Respiratory Examination

Respiratory Examination

BYASHRAF OKBA

PROF. OF INTERNAL MEDICINEAIN SHAMS UNIVERSITY

Personal History:

Stress on the following points

Occupation: e.g.

– Silicosis may be complicated by pulmonary T.B.

– Asbestosis may be complicated by mesothelioma

Ask about the following:

1-Duration of exposure: several years needed for pneumoconiosis.

2-Adherence to safety measures as wearing special masks.

Special Habits smoking cigarettes, shesha and goza.

The six cardinal symptoms of chest diseases are:

1- Cough

2- Expectoration (sputum)

3- Hemoptysis

4- Chest pain

5- Dyspnea

6- Wheezes

History of the present illness

Other symptoms of importance in chest diseases :

1- Symptoms of mediastinal syndrome as dysphagia and hoarseness of voice.

2- Symptoms of toxemia as night fever, night sweats, loss of appetite and weight as in T.B.

3- Symptoms of RVF as LLs edema and pain in the RUQ of the abdomen ( due to congested tender liver).

4- Fever as in upper and lower resp. tract infections.

Finally any other symptoms related to other systems.

History of the present illness2

Attack or disease similar to the present one: e.g. - Asthma. - Recurrent pneumoniaAllergic disorders: eczema, urticaria, angioedema and

hay fever.Acute abdominal conditions. Admission in any hospital before and why?Bilharziasis: bilharzial cor pulmonale.

Past HistoryPast History11

Chest injuries and operations.

Other Surgical Procedures.

Coma , convulsions….may predispose to aspiration lung abscess

Cardiac diseases and history of rheumatic fever.


Diabetes mellitus

Hypertension. Cough may result from ACE inhibitors

T.B and history of admission to a chest hospital for treatment of T.B. medicines, duration of the treatment and the adherence to it.

Previous radiological examination: comparison with the current radiograph


Similar condition in the family.

History of T.B.

History of allergy as eczema and hay fever.

History of DM

Family and Social HistoryFamily and Social History

Ask about the following:

The frequency

The severity

Dry or productive

Time of occurrence

Relation to posture

Character of cough (better observed by the physician)

CoughCough

Analysis of Chest SymptomsAnalysis of Chest Symptoms11

SputumSputum


Amount

Color

Character (seous, mucoid,purulent and mucopurulent)

Odor

Relation to posture

What increases or decreases it

Associated conditions

HemoptysisHemoptysis11::Analysis of Chest SymptomsAnalysis of Chest Symptoms33

The most important causes of hemoptysis are

•Mitral stenosis

•Pulm tuberculosis

•Pulm infarction

•Brochiectasis

•Bronchogenic carcinoma

•Bronchial adenoma

•Bleeding tendency

Differentiate between hemoptysis and hematemesis Ask about :

•Type and Degree

•Frequency and Duration

Ask about the preceding events e.g. DVT or chest infection

HemoptysisHemoptysis22::


Type and Degree

HemoptysisHemoptysis33::


•Frank hemoptysis

•Blood-stained sputum

•Blood streaked sputum

•Rusty sputum

Frequency and duration

Chest pain: The onset..

Site.

Character.

Radiation.

What increases the pain

what relieves or decreases it.

Associated symptoms.


Wheeze

What dose the patient mean by wheezing?

differentiate between wheeze and stridor.

Wheezing may be intermittent as in asthma or persistent as in chronic bronchitis.

Wheezing may be diffuse as in asthma and chronic bronchitis or localized as in bronchogenic carcinoma.


CHEST EXAMINATION

Inspection of anterior chest wall

1) Ask the patient to lie supine.

2) Ask the patient to lower his gown to waist level.

3) Stand at the feet of patient.

4) Inspect the shape of the chest (ratio of antero-posterior and transverse diameters).

5) Inspect the symmetry of the patient’s chest on both sides with comparison.

Chest wall Pectus carinatum Pectus excavatum

Inspection of anterior chest wall6) Inspect patient’s chest normal breathing

movement. 7) Inspect patient’s chest for accessory muscle use. 8) Inspect patient’s chest for retraction of lower

intercostal spaces. 9) Stand again to the right of patient and look

tangentially for apical and epigastric pulsation. 10) Inspect the chest wall and skin for swelling,

scars, skin eruption or engorged veins.

Palpation of anterior chest wall 1) Stand to the right of the patient. 2) Ask the patient to lie supine. 3) Palpate upper lung zone to confirm the movement by placing

the palms in the infraclavicular fossa and the two thumbs in the midline at the level of suprasternal notch. Let the patient inspire deeply and let your thumbs follow chest movement.

