Physical Diagnoses

Respiratory System
 Respiratory System

COUGH is one of the most commonest

symptoms of disease of the lungs and air
passages.
Important to enquire further about its nature:dry
or productive of sputum, ask if it is worse at any
particular time of the day.
Aggravated by any particular situation such as
cold exposure, dust or pollen.
If the cough has sputum production, the patient
should be asked to estimate the quantity
produced 24 hours using a teaspoon.
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Consistency
Colour
-mucoid sputum is characteristic in patients with
chronic bronchitis, clear and sticky not
produced in large volume.
-tenacious form of mucoid sputum produced by
Asthmatics
-black sputum produced by patients having
bronchopulmonary Aspergillosis.
-purulent sputum occurs when infection is
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...present usually bacterial e.g.bronchitis,

pneumonia, bronchiectasis or lung abscess.
In the last two conditions, quantities are large
and foul smelling( anaerobic organisms should
be considered)
White or pink frothy sputum in patients with
pulmonary edema
Blood streaked/stained sputum(hemoptysis)-
lung cancer, TB, pulmonary embolism,
bronchiectasis and cardiac causes such as
mitral stenosis.
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Anchovy sauce sputum-when amebic liver

abscess discharges into the lung.
DYSPNEA:shortness of breath/breathlessness
Def:subjective experience of breathing
discomfort that consists of qualitatively distinct
sensations that vary in intensity.
Ask the patient if breathlessness occurs at rest
or only after certain type of exertion.
Is breathlessness consistently present
whenever the exertion is undertaken or is it
intermittent?
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If dyspnea is chronic, it is valuable to record

some measures of exercise tolerance such as
the distance walked before the patient has to
stop and rest.
Severe breathlessness may be present at all
times,unrelieved even at rest.
Patients who are breathless should be asked
whether their chest makes any noise-
wheezes:musical respiratory sounds audible
both to the patient and others.
Nocturnal wheezing is particularly common in
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...patients with Asthma.

CHEST PAIN: when associated with pulmonary
disease it is usually pleuritic -sharp and
aggravated by deep breathing or coughing.
Useful to enquire about sinus or nasal
symptoms-may indicate sinusitis, polyposis
which is aggravating the respiratory symptom.
Patients who have severe chronic lung disease
may develop hear failure, called Cor Pulmonale.
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Patients with such conditions may develop

peripheral edema.
Patients with lung cancer may present with
malaise or weight loss.
Change in voice may be noticed if recurrent
laryngeal nerve palsy(paralysis) occur due to
large size of a tumor.
Occupations including all past occupations are
of great importance as the patient may have
been exposed to asbestos or other mineral and
dusts.
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Exposure to allergens may provoke

occupational asthma or allergic alveolitis.
Smoking habits should be carefully recorded
both present and past.
Type,amount & duration of smoking should be
specified.
Amount is reported in pack year i.e average
number of cigarette smoked pre day multipled
by total number of years of smoking
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Anatomy of the chest wall

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Locations on the chest-familiar general

anatomic terms used to locate chest findings
Supraclavicular-above the clavicles
Infraclavicular-below the clavicles
Interscapular-between the scapulae
Infrascapular-below the scapulae
Bases of the lungs-the lower most portions.
Upper,middle and lower lung fields
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To make vertical locations, you must be able

to count the ribs and interspaces.
The sternal angle, also called angle of Louis, is
the best guide.
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Place your finger in the hollow curve of the

suprasternal notch, then move your finger down
about 5cm to the horizontal bony ridge joining
the manubrium to the body of the sternum.
Then move your finger laterally and find the
adjacent 2nd rib and costal cartilage.From here,
using two fingers, you can walk down the
interspaces, one space at a time.
In a woman, to find the interspace either
displace the breast laterally or palpate a little
more medially.
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Avoid pressing too hard on tender breast

tissues.
Posteriorly, the 12th rib is another possible
starting point for counting ribs and interspaces.
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 Respiratory System

The inferior tip of the scapula is another useful

bony marker-it usually lies at the level of the 7th
rib or interspace.
When the neck is flexed forward, the most
protruding process is usually the vertebra of C7
To locate findings around the circumference of
the chest, use a series of vertical lines as
shown in the FIG-the midsternal, midclavicular,
anterior and posterior axillary lines drop
vertically from the anterior and posterior axillary
folds.
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Posteriorly, the vertebral line overlies the

spinous processes of the vertebrae.
The scapular line drops from the inferior angle
of the scapula.
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Lungs, fissures, lobes

