Respiratory System Exam....Dr Sana Kauser Patho.pdf

EXAMINATION OF
RESPIRATORY
SYSTEM
‫سفنت‬‫اظنم‬‫ااحتمن‬
Exam. of RS...Dr Sana Kauser (Pathology) 1

Dr Sana Kauser Ateeque Ahmed
Assistant Professor
Dept. of Mahiyatul Amraz
Al-Ameen Unani Medical College & Hospital, Malegaon

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

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)

1. HISTORY TAKING
‫رمضی‬‫روداد‬

“
”
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

Bio data of the patient
Name
Age
Sex
Occupation
Address
Religion
Marital status
7

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

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

Cardinal symptoms
The primary or major symptom by which a diagnosis is made
• Cough
• Expectoration/ Sputum
• Haemoptysis
• Breathlessness/ dyspnoea
• Wheezing
• Pain in the chest

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
11

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
12

Cont..
Productive
Chronic
bronchitis
Bronchiectasis
Tuberculosis
Dry
Pharyngitis
Laryngitis
Tracheatis
Tonsillitis

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

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

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

Paroxysmal dyspnoea
Whooping cough
Bronchiectasis
Bronchial asthma
Cardiac asthma

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
18

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.

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

2. GENERAL
EXAMINATION
‫ومعیم‬‫ااحتمن‬

GENERAL EXAMINATION
• Physique/ Built
(wasting)
• Nourishment
• Anemia and pallor
• Jaundice
• Cyanosis
• Pigmrntation
• Clubbing
• Koilynochia
• Lymphadenopathy
• Pedal edema
• Vitals –
Pulse
BP
Temp
Respirations-
Rate
Regular
Type of Respiration
• Voice
• Breathlessness
• Clubbing of the
fingers
• Tobacco staining of
fingers
• Bruising
• Thinning of skin
• Venous pulsus
• Ptosis
• Swollen face

FACE
Types of face
24

Cont…
 Pink puffers (emphysema)
 Blue bloaters (chronic
bronchitis)
 Parotid enlargement (alcohol)
 Rashes
25

MOUTH
• Breath (fetor hepaticus)
• Lips
• Angular stomatitis
• Cheilitis
• Ulceration
• Peutz-Jeghers syndrome
• Gums
• Gingivitis, bleeding
• Candida albicans
• Pigmentation

Atrophic glossitis Thrush
Tongue
• Atrophic glossitis
• Leicoplakia
• Furring
Cont…

• Conjuctival pallor
(anaemia)
• Sclera: jaundice
EYES

 Cornea: Kaiser Fleischer’s
rings (Wilson’s disease)
 Xanthelasma (cholesterol
deposit, primary biliary
cirrhosis)

Cont…
 Horner’s syndrome- ca. bronchus
 Chemosis
 Conjunctivitis
30

NECK
Enlarged Lymph nodes:
• TB
• Lymphoma
• Sarcoidosis
• Malignancy
Congested neck veins

32

SKIN
 Rashes:
Herpes zoster
Typhoid
Skin diseases
Allergic conditions
 Dilated veins---SVC
obstruction
 Scars:
Previous operation
Injury
Burns
Biopsies
 Pigmentation-
haemochromotosis

34

CYANOSIS
Central
Peripheral
Causes of central:
COPD
Resp. failure
Pulmonary fibrosis
Bronchial asthma
Congenital cyanotic heart disease (ASD, VSD, PDA)
Pulmonary embolism

Cyanosis
36

OEDEMA
General:
• Right ventricular failure
• Cor pulmonale
• Renal failure
Local:
• Lymphatic obstruction
• Inflammation
37

HANDS
• Nails
• Clubbing
• Koilonychia
• Leuconychia
• Palmar erythema
• Dupuytren’s contractures

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
39

Schamroth’s sign
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

HANDS
Palmar erythema Dupuytren’s contractures

HANDS
Peripheral
Cyanosis
42

ARMS
• Spider naevi (telangiectatic lesions)
• Bruising
• Wasting
• Scratch marks (chronic cholestasis)
43

PULSE
 Normal- 78/min
 Tachycardia- >120/min—Infections
---P.E
--B. asthma
--COPD exacerbation
 Bradycardia: Generally no underlying disease, fitness
 Collapsing pulse- Large volume bounding pulse (aortic regurgitation)
PULSES PARADOXUS
 Status Asthmaticus
 Massive pulmonary embolism
 Tension pneumothorax
 Cardiac temponade
45

2. SYSTEMIC
EXAMINATION
‫اظنیم‬‫ااحتمن‬

EXAMINATION OF
RESPIRATORY SYSTEM
INSPECTION
PALPATION
AUSCULTATION
PERCUSSION

INSPECTION
‫ابرظنل‬‫ااحتمن‬

49

INSPECTION
• Upper respiratory tract (nose, oral cavity, larynx)
• Trachea
• Shape of chest
• Apex impules
• Engorged veins, pulsations
• Scars, sinuses, swellings, bulgings

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

SHAPE OF THE CHEST
Normal: transverse diam> AP
A-P diameter
Pectus excavatum---funnel chest
Pectus carinatum---pigeon chest
Kyphoscoliosis

Pigeon chest
Funnel chest
53
Barrel chest

Kyphosis Scoliosis
54

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

Cont…
• Character:
Abdominal, thoracic, thoraco-abdominal, abdomino-thoracic
• Respiratory movements:
 Bilaterally equal
 Flail chest

Deviated Trachea

DILATED VEINS
SVC obstruction---Ca lung
58

PALPATION
‫ابسمل‬‫ااحتمن‬

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

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
61

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

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

Palpation of respiratory movements
Anterior, Apical, Posterior

Palpation of inter costal spaces

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).
66

67

PERCUSSION
‫ابرقلع‬‫ااحتمن‬

“
”
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

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
70

Cont…
Tidal percussion
Kronig isthmus
Traube’s space
S-shifting dullness
S –succusion splash
Skodaic resonance
Coin test above the fluid level
Liver dullness

72

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.

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.
74

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).

Areas of Percussion

AUSCULTATION
‫ع‬‫م‬‫س‬‫ل‬
‫اب‬‫ااحتمن‬

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.
78

ADDED SOUNDS
• However, it may include some irregular breath sounds.
 Added/ adventitious sounds:

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

Cont…
• Crackles/Crepitations:
https://www.youtube.com/watch?v=z2Ra9UxndI0
https://www.google.com/search?q=crackles+sound&rlz=1
Crackles, are high pitched breath sounds that are similar to
popping or snapping.
These sounds occur if the small air sacs in the lungs fill with
fluid and there’s air movement in the sacs, such as when
you’re breathing. The air sacs fill with fluid when a person
has pneumonia or heart failure.
Fine
• Heart failure
• Fibrosing alveolitis
Coarse
• Bronchiectasis
• Infections
81

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.
82

83

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'.
84

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

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).

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
87

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.

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.
89

THANK
YOU

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