4) Palpate middle lung zone by putting the palm in the middle part with tips of thumbs in the midline. Let the patient inspire deeply and let your thumbs follow chest movement.

Palpation of anterior chest wall

5) Palpate lower lung zone by putting the palm in the lower part with tips of thumbs in the midline. Let the patient inspire deeply and let your thumbs to follow chest movement.

6) Palpate for palpable rhonchi, pleural rub or chest wall tenderness by putting the palm on various areas of chest wall.

7) Palpate for Tactile vocal fremitus a) Place the palm of hand over various area of chest wall in the

direction of bronchial tree away from midline with comparison.

b) Ask the patient to repeat the words “44” in arabic

TVF2

Increased TVF Decreased TVF

ConsolidationCavitationCollapse with patent main bronchus

Thick chest wallPleural effusion Pleural fibrosisPneumothoraxEmphysemaCollapse

Tracheal examination:a) Stand to the right of the patient. b) Ask the patient to sit up with the head straight. c) Inspect for tracheal position “Trill’s sign”. d) Tracheal shift: Insert the index finger in horizontal position in

the pouch between the medial end of sternomastoid and the lateral aspect of trachea with comparison.

e) Check the cricosternal distances. This is the distance between the cricoid cartilage and the suprasternal notch. If it is less than 3 finger breadths, this indicates hyperinflation of the lung.

f) Tracheal descent: place the tip of the index finger on the thyroid cartilage during inspiration to observe its descent.

Percussion technique Place left hand on chest wall, palm

downwards with fingers separated 2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx

producing hammer effect Entire movement comes from wrist

Percussion of the chest anterior chest wall 1- Stand to the right of the patient. 2- Ask the patient to lie supine. 3- Use light percussion. 4- Krönig’s isthmus: Percuss both areas right and left from dullness to

resonance (start from the neck) with comparison. 5- Percuss both clavicles directly (over medial third) 6- Percuss the infraclavicular regions. 7- Percuss both parasternal lines right and left, from the second space

to the sixth space with comparison. 8- Spare bare area to be percussed late with special areas

percussion. 9- Percuss both midclavicular lines right and left, from the second

space to the sixth space with comparison. 10-Comment on dullness found.

Percussion of the lateral chest wall

1-Stand to the right of the patient. 2-Ask the patient to lie supine and raise his hands above his

head. 3-Use light percussion. 4-Percuss both anterior axillary lines right and left, from the

fourth space to the eighth space with comparison. 5-Percuss both middle axillary lines right and left, from the

fourth space to the eighth space with comparison. 6-Percuss both posterior axillary lines right and left, from the

fourth space to the eighth space with comparison. 7-Comment on dullness found.

Upper border of the liver

1- Stand to the right of the patient.

2- Ask the patient to lie supine.

3- Use heavy percussion.

4- Start in the right midclavicular line from second space down to the first dullness.

5- Decide the upper border of the liver.

Bare area of the heart


2- Ask the patient to lie supine.

3- Place the left hand in the left 4th and the 5th spaces between midline and parasternal line.

4- Percuss lightly with right hand.

5-Comment.

Tidal percussion 1- Stand to the right of the patient. 2- Ask the patient to sit. 3- After percussing the back using heavy

percussion if any infrascapular dullness was found, fix the left hand over it and ask the patient to take a deep breath and hold it then percuss again.

4- Comment on whether it changed to be resonant or not and explain.

Percussion of the lateral chest wall

1- Stand to the right of the patient. 2- Ask the patient to lie supine and raise his hands above his

head. 3- Use light percussion. 4- Percuss both anterior axillary lines right and left, from the

fourth space to the eighth space with comparison. 5- Percuss both middle axillary lines right and left, from the

fourth space to the eighth space with comparison. 6- Percuss both posterior axillary lines right and left, from the

fourth space to the eighth space with comparison. 7- Comment on dullness found.

Kronig’s isthmus


2- Ask the patient to sit and stand behind him.

3- Use light percussion.

4- Percuss both areas right and left from dullness to resonance with comparison.

5- Comment on dullness found.

Auscultation of the chest anterior chest wall

1) Stand to the right of the patient

2) Ask the patient to lie supine.

3) Auscultate both midclavicular lines right & left, from the second space to the sixth space with comparison.