Anteriorly, the apex of each lung arises about 2-
4cm above the inner third of the clavicle.
The lower boarder of the lung crosses the 6th rib
at the midclavicular line and 8th rib at the
midaxillary line.
Posteriorly, the lower boarder of the lung lies at
about the level of T10 spinous process.On
inspiration it descends further.
Each lung is divided roughly in half by an
oblique(major)fissure.
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The right lung is further divided by the

horizontal(minor)fissure.
The right lung is thus divided into upper,
middle& lower lobes.The left lung has only two
lobes, upper and lower lobes.
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The Trachea and major Bronchi

Breath sounds over the trachea and lung
parenchyma differs.
The trachea bifurcates into its mainstem bronchi
at the level of the sternal angle anteriorly and at
T4 spinous process posteriorly.
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 Respiratory System

The Pleurae
Pleurae area serous membrane that cover the
outer surface of each lung called the visceral
pleura.
The parietal pleura lines the inner rib cage and
upper surface of the diaphragm.
Their smooth opposing surfaces, lubricated by
pleural fluid, allow the lungs to move easily
within the rib cage during inspiration and
expiration.
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The pleural space is a potential space between

the visceral & parietal pleura.
Breathing which is an automatic act, contrlled in
the brain stem
The dome-shped diaphragm is the primary
muscle of respiration.When it contracts, it
descends in the chest and enlarges the thoracic
cavity.
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General Assessment
Even if examining the respiratory system, it is
incomplete if there is not also some general
examination of the patient.
Ideally the patient should be comfortably resting
on a bed, sitting at an angle of 450 and
supported by pillows.
The general nourishment of the patient should
be noted.
The patient may be breathless even after the
minimal exertion of undressing.
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The nature of the voice(is it hoarse?) should be

noted.
The hands should be inspected for clubbing,
pallor and cyanosis.
Clubbing:the tissues at the base of the nails are
thickened and angle between the nail base and
adjacent skin of the finger is obliterated.The nail
becomes convex from above downwards as
well as from side to side.
Cyanosis: bluish discoloration caused by
impaired venous return.
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The lips and tongue should be inspected for

central cyanosis.
A breathless patient may be using accessory
muscles of respiration(e.g. Sternomastoid),
intercostals and subcostals muscles which
indicates severity of breathlessness.
The lymph nodes in the supraclavicular fossae,
cervical regions and axillary regions should be
palpated in case of spread of malignancy from
the chest.
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Basic steps followed on examination of every

system: Inspection, Palpation, Percussion &
Auscultation.
Inspection:patient should undress the upper
part of the cloth.
1. shape of the chest
Normal chest is bilaterally symmetrical and
elliptical in cross-section.Its lateral diameter is
larger than its AP(anterioposterior) diameter.
kyphosis(forward bending) or scoliosis(lateral
bending)of the vertebral column will lead to
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...asymmetry of the chest and may significantly

restrict lung movement.
Scoliosis may displace trachea and apex beat.
Deformities of the chest
Funnel chest(pectus excavatum)-characterized
by a depression in the lower portion of the
sternum.
Barrel chest- increased AP diameter
Pigeon chest(pectus carinatum)- sternum is
displaced anteriorly, increasing the AP
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...diameter. The coastal cartilage adjacent to the

protruding sternum are depressed.
Traumatic flail chest- if multiple ribs are
fractured, paradoxical movement of the thorax
may be seen.As descent of the diaphragm
decreases intrathrocic pressure on inspiration,
the injured area caves inward, on expiration it
moves outward.
Unilateral apical fibrosis secondary to TB may
produce obvious flattening of the affected side.
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2.Movement of the chest

The normal rate of respiration in a relaxed adult
is about 14-16 breaths per min.
If possible, patients should be unaware when
rate is being counted.
Increased rate of respiration-tachypnea may be
caused by nervousness, exertion, fever or
hypoxia.
Cheyne-stokes breathing-gradual deepening
and then diminished respiratory effort and rate,
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...sometimes associated with short periods of

complete apnea(cessation of respiration).Seen
in cardiac failure, narcotic drug poisoning &
neurological disorders.
Asymmetrical expansion of the chest may occur
when the underlying lung is abnormal.A pleural
effusion, pneumothorax, extensive consolidaion
or collapse or fibrosis can all diminish
expansion on the affected side.
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Palpation
Useful to palpate any part of the chest which
presents with an obvoius swelling.
Any swelling should be characterized: shape,
size, location, consistency, mobility, tenderness.
Flactuation occurs when an abscess is formed
in the chest wall.
Palpate where the patient complains of pain-
tenderness.
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Feel gently, as pressure may increase the pain.

