
80. Cont…
• Stridor: https://www.google.com/search?q=stridor+sound&rl
A harsh, vibratory sound that occurs due to the narrowing
of the upper airway, heard most prominently in inhalation.
• Pleural rub: https://youtu.be/xxVvxdoAUPk
A Pleural friction rub or Pleural rub, is an audible raspy
breathing sound. It is a medical sign present in some patients
with pleurisy and other conditions affecting the chest cavity.
It can be noticed by listening to the internal sounds of the
body, usually using a stethoscope on the lungs.
These are the squeaking or grating sounds of the pleural
linings rubbing together. It is best described as the sound
made by treading on fresh snow.
Pleural rubs are common in pneumonia, pulmonary
embolism, and pleurisy.
Exam. of RS...Dr Sana Kauser (Pathology)
82
82. VOCAL RESONANCE
• Definition: Vocal resonance is an assessment of the
density of lung tissue, performed by auscultating the chest
and asking the patient to speak. Increased vocal resonance
suggests increased density, while reduced vocal resonance
suggests an increase in the amount of air present.
• How to Assess:
Auscultate the patient's chest, starting at the top and moving
to the bottom, as they perform the following:
Bronchophony - ask the patient to say ' blue balloons'.
Whispered pectoriloquy - ask the patient to whisper 'blue
balloons'.
Egophony - ask the patient to say 'eeee'.
Exam. of RS...Dr Sana Kauser (Pathology)
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83. Impaired vocal resonance
• Increased Vocal Resonance
• Increased resonance of vocal
sounds on auscultation of the chest.
• Significance
• Occurs due to increased density
within the lung parenchyma.
• Causes of Increased Vocal
Resonance
• Pneumonia
• Atelectasis
• Lung cancer
• Reduced Vocal Resonance
• Reduced resonance of vocal sounds
on auscultation of the chest.
• Significance
• Occurs due to reduced density
within the lung parenchyma.
• Causes of Reduced Vocal
Resonance
• Pneumothorax
• Emphysema
• Haemothorax
• Pleural effusion
• Obesity
Exam. of RS...Dr Sana Kauser (Pathology) 85
84. Bronchophony
• Bronchophony is a type of pectoriloquy, in which voice
transmission through lung structures is heard with a higher
resonance. In particular, bronchophony refers to an
atypical increase in the intensity and clarity of the
individual's spoken voice heard when auscultating the
lungs with a stethoscope.
• Why Blue Balloons?
• Tactile fremitus was first described by a German physician who called
for the patient to say "neunundneunzig" (ninety-nine). "Blue Balloons"
is an English phrase that closely resembles the sound and vibration
emitted from the lungs when saying "neunundneunzig" (a low
frequency 'diphthong' phrase).
Exam. of RS...Dr Sana Kauser (Pathology) 86
85. Egophony
Egophony (also known as “E” to “A” change) is an
auscultatory finding due to a change in the quality of the
voice.
A solid (consolidated), fluid-filled, or compressed lung
decreases the amplitude and only allows select frequencies
to pass through. This changes the sound of the vowel “E”
to "A."
Method:
• ask the patient to say “ ee “ continuously
• you should hear muffled ‘’ee ‘’
• if you hear an ‘’ ay ‘’ then it is egophony
Exam. of RS...Dr Sana Kauser (Pathology)
87
86. Whispering pectroloquy
Pectoriloquy is the increased resonance of the voice through
the lung structures, so that it is clearly comprehensible using
a stethoscope on the chest. It usually indicates consolidation
of the underlying lung parenchyma.
Method:
• Ask the patient to whisper 99
• you should hear only faint sounds or nothing
• Consolidation- If you hear the sound clearly then this is
referred as whispering pectroloquy.
Exam. of RS...Dr Sana Kauser (Pathology) 88
87. Bronchophony vs Egophony vs Pectoriloquy
Bronchophony:
Vocal resonance
increased in
intensity and
clearness.
Pectoriloquy:
Exaggerated
bronchophony
with articulated
overtones-
syllabic speech.
Whispered
pectoriloquy:
sounds heard
with whispered
voice.
Egophony:
A variety of
bronchophony
having a nasal
or bleating
quality.
Exam. of RS...Dr Sana Kauser (Pathology)
89