4) Ask the patient to say ‘ 44 ’ and auscultate both midclavicular lines right & left, from the second space to the sixth space with comparison

Anterior Auscultation

Auscultation of the lateral chest wall

1) Auscultate both midaxillary lines right & left, from the fourth space to the eighth space with comparison

2) Ask the patient to say ‘ 44 ’ and auscultate both midaxillary lines right & left, from the fourth space to the eighth space with comparison

Comment on : a) Breath sounds (character, intensity) b) Adventitious sounds (wheeze, crepitations) c) Type of wheeze if present ( inspiratory or expiratory, localized or

generalized ) d) Type of crepitations if present (fine or coarse, change with cough) e) Vocal resonance

Breathing Patterns

Examination of posterior chest wall

Inspection of posterior chest wall

1) Stand behind the patient in a midline position.

2) The patient should be sitting with the posterior thorax exposed.

3) Inspect the cervical, thoracic and upper lumbar spine for deformity.

4) Assess for costovertebral tenderness by placing the ball of one hand in the costovertebral angle and strike it with the ulnar surface of your fist

5) Inspect for scars.

Palpation of posterior chest wall1) Stand behind the patient in a midline position. 2) The patient should be sitting with the posterior

thorax exposed. 3) Assess extent and symmetry of lower thoracic

expansion by a) Place your thumbs at the level of the 10th ribs with your

fingers loosely grasping the rib cage and gently slide them medially.

b) Ask the patient to inhale deeply and observe whether your thumbs move apart symmetrically.

4) With palms of hands, assess symmetry of fremitus throughout lung fields.

Percussion of the posterior chest wall1-Stand to the right of the patient. 2-Ask the patient to sit and his hands folded across

the anterior chest wall. 3-Use heavy percussion. 4-Percuss suprascapular area with comparison 5-Percuss both scapulae directly. 6-Percuss both infrascapular areas to the 10th space

comparing right and left sides. 7-Percuss interscapular area on the right and left

sides with comparison 8-Comment on dullness found.

Auscultation of the posterior chest wall

1) Stand to the right of the patient. 2) Ask the patient to sit and his hands folded

across the anterior chest wall 3) Auscultate both scapular lines right & left,

from the apex to the tenth space with comparison.

4) Ask the patient to say ‘44 ’ and auscultate both scapular lines right & left, from the apex to the tenth space.

Posterior Auscultation

Interpretation of findingsPleural effusion reduced tactile vocal

fremitus reduced chest expansion stony dull reduced air entry no added sounds reduced vocal resonance

Consolidation increased tactile vocal

fremitus reduced expansion dull percussion bronchial breathing coarse creps increased vocal

resonance whispering pectoriloquy

Interpretation of findingsPneumothorax deviated trachea reduced tactile vocal

fremitus hyper-resonance reduced air entry reduced vocal

resonance

Collapse deviated trachea reduced tactile vocal

fremitus dull percussion reduced air entry +/- creps

Technique of Auscultation1

•Patient relaxes and breathes normally with mouth open, auscultate lungs, apices and middle and lower lung fields posteriorly, laterally and anteriorly.

•Alternate and compare both sides at each site.

•Listen at least one complete respiratory cycle at each site.

•Listen to quiet respiration. If sounds are inaudible, then ask him take deep breaths.

•First describe the breath sounds and then the adventitious sounds.

Technique of Auscultation2

•Note intensity of breath sounds and compare with opposite side.

•Assess length of inspiration and expiration.

•Listen for a pause between inspiration, expiration and the quality of pitch of sound

•compare intensity of breath sounds between upper and lower chest in upright position.

•Compare intensity of breath sounds from dependent to top lung in decubitus position.

•Note the presence or absence of adventitious sounds.

Normal Breath Sounds1

The normal breath sounds over lung tissue are vesicular breathing.

The vesicular breathing is lower pitched and softer than bronchial breathing.

Expiration is shorter (I > E) and no pause between inspiration and expiration.

The breath sounds are symmetrical and louder in intensity in bases compared to apices in erect position and dependent lung areas in decubitus position.

No adventitious sounds are heard.

Normal Breath Sounds2

The breath sounds over tracheobronchial tree are bronchial breathing.

only place where tracheobronchial trees are close to chest wall without surrounding lung tissue are

Trachea

right sternoclavicular joints

posterior right interscapular space.

These sites where bronchial breathing can be normally heard.

bronchial breath sounds have a higher pitch, louder, inspiration and expiration are equal and pause between inspiration and expiration.

prolonged expiratory phase (E > I) indicates airway narrowing, as in:

Vesicular breathing with prolonged expiration

Bronchial asthma.

Chronic bronchitis

Health & Medicine

Respiratory Examination