Introduction to physical examination of respiratory system

1. Dr Saneesh P J
Sultan Qaboos University Hospital, Muscat

2. Acute Shortness of Breath
Chest pain

7. cough
sputum production
haemoptysis
chest pain
breathlessness
wheeze

8. Location
Quality
Quantity or severity
Timing
Setting in which it occurs
Aggravating or relieving factors
Assoc manifestations; addl relevant features of
each symptom

9. Breathlessness (dyspnoea) is an undue
awareness of breathing

10. How fast did it happen?
Do you have chest pain?
Does the pain change with respiration (pleuritic)
?
Does your SOB gets better or worse with
walking?
Does your breathing pattern improve when you
sit up?

11. Do you have a history of asthma or emphysema
(COPD)?
Have you had clots in your legs?
Have you been hit in the chest?
Are you sleepy during the day?

16. Breathlessness when lying flat
Usually associated with left ventricular failure.
It can also be a feature of respiratory muscle
weakness, large pleural effusion, massive ascites,
morbid obesity or any severe lung disease.

17. Breathlessness that wakes the patient from
sleep
typical of asthma and left ventricular failure
Patients with asthma typically wake between 3
and 5 a.m. and have associated wheezing.
Breathlessness worse on waking is more typical
of COPD and may improve after coughing up
sputum.

18. Patients with may
notice that the breathlessness continues to
worsen for 5–10 minutes after stopping activity.

19. If you suspect asthma, ask about
exposure to allergens, smoke, perfumes, fumes,
cold air or drugs, e.g. aspirin, non-steroidal anti-
inflammatory drugs.
Common allergens are house dust mite (shaking
bedding, hoovering), animals (cats, dogs, horses)
and grass pollens (mowing the lawn, the ‘hayfever
season’) and tree pollens.

20. Breathlessness improving at weekends or
holidays

21. Breathlessness on sitting up with relief on lying
down
Right-to-left shunting through a patent foramen
ovale, atrial septal defect or a large intrapulmonary
shunt.

22. Breathlessness when lying on one side
due to unilateral lung disease (patient prefers the
healthy lung down), dilated cardiomyopathy
(patient prefers right side down) or tumours
compressing central airways and major blood
vessels.

26. COPD is characterised by airflow obstruction
that is usually progressive and not fully
reversible. It is defined as a reduced post-
bronchodilator forced expiratory volume in 1
second (FEV1)/forced vital capacity (FVC) ratio
of <70%.
Asthma is reversible airways obstruction

28. Site
Radiation
mode of onset
duration
severity
aggravating/relieving factors including the
effects of breathing and movement

31. Sharp
Stabbing
Intensified by inspiration or coughing
Irritation of the parietal pleura of the upper six
ribs causes localised pain.
Irritation of the parietal pleura overlying the
central diaphragm innervated by the phrenic
nerve is referred to the neck or shoulder tip.

32. The lower six intercostal nerves innervate the
parietal pleura of the lower ribs and the outer
diaphragm, and pain from these sites may be
referred to the upper abdomen.
Common causes of pleuritic chest pain are
pulmonary embolism
pneumonia
pneumothorax
fractured ribs

33. Sudden and localised after vigorous coughing or
direct trauma is characteristic of rib fractures or
intercostal muscle injury.
Prevesicular herpes zoster and intercostal nerve
root compression can cause chest pain in a
thoracic dermatomal distribution.

34. Chest wall pain due to direct invasion by lung
cancer, mesothelioma or rib metastasis is
typically dull, aching or gnawing, unrelated to
respiration, progressively worsens and disrupts
sleep.
Pancoast’s tumour of the lung apex may involve
the first rib and the brachial plexus, causing
referred pain down the medial side of the
ipsilateral arm.

35. Central, retrosternal and unrelated to
respiration or cough.
Irritant dusts or infection of the
tracheobronchial tree produce a raw, burning
retrosternal pain worse on coughing.
A dull, aching retrosternal pain that disturbs
sleep is a feature of cancer invading mediastinal
lymph nodes or an enlarging thymoma.

36. Massive pulmonary thromboembolism acutely
increasing right ventricular pressure may
produce central chest pain similar to myocardial
ischaemia

38. W
I
P
E
S

44. Respiratory Rate
Tachypnoea
Bradypnoea
Hyperpnoea
Breathing patterns
Hyperventilation
Kussmaul’s breathing
Hypoventilation
Periodic breathing (Cheyne–Stokes respiration)

46. Obstructive sleep apnoea/ hypopnoea
syndrome (OSAHS)
combination of excessive daytime sleepiness and
recurrent upper airway obstruction with sleep
fragmentation caused by upper airway obstruction
from collapse of the retropharynx

47. A) Hyperinflated chest with intercostal indrawing. (B) Kyphoscoliosis.

48. (C) Pectus carinatum with prominent Harrison’s sulcus (arrow). (D) Pectus excavatum.

50. Trail sign: Sternomastoid prominence on the side of tracheal shift

52. On one side
pleural effusion
lung or lobar collapse
pneumothorax an
unilateral fibrosis
Paradoxical inward
movement
diaphragmatic paralysis
severe COPD
Flail chest
Bilateral
severe COPD
diffuse pulmonary fibrosis

53. Subcutaneous emphysema
Mediastinal emphysema occurs if air tracks into
the mediastinum and is associated with a
characteristic systolic ‘crunching’ sound on
auscultating the precordium (Hamman’s sign).
Tenderness over the costal cartilages is found in
the costochondritis of Tietze’s syndrome.
Localised rib tenderness can be found over
areas of pulmonary infarction or fracture.

56. Ewart’s sign
Dullness below the left scapula – large pericardial
effusion
Conner’s sign
Dullness to percussion below the right scapula –
large pericardial effusion
Kellock’s sign
Feeling increased rib vibration in the anterior chest
to percussion posteriorly – pleural effusion

57. D’Amato’s sign
Change in percussible dullness with change in
position – pleural effusion
Skodaic hyper-resonance
Hyper-resonance just above an area of dullness – a
useful sign of pleural effusion

65. Important sign of a posterior mediastinal mass
At the level of mid-scapula (about T5) – listen
over the vertebral spinous process and on
either side of the vertebral column. Normally
the lateral sounds are louder and more distinct.
When the upper airway sounds are of greater
intensity than the corresponding lateral lung
sounds – implies a continuity (a mass) between
a mainstem bronchus and vertebra

66. Post-tussive Rales
Lung abscess
Egophony (Goat sound)
“E” to “A” – pulmonary consolidation
Whisper pectoriloquy
“sixty-six whiskeys, please”
Consolidation
Bronchophony
Consolidation/compressed lung

69. Note the patient’s general appearance and
demeanour.
Look for central cyanosis of the lips and tongue.
Examine the skin for rashes and nodules.
Listen for hoarseness and stridor.
Examine the hands for finger clubbing,
peripheral cyanosis and tremor.

70. Measure the blood pressure.
Examine the neck for raised JVP and cervical
lymphadenopathy.
Record the respiratory rate.
Observe the breathing pattern, and look for use
of accessory muscles.

86. Normal Chest x ray

87. Pleural effusion (Left)

88. Pneumothrorax

89. Pneumonia - consolidation

90. Pleural Effusion Consolidation
Tracheal deviation Contralateral None
Fremitus Decreased Increased
Percussion Dull Dull
Breath sounds Decreased Decreased

91. Emphysema Pneumothorax
Tracheal deviation None Contralateral
Fremitus Decreased Decreased
Percussion Hyper-resonant Hyper-resonant
Breath sounds Crackles Decreased