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RESPIRATORY SYSTEM EXAMINATION
WHERE DOES A PATIENT GET ADMITTED?
HOW WE MANAGE A PATIENT
history examination investigation
m a n a g e m e n t
A COMMON BANGLADESH MEDICINE WARD
TYPES OF DIAGNOSIS
TYPES OF INVESTIGATION
Basic/ general/ baseline Specific
Done for all patient, to know patient status For making a diagnosis
• CBC,
• URINE RME,
• ECG,
• ALT-AST,
• SERUM CREATININE,
• SERUM ELECTROLYTES
RT-PCR
HIV
HBV
DENGUE NS1 ANTIGEN
EXAMINATION
GENERAL SYSTEMIC
FOR ALL PATIENT AS PER COMPLAINTS
LESS FOCUSES MORE FOCUSED
ALL SYSTEMIC EXAMINATION HAS FOUR PARTS
1. INSPECTION 2. PALPATION
3. PERCUSSION 4. AUSCULTATION
INSPECTION
RESPIRATORY RATE
CHEST EXPANSION
CHEST EXPANSIBILITY
Respiratory system examination
MOVEMENT OF CHEST WALL
PROMINENT ACCESSORY MUSCLES
Respiratory system examination
COPD- VERY COMMON IN BANGLADESH
TWO PRESENTATIONS OF COPD
TWO TYPES OF COPD
WHY COPD OCCURS
ABNORMAL CHEST SHAPE
PECTUS CARINATUM VS EXCAVATUM
ABNORMAL CHEST SHAPE
Barrel chest
Respiratory system examination
HANDS AND ARMS
 Clubbing
 Hypertrophic pulmonary
osteoarthropathy, in which
painful, tender swelling of
the wrists and ankles
accompanies pronounced
finger clubbing. X-rays of the
distal forearm and lower legs
show subperiosteal new
bone formation overlying the
cortex of the long bones.
EXAMINATION SEQUENCE
• Examine the hands for finger clubbing, tar
staining, nail discoloration and cyanosis.
• Ask the patient to hold their arms out
straight with the wrists extended
• Check the pulse while examining the hands.
• Check for any tenderness in the distal
forearm
FLAPPING TREMOR- ASTERIXIS
Causes-
• Hepatic failure
• Renal failure
• Respiratory failure
• Hepatic encephalopathy
FACE
 Superior venacaval obstruction
FACE EXAMINATION
• Check the conjunctiva of one eye for anaemia, and the colour of the tongue for central cyanosis
• Check for ptosis and pupil asymmetry.
PALPATION
• Locate the apex beat, the most
inferior and lateral place
where the finger is lifted by the
twisting systolic movement
of the cardiac apex. This is normally
in the fifth intercostal
space in the mid-clavicular line;
count down the intercostal
spaces from the second, which is
just below the sternal
angle.
• Palpate for a right ventricular
heave using a straight arm,
with the palm over the lower
sternum
PALPATION EXAMINATION SEQUENCE
1. Tracheal position and tug
2. Crico-sternal distance
3. Chest expansion and symmetry
4. Expansibility
5. Vocal fremitus
6. Apex beat
APEX BEAT LOCATION
APEX BEAT IMPALPABLE - CONSIDER EMPHYSEMA
Respiratory system examination
RIGHT VENTRICULAR HEAVE IS FOUND IN RIGHT VENTRUICULAR
HYPERTROPHY
HOW TO SEE TRACHEAL TUG
TRACHEAL PUSH VS PULL
HOW TO PERCUSS
• To percuss the chest, apply the middle finger of your
non-dominant hand firmly to an intercostal space, parallel
to the ribs, and drum the middle phalanx with the flexed
tip of your dominant index or middle finger
• Percuss in sequence, comparing areas on the right with
corresponding areas on the left before moving to the next
level
• Posteriorly, the scapular and spinal muscles obstruct
percussion, so position the patient sitting forwards with
their arms folded in front to move the scapulae laterally.
Percuss a few centimetres lateral to the spinal muscles,
taking care to compare positions the same distance from
the midline on right and left
VOCAL FREMITUS
CRICO STERNAL DISTANCE
Respiratory system examination
PERCUSSION EXAMINATION SEQUENCE
• Percuss along
1. Midclavicular
line
2. Midaxillary line
3. Midscapular
line
• Check liver
dullness
Respiratory system examination
Respiratory system examination
Respiratory system examination
Respiratory system examination
IMPORTANT NOTES
***Students quickly learn to keep the middle fingernail of their right hand
well-trimmed!
