Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. I'm barely responsible for compilation of various resources per my interest. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.

1. 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

5. TYPES OF DIAGNOSIS

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

10. INSPECTION

11. RESPIRATORY RATE

12. CHEST EXPANSION

13. CHEST EXPANSIBILITY

15. MOVEMENT OF CHEST WALL

16. PROMINENT ACCESSORY MUSCLES

18. COPD- VERY COMMON IN BANGLADESH

19. TWO PRESENTATIONS OF COPD

20. TWO TYPES OF COPD

21. WHY COPD OCCURS

22. ABNORMAL CHEST SHAPE

23. PECTUS CARINATUM VS EXCAVATUM

24. ABNORMAL CHEST SHAPE
Barrel chest

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

29. FACE
 Superior venacaval obstruction

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

33. APEX BEAT LOCATION

34. APEX BEAT IMPALPABLE - CONSIDER EMPHYSEMA

36. RIGHT VENTRICULAR HEAVE IS FOUND IN RIGHT VENTRUICULAR
HYPERTROPHY

37. HOW TO SEE TRACHEAL TUG

38. TRACHEAL PUSH VS PULL

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

40. VOCAL FREMITUS

41. CRICO STERNAL DISTANCE

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.

51. NORMAL BREATH SOUNDS

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.