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Respiratory System Physical Examination
Dr. Saneesh P J discusses various symptoms of acute shortness of breath including cough, sputum production, hemoptysis, chest pain, breathlessness, and wheeze. He examines the location, quality, timing, and aggravating/relieving factors of each symptom. Dr. Saneesh also evaluates different breathing patterns, histories of underlying lung conditions, and how activity impacts shortness of breath. Based on the symptom details, potential conditions like asthma, COPD, pulmonary embolism, and heart failure are considered.
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Respiratory System Physical Examination
- 1. Dr Saneesh PJ Sultan Qaboos University Hospital, Muscat
- 2. Acute Shortness ofBreath Chest pain
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- 8. Location Quality Quantity or severity Timing Settingin which it occurs Aggravating or relieving factors Assoc manifestations; addl relevant features of each symptom
- 9. Breathlessness (dyspnoea) isan undue awareness of breathing
- 10. How fast didit 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 havea 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 lyingflat 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 wakesthe 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 noticethat the breathlessness continues to worsen for 5–10 minutes after stopping activity.
- 19. If you suspectasthma, 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 atweekends or holidays
- 21. Breathlessness on sittingup 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 lyingon 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 characterisedby 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/relievingfactors including the effects of breathing and movement
- 31. Sharp Stabbing Intensified by inspirationor 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 sixintercostal 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 localisedafter 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 paindue 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 andunrelated 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 thromboembolismacutely increasing right ventricular pressure may produce central chest pain similar to myocardial ischaemia
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- 44. Respiratory Rate Tachypnoea Bradypnoea Hyperpnoea Breathing patterns Hyperventilation Kussmaul’sbreathing 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 chestwith intercostal indrawing. (B) Kyphoscoliosis.
- 48. (C) Pectus carinatumwith prominent Harrison’s sulcus (arrow). (D) Pectus excavatum.
- 50. Trail sign: Sternomastoidprominence on the side of tracheal shift
- 52. On one side pleuraleffusion 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 emphysemaoccurs 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 belowthe 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 inpercussible 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 ofa 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’sgeneral 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 bloodpressure. Examine the neck for raised JVP and cervical lymphadenopathy. Record the respiratory rate. Observe the breathing pattern, and look for use of accessory muscles.
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- 90. Pleural Effusion Consolidation Trachealdeviation Contralateral None Fremitus Decreased Increased Percussion Dull Dull Breath sounds Decreased Decreased
- 91. Emphysema Pneumothorax Tracheal deviationNone Contralateral Fremitus Decreased Decreased Percussion Hyper-resonant Hyper-resonant Breath sounds Crackles Decreased