Respiratory System Examination

a. general examination :
1. inspect movement with respiration
females normally move their thorax
males normally move their abdomen
**using accessory muscles in respiration >> severe COPD and acute severe
asthma
**pursed lips >> severe COPD , during expiration
**abdomen and thorax move paradoxically during inspiration ( abdomen moves
**in and thorax moves out ) >> severe respiratory failure
2. stridor : ask the ptn to cough then take deep breath in and out with opened
mouth and hear if there is stridor
3. cyanosis : check at lips and under tongue
cyanosis occur if O2 saturation falls below 90 %
if ptn is polycythemic cyanosis appear before if the ptn was anemic
4. blood pressure and pulse :** if diastolic less than 60 mmHg increase mortality
rate in community acquired pneumonia
5. skin appearance :
**erythema nodosum over the skin >> acute sarcoidosis or TB
**metastatic skin nodules of lung cancer
b. hands :
1. clubbing :** seen in lung cancer , bronchoctasis , interstitial lung disease and
empyema
2. discoloration of finger and nails :
**brownish stain : tan from smoking
**yellow nail syndrome : lymphoedema and exudative pleural effusion
3. tremor :
**fine finger tremor : excessive use of beta agonist ( bronchodilator drugs )
**flapping tremor : CO2 retention in severe ventilator failure
to test for it u can ask the ptn to grip ur index and middle finger for 30-60
seconds if he couldn`t then he have flapping tremor

c. neck :
1. jugular vein pressure :
**raised in 1. Right sided heart failure ( cor pulmonale )
2. Chronic hypoxia in COPD
3. Tension pnuemothorax
4. Severe acute asthma
5. Massive pulmonary embolism
6. Superior vena cava obstruction SVCO ( JVP is raised and non pulsatile )

Group A5/2010

Page 1

Respiratory System Examination

Beats
Palpation
Occlusion

Head up tilt HUT

Variation with
respiration

JVP
Twice per cardiac cycle
Non palpable
Occluded by pressing against
neck
Vary with HUT
Decrease with deep inspiration

carotid
Once per cardiac cycle
Palpable
Not occluded
Not variable
Not variable

2. neck lymph nodes :

most important : scalene , supraclavicular and cervical
**scalene node enlargement maybe first evidence of lung cancer metastasis
**palpable supraclavicular node highly suggest lung cancer metastatic spread
**cervical node enlargement >> lymphoma
**in hodgkin >> rubbery LN
**dental sepsis and tonsillitis >> tender LN
**in TB and metastatic cancer >> matted together
**hard , fixed to deep structure LN are usually malignant

d. thorax :
examine the back of the thorax then the front
1. chest shape :
**1. Barrel shaped :in severe COPD
**2. Kyphoscoliosis : produce CO2 retention and cor pulmonale in early age
**3. Pectus carinatum ( pigon chest ) with harison sulcus : seen in poorly
controlled childhood asthma or maybe seen in rickets or ostiomalacia
**4. Pectus excavatum ( funnel chest ) : usually asymptomatic
2. skin :
**metastatic tumor nodules
**neurofibroma or lipoma
**dilated veins in SVCO
3. palpation :
1. Palpate the trachea , slight displacement to right is normal
2. Mesure distance between suprasternal notch and cricoids cartilage , should be
3-4 fingers ,** if less >> lung hyperinflation
3. Palpate apex beat , if displaced

Group A5/2010

Page 2

Respiratory System Examination

4. **Tracheal tug in severe hyper inflation , finger on trachea moves with
inspiration
**crackling sensation >> emphysema
**tender over costal cartilage >> tietze syndrome ( inflammation in costal
**cartilage with selling ) or costocondritis ( inflammation without swelling )
4. chest expansion :
1. Asses expansion of upper lobes by looking from back
2. To asses lower lobes put your fingers on chest wall so your thumbs meet each
other , then ask ptn to take deep breath , ur thumbs should be 5 cm apart
**unilateral reduced expansion : pleural effusion
lung collapse
pneumothorax
unilateral fibrosis
**bilateral reduced expansion : COPD
diffuse fibrosis
5. percussion
1. Medial third of clavicle
2. Three other points bilaterally
3. On the back start a little bit medially then go laterally
normal lung >> resonance
**pneumothorax >> hyper resonance
**consolidation , collapse , fibrosis >> dull
**pleural effusion , hemothorax >> stonydullness
percussion after 5th intercostals produce dull because of liver ,** if resonance
after 5th intercostals >> COPD
normally dull above pericardium
in back normal basal dullness due to elevated diaphragm
6. auscultation :
1. Listen anteriorly above clavicle to 6th rib
2. Laterally from axilla till 8th rib
3. Posteriorly down to 11th rib
normally it is vesicular with no gap
**reduced vesicular : obesity
pleural effusion
pneumothorax
bronchial breath : normal above trachea
** consolidation ( pneumonia )
**above pericardium if crunching sound is heard then this is hamman`s sign in
mediastinal emphysema

Group A5/2010

Page 3

Respiratory System Examination

7. added sounds :
**crackles
in early inspiration >> bronchiolitis
in middle inspiration >> pulmonary edema
in late inspiration >> fibrosis
edema
COPD
pneumonia
abscess
biphasic >> bronchictasis
8. vocal resonance
ask ptn to say at loud which you should hear by your stethoscope
ask ptn to whisper which you shouldn`t hear
**if the voice is clearly audible >> consolidation , you can hear the whispering
too ( whispering pectoriloquy )
**muffled voice >> effusion

P.S. ( ** ) means abnormal

Done by : Feryal Khateeb / A5 2010

Group A5/2010

Page 4