The document provides information on examining the respiratory system, including: - Key anatomical structures of the chest and how to locate findings - Main symptoms to ask about including cough, dyspnea, hemoptysis, and wheezing - How to perform a physical exam of the chest including inspection, palpation, percussion, and auscultation - What different lung sounds and abnormalities indicate

1. Respiratory system
History & Physical examination
Dr Aklilu M(MD, Internist)

2. Outline
• Anatomical structures
• Main symptoms of pulmonary disease
• Physical examination
• Reporting

3. Anatomical structures
To describe physical signs in the chest accurately, you should
understand the topographic landmarks of the chest wall.
• Sternum
• Clavicle
• Suprasternal notch
• Sternomanubrial angle
• Midsternal line
• Midclavicular lines
• Anterior axillary lines
• Midaxillary lines
• Posterior axillary lines
• Scapular lines
• Midspinal line

4. Anatomical structures

5. Anatomical structures
• Locating Findings on the Chest.
• Describe abnormalities of the chest in two
dimensions: along the vertical axis and around
the circumference of the chest.

6. The history
1. Breathlessness /dyspnea
• It is not due simply to hypoxia or hypercapnia,
although these may play a significant part.
• Lung,CVS
• Dyspnea related only to exertion?
• Is there variability in the symptom?
• Orthopnea, platypnea, trepopnea

7. • Positional Dyspnea
Type Possible Causes
Orthopnea Congestive heart failure
Mitral valvular disease
Severe asthma (rarely)
Emphysema (rarely)
Chronic bronchitis (rarely)
Neurologic diseases (rarely)
Trepopnea Congestive heart failure
Platypnea Status post-pneumonectomy
Neurologic diseases
Cirrhosis (intrapulmonary shunts)
Hypovolemia

8. The history…
2. Cough
• May be dry or productive of sputum.
• Is sputum produced?
– What does it look like? description of its Color
consistency.
– How much is produced?
• How long has the cough been present?
• Is the cough worse at any time of day or night?
• Is the cough aggravated by anything, for example dust,
pollen or cold air?

9. Appearance Possible Causes
Mucoid/Mucopurulent Asthma, tumors, tuberculosis, emphysema,
pneumonia
Yellow-green, purulent Bronchiectasis, chronic bronchitis
Rust-colored, purulent Pneumococcal pneumonia
Red currant jelly Klebsiella pneumoniae infection
Foul odor Lung abscess
Pink, blood-tinged Streptococcal or staphylococcal pneumonia
Gravel Broncholithiasis
Pink, frothy Pulmonary edema
Profuse, colorless (also
known as bronchorrhea)
Alveolar cell carcinoma
Bloody Pulmonary emboli, bronchiectasis, abscess,
tuberculosis, tumor, cardiac causes,
bleeding disorders

10. The history…
3. Haemoptysis
• Blood may be coughed up alone, or sputum may be
bloodstained.
– Is there any blood in the sputum?
– Is it fresh or altered?
– How often has it been seen, and for how long?
• It is sometimes difficult to describe whether or not
the blood has originated from the chest or other.
– always be asked about associated conditions such as
epistaxis or melaena.

11. Qs
• "Do you smoke?" If yes, "How much, and for how long?"
• "Did the coughing up of blood occur suddenly?"
• "Have there been recurrent episodes of coughing up blood?"
• "Is the sputum blood-tinged, or are there actual clots of blood?"
• "How long have you noticed the blood?"
• "What seems to bring on the coughing up of blood? vomiting?
coughing?"
• "Have you ever had tuberculosis?"
• "Do you take any 'blood thinners'?"
• "Are you aware of any bleeding tendency?"
• "Have you had night sweats? shortness of breath? palpitations?
irregular heartbeats? hoarseness? weight loss? swelling or pain
in your legs?"

12. Hemoptysis vs hematemesis
• Characteristics distinguishing hemoptysis from
hematemesis
Features Hemoptysis Hematemesis
Prodrome Coughing Nausea and vomiting
Past history Possible history of
cardiopulmonary
disease
Possible history of
gastrointestinal
disease
Appearance Frothy Not frothy
Color Bright red Dark red, brown, or
"coffee grounds"
Manifestation Mixed with pus Mixed with food
Associated symptoms Dyspnea Nausea

13. The history…
4. Wheezing
• Wheezes are musical respiratory sounds that may be
audible both to the patient and to others
• Suggests partial airway obstruction from secretions,
tissue inflammation, or a foreign body.
• Sometimes stridor may be mistaken for wheezing by
both patient and doctor

14. Qs
• "At what age did the wheezing begin?"
• "How often does it occur?"
• "Are there any precipitating factors, such as
foods, odors, emotions, animals, etc.?"
• "What usually stops the attack?"
• "Have the symptoms worsened over the years?"
• "Are there any associated symptoms?"
• "Is there a history of nasal polyps?"
• "What is your smoking history?"
• "Is there a history of heart disease?"