• Practise on yourself, friends, and on objects around the house. You’ll
soon learn the different feel and sound produced by percussing over
hollow and dense objects like the lung and the liver.
• In clinical practice, one should percuss each area of the lung, each
time comparing right then left.
• Don’t forget the apices which can be assessed by percussing directly
onto the patient’s clavicle (no left hand needed).
• If an area of dullness is heard (or felt) this should be percussed in
more detail so as to map out the borders of the abnormality.
FINDINGS
• ‘Dullness’ is heard/felt over areas of increased density
(consolidation, collapse, alveolar fluid, pleural thickening,
peripheral abscess, neoplasm).
• ‘Stony dullness’ is the unique extreme dullness heard over a
pleural
effusion.
• ‘Hyper-resonance’ indicates areas of decreased density
(emphysematous bullae or pneumothorax).
• COPD can create a globally hyper-resonant chest.
LIVER DULLNESS
Normal dull areas
• There should be an area of
dullness over the heart which
may be diminished in
hyperexpansion states (e.g.
COPD or asthma).
The liver is manifested by
an area of dullness below
the level of the 6th rib
anteriorly on the right. This
will be lower with
hyperinflated lungs.
NORMAL BREATH SOUNDS
AUSCULTATION
TECHNIQUE
 The diaphragm of the stethoscope should be used except where better surface contact is
needed in very thin or hairy patients.
 Ask the patient to ‘take deep breaths in and out through the mouth’.
 • Listen to the whole of both inspiration and expiration.
 • Listen over the same areas percussed, comparing left to right.
 • If an abnormality is found, examine more carefully and define borders
 • Listen for the breath sounds and any added sounds—and note at which point in the
respiratory cycle they occur.
BREATH SOUNDS
 Normal: ‘vesicular’. Produced by airflow in
the large airways and larynx and altered
by passage through the small airways
before reaching the stethoscope. Often
described as ‘rustling’. Heard especially
well in inspiration and early expiration.
BREATH SOUNDS
 Normal: ‘vesicular’. Produced by airflow in
the large airways and larynx and altered
by passage through the small airways
before reaching the stethoscope. Often
described as ‘rustling’. Heard especially
well in inspiration and early expiration.
BREATH SOUNDS
 Normal: ‘vesicular’. Produced by airflow in
the large airways and larynx and altered
by passage through the small airways
before reaching the stethoscope. Often
described as ‘rustling’. Heard especially
well in inspiration and early expiration.
BREATH SOUNDS
 Normal: ‘vesicular’. Produced by airflow in
the large airways and larynx and altered
by passage through the small airways
before reaching the stethoscope. Often
described as ‘rustling’. Heard especially
well in inspiration and early expiration.

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Respiratory system examination

  • 2. WHERE DOES A PATIENT GET ADMITTED?
  • 3. HOW WE MANAGE A PATIENT history examination investigation m a n a g e m e n t
  • 4. A COMMON BANGLADESH MEDICINE WARD
  • 6. TYPES OF INVESTIGATION Basic/ general/ baseline Specific Done for all patient, to know patient status For making a diagnosis • CBC, • URINE RME, • ECG, • ALT-AST, • SERUM CREATININE, • SERUM ELECTROLYTES RT-PCR HIV HBV DENGUE NS1 ANTIGEN
  • 7. EXAMINATION GENERAL SYSTEMIC FOR ALL PATIENT AS PER COMPLAINTS LESS FOCUSES MORE FOCUSED
  • 8. ALL SYSTEMIC EXAMINATION HAS FOUR PARTS 1. INSPECTION 2. PALPATION
  • 9. 3. PERCUSSION 4. AUSCULTATION
  • 18. COPD- VERY COMMON IN BANGLADESH
  • 20. TWO TYPES OF COPD
  • 23. PECTUS CARINATUM VS EXCAVATUM
  • 26. HANDS AND ARMS  Clubbing  Hypertrophic pulmonary osteoarthropathy, in which painful, tender swelling of the wrists and ankles accompanies pronounced finger clubbing. X-rays of the distal forearm and lower legs show subperiosteal new bone formation overlying the cortex of the long bones.
  • 27. EXAMINATION SEQUENCE • Examine the hands for finger clubbing, tar staining, nail discoloration and cyanosis. • Ask the patient to hold their arms out straight with the wrists extended • Check the pulse while examining the hands. • Check for any tenderness in the distal forearm
  • 28. FLAPPING TREMOR- ASTERIXIS Causes- • Hepatic failure • Renal failure • Respiratory failure • Hepatic encephalopathy
  • 30. FACE EXAMINATION • Check the conjunctiva of one eye for anaemia, and the colour of the tongue for central cyanosis • Check for ptosis and pupil asymmetry.
