Respiratory Examination

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.

History of the present illness

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 illness2

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.

Past History

Attack or disease similar to the present one: e.g. Asthma. - Recurrent pneumonia Allergic disorders: eczema, urticaria, angioedema and hay fever. Acute abdominal conditions. Admission in any hospital before and why? Bilharziasis: bilharzial cor pulmonale.

Past History

Chest injuries and operations.

Other Surgical Procedures.

Coma , convulsions.may predispose to aspiration lung abscess

Cardiac diseases and history of rheumatic fever.

Past History

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:

with the current radiograph

comparison

Family and Social History

Similar condition in the family.
History of T.B. History of allergy as eczema and hay fever. History of DM

Analysis of Chest Symptoms1 Cough

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)

Analysis of Chest Symptoms2

Sputum
Amount Color Character (seous, mucoid,purulent and mucopurulent)

Odor
Relation to posture

What increases or decreases it

Associated conditions

Analysis of Chest Symptoms3 Hemoptysis1:

The most important causes of hemoptysis are

Mitral stenosis Pulm tuberculosis

Pulm infarction
Brochiectasis

Bronchogenic carcinoma
Bronchial adenoma Bleeding tendency

Analysis of Chest Symptoms4

Hemoptysis2:
Differentiate between hemoptysis and hematemesis Ask about : Type and Degree Frequency and Duration Ask about the preceding events e.g. DVT or chest
infection

Analysis of Chest Symptoms5

Hemoptysis3:
Type and Degree
Frank hemoptysis Blood-stained sputum

Blood streaked sputum

Rusty sputum

Frequency and duration

Analysis of Chest Symptoms6

Chest pain:
The onset.. Site. Character. Radiation. What increases the pain what relieves or decreases it.

Associated symptoms.

Analysis of Chest Symptoms7

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 patients chest on both sides with comparison.

Chest wall
Pectus carinatum Pectus excavatum

Inspection of anterior chest wall

6) Inspect patients chest normal breathing movement. 7) Inspect patients chest for accessory muscle use. 8) Inspect patients 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

2 TVF
Increased TVF
Consolidation Cavitation Collapse

Decreased TVF
Thick

with patent main

bronchus

chest wall Pleural effusion Pleural fibrosis Pneumothorax Emphysema Collapse

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 Trills 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- Krnigs 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

1- Stand to the right of the patient. 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.

Kronigs isthmus
1- Stand to the right of the patient. 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 wall

1) 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 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-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 findings
Pleural 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 findings
Pneumothorax 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

2 Auscultation

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.

Vesicular breathing with prolonged expiration

prolonged expiratory phase (E > I) indicates airway narrowing, as in: Bronchial asthma.
Chronic bronchitis