15. The history…
5. Chest pain
• If caused by lung disease usually arises from the
pleura(infection, pneumothorax, tumor, effusion)
• Pleuritic pain is sharp and stabbing, and is made
worse by deep breathing or coughing.
• Constant pain, unrelated to breathing

16. The history…
6. Other symptoms /history
• Ear, nose and throat
• Smoking history: average consumption for both
current and ex-smokers
• FAMILY HISTORY
• OCCUPATIONAL HISTORY

17. Physical examination
A. General assessment
• Patient should be resting comfortably on a bed or couch
• Points to note in a general assessment
– Physique
– Voice
– Breathlessness
– Clubbing
– Cyanosis or pallor
– Intercostal recession
– Use of accessory respiratory muscles
• Examine hands, lips and tongue,
Central cyanosis vs
peripheral cyanosis alone?

18. Physical examination
A. Inspection
• Appearance of the chest/Deformities
– Scars, - barrel-shaped
– Kyphosis or scoliosis - masses or sinus tracts
• Impaired respiratory movement on one or
both sides or a unilateral lag (or delay) in
movement.
• Abnormal retraction of the interspaces during
inspiration.

20. Physical examination
B. Palpation
• Swellings and tenderness
• Tracheal position
– position of the mediastinum has been altered by disease
of the lungs or pleura.
• pushed away from the affected side by a pleural effusion
or pneumothorax.
• Fibrosis or collapse of the lung will pull towards the
affected side.
• Chest expansion/Asymmetry
• Tactile fremitus

21. Physical examination
B. Palpation
• Tactile fremitus
– Speech creates vibrations
– provides useful information about the density of the
underlying lung tissue and chest cavity
– asks the patient to say "ninety-nine."
i. Increased
– Pneumonia
ii. Decreased
A. Unilateral: Pneumothorax, Pleural effusion, Atelectasis, fibrosis(pleural
thickening)
B. Bilateral: Chronic obstructive lung disease, Chest wall thickening

23. Physical examination
C. Percussion
• Sound heard and the tactile sensation felt depend
on the air-tissue ratio
• Enable you to evaluate the lung tissue to a depth of
only 5 to 6 cm,
• Evaluate Diaphragmatic Movement
• Points to note on percussion of the chest
– Resonance
• Reduction of resonance
• Increase in resonance/hyperresonance
– Dullness: relative dullness and stony dullness

24. Physical examination
Percussion Notes and Their Characteristics
Relative
intensity
Relative
pitch
Relative
duration
Example of
Location
Pathologic
Examples
Flatness Soft High Short Thigh
Large pleural
effusion
Dullness Medium Medium Medium Liver Lobar pneumonia
ResonanceLoud Low Long
Normal
lung
Simple chronic
bronchitis
Hyperreso
nance Very loud Lower Longer
None
normally
Emphysema,
pneumothorax
Tympany Loud High* *
Gastric air
bubble or
Large
pneumothorax,
bowel
obstruction

26. • The difference between the inspiration and expiration
levels represents diaphragmatic motion, which is normally
4 to 5 cm.
• An abnormally high level suggests pleural effusion, or a
high diaphragm as in atelectasis or diaphragmatic
paralysis.

27. Physical examination
D. Auscultation
• Listen to the chest with the diaphragm, not the bell,
of the stethoscope
• Listen in comparable positions to each side
alternately.
• Auscultation involves
a) listening to the sounds generated by breathing,
b) listening for any adventitious (added) sounds,
c) if abnormalities are suspected, listening to the sounds
of the patient’s spoken or whispered voice as they are
transmitted through the chest wall.

28. Physical examination
I. Breath Sounds (Lung Sounds).
• identify patterns of breath sounds by their
intensity, their pitch, and the relative duration of
their inspiratory and expiratory phases.
• Normal breath sounds are:
D. Auscultation

30. Physical examination
• Crackles:due to abnormalities of the lungs or of the airways
• Wheezes suggest narrowed airways
• Rhonchi suggest secretions in large airways.
(pneumonia, fibrosis, CHF, bronchiecta

31. Physical examination
III. Transmitted Sounds.
• Ask the patient to say “ninety-nine.” Normally the sounds
transmitted through the chest wall are muffled and indistinct.
– Louder, clearer voice sounds are called bronchophony.
• Ask the patient to say “ee.” You will normally hear a muffled
long E sound.
– When “ee” is heard as “ay,” an E-to-A change (egophony) is
present, as in lobar consolidation from pneumonia.
• Ask the patient to whisper “ninety-nine” or “one-two-three.”
The whispered voice is normally heard faintly and indistinctly,
if at all.
– Louder, clearer whispered sounds are called whispered
pectoriloquy.
D. Auscultation

32. Reporting
A. Inspection: no cyanosis, no finger clubbing.
Chest moves symmetrically with increased AP
diameter, decreased expansion.
B. Palpation: no tenderness, trachea located
centrally, tactile fremitus decreased
C. Purcussion: Lungs are hyperresonant,
diaphragms descend 2 cm bilaterally.
D. Auscultation: Breath sounds are distant with
delayed expiratory phase and scattered
expiratory wheezes.; no bronchophony,
egophony, or whispered pectoriloquy.