  • 31. PALPATION • Locate the apex beat, the most inferior and lateral place where the finger is lifted by the twisting systolic movement of the cardiac apex. This is normally in the fifth intercostal space in the mid-clavicular line; count down the intercostal spaces from the second, which is just below the sternal angle. • Palpate for a right ventricular heave using a straight arm, with the palm over the lower sternum
  • 32. PALPATION EXAMINATION SEQUENCE 1. Tracheal position and tug 2. Crico-sternal distance 3. Chest expansion and symmetry 4. Expansibility 5. Vocal fremitus 6. Apex beat
  • 34. APEX BEAT IMPALPABLE - CONSIDER EMPHYSEMA
  • 36. RIGHT VENTRICULAR HEAVE IS FOUND IN RIGHT VENTRUICULAR HYPERTROPHY
  • 37. HOW TO SEE TRACHEAL TUG
  • 39. HOW TO PERCUSS • To percuss the chest, apply the middle finger of your non-dominant hand firmly to an intercostal space, parallel to the ribs, and drum the middle phalanx with the flexed tip of your dominant index or middle finger • Percuss in sequence, comparing areas on the right with corresponding areas on the left before moving to the next level • Posteriorly, the scapular and spinal muscles obstruct percussion, so position the patient sitting forwards with their arms folded in front to move the scapulae laterally. Percuss a few centimetres lateral to the spinal muscles, taking care to compare positions the same distance from the midline on right and left
  • 43. PERCUSSION EXAMINATION SEQUENCE • Percuss along 1. Midclavicular line 2. Midaxillary line 3. Midscapular line • Check liver dullness
  • 48. IMPORTANT NOTES ***Students quickly learn to keep the middle fingernail of their right hand well-trimmed! • Practise on yourself, friends, and on objects around the house. You’ll soon learn the different feel and sound produced by percussing over hollow and dense objects like the lung and the liver. • In clinical practice, one should percuss each area of the lung, each time comparing right then left. • Don’t forget the apices which can be assessed by percussing directly onto the patient’s clavicle (no left hand needed). • If an area of dullness is heard (or felt) this should be percussed in more detail so as to map out the borders of the abnormality.
  • 49. FINDINGS • ‘Dullness’ is heard/felt over areas of increased density (consolidation, collapse, alveolar fluid, pleural thickening, peripheral abscess, neoplasm). • ‘Stony dullness’ is the unique extreme dullness heard over a pleural effusion. • ‘Hyper-resonance’ indicates areas of decreased density (emphysematous bullae or pneumothorax). • COPD can create a globally hyper-resonant chest.
  • 50. LIVER DULLNESS Normal dull areas • There should be an area of dullness over the heart which may be diminished in hyperexpansion states (e.g. COPD or asthma). The liver is manifested by an area of dullness below the level of the 6th rib anteriorly on the right. This will be lower with hyperinflated lungs.
  • 52. AUSCULTATION TECHNIQUE  The diaphragm of the stethoscope should be used except where better surface contact is needed in very thin or hairy patients.  Ask the patient to ‘take deep breaths in and out through the mouth’.  • Listen to the whole of both inspiration and expiration.  • Listen over the same areas percussed, comparing left to right.  • If an abnormality is found, examine more carefully and define borders  • Listen for the breath sounds and any added sounds—and note at which point in the respiratory cycle they occur.
  • 53. BREATH SOUNDS  Normal: ‘vesicular’. Produced by airflow in the large airways and larynx and altered by passage through the small airways before reaching the stethoscope. Often described as ‘rustling’. Heard especially well in inspiration and early expiration.
  • 54. BREATH SOUNDS  Normal: ‘vesicular’. Produced by airflow in the large airways and larynx and altered by passage through the small airways before reaching the stethoscope. Often described as ‘rustling’. Heard especially well in inspiration and early expiration.
  • 55. BREATH SOUNDS  Normal: ‘vesicular’. Produced by airflow in the large airways and larynx and altered by passage through the small airways before reaching the stethoscope. Often described as ‘rustling’. Heard especially well in inspiration and early expiration.
  • 56. BREATH SOUNDS  Normal: ‘vesicular’. Produced by airflow in the large airways and larynx and altered by passage through the small airways before reaching the stethoscope. Often described as ‘rustling’. Heard especially well in inspiration and early expiration.