If you palpate tenderness may be due to recent
injury to the chest wall or due to inflammatory
conditions.
Fracture of rib(s) should cause crepituous
feeling on palpation.
Position of the trachea:feel for the trachea in
the suprasternal notch and decide whether it is
central or deviated to one side.
Normally slight deviation of the trachea to the
right side may be found in healthy people.
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Avoid heavy-handedness in this situation as it is

uncomfortable for the patient if examiner is
rough.
Displacement of the trachea suggests that the
position of the mediastinum has been altered by
disease of the lungs or pluera.
The mediastinum may be pushed away from
the affected side by a plueral effusion or
pneumothrox.
Fibrosis or collapse of the lung will pull the
mediastinum towards the affected side.
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Measurement of chest expansion

recorded by a tape meter around the chest at
about the level of the nipples.
We ask the patient to inspire fully then take the
measurement, then ask patient to expire fully
take the measurement, subtract the two
measurements-normal range 5-8cm
In a patient with severe emphysema it may
expand less than 1cm
Another method to measure asymmetry-face
the patient and place the fingertips of both
 Respiratory System

...hands on either side of the lower ribcage, so

that the tips of the thumbs meet in the midline
infront but not touching the chest, then a deep
breath by the patient will increase the distance
between the thumbs and indicate the degree of
expansion.
If one thumb remains closer to the midline, this
is a confirmation of diminished expansion on
that side.FIG
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Tactile Fremitus:fremitus refers to the palpable

vibrations transmitted through the
bronchopulmonary tree to the chest wall when
the patient speaks.
To detect fremitus, use the ball( bonny part of
the palm at the base of the fingers)
Ask the patient to repeatforty-four(44)
Fremitus is decreased or absent when the voice
is soft or when the transmission of vibration
from the larynx to the surface of the chest is
impeded.Causes include an obstructed
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Respiratory Syatem
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...bronchus, COPD, separation of the pleural

surfaces by fluid(pleural effusion),
fibrosis(pleural thickening), air(pneumothorax),
infilterating tumour and also very thick chest
wall.
Percussion
Helps whether the underlying tissues are air-
filled, fluid-filled or solid.
It penetrates only about 5-7cm into the chest,
however, willnot help you to detect deep-seated
lesions.
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Hyperextend the middle finger of your left

hand(pleximeter), press its distal
interphalyngeal joint firmly on the surface to be
percussed.
The thumb, 2nd ,4th ,5th fingers are not touching
he chest wall-will dampen vibrations.
Position your right forearm close to the surface,
the middle finger should be partially flexed,
relaxed and poised to strike.FIG
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 Respiratory System

With a quick sharp but relaxed wrist motion,

strike the pleximeter finger with the right middle
finger(plexor finger)
Aim at your distal interphayngeal joint.
Your plexor finger should be at right angle to
the pleximeter.
A short finger nail recommended to avoid self-
injury.FIG
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When percussing the lower posterior chest,

stand somewhat to the side rather than directly
behind the patient.This allows you to place your
pleximeter finger more firmly on the chest and
your plexor is more effective, making a better
percussion note.
Percuss twice in each location comparing the
right and left.
Normal lung percussion note is resonant.
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5 percussion notes
Relative Relative Relative
Location
intensity pitch duration
Flatness soft high short thigh
Dullness medium medium medium Liver
Normal
Resonance loud low long
Lung
hyperreson
Very loud lower longer none
ance
Gastric air
tympanic loud high -
bubble
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While the patient keeps both arms crossed in

front of the chest, percuss the thorax in
symmetric locations from apices to the lung
bases.FIG
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A feeling of resistance to the percussion blow

within the finger used for tapping is usually
found when there is underlying pleural fluid-
stony dullness.
It is easier to detect a unilateral pleural
effusion but, of course, effusions may occur
bilaterally in many patients.
Dullness replaces resonance when fluid or
solid tissue replaces air-containing lung or
pleural space e.g. lobar pneumonia in which
the alveoli are filled with fluid, pleural effusion,
blood(hemothorax), pus(emphyema), fibrous
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Generalized hyper resonance may be heard

over hyper inflated lungs or emphysema or
asthma.
Diaphragmatic excursion
Identify the descent of the diaphragm
Hold the pleximeter finger above and parallel
to the expected level of dullness, percuss
downward in progressive steps until dullness
clearly replaces resonance.
Note that with this technique you are
identifying the boundary between the resonant
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Now estimate the extent of diaphragmatic

excursion and the level of dullness on full
expiration and the level of dullness on full
inspiration.
Normal range 5-6cm.FIG
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An abnormally high level suggests pleural

effusion or a high diaphragm as in aletectasis
or diaphragmatic paralysis.
Auscultation
Useful for assessing airflow through the
tracheobronchial tree.
Together with percussion helps to assess the
condition of the surrounding lungs and pleural
space.
Auscultation involves:
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1.listening to sounds generated by breathing

2.listening for adventitous(added) sounds
3.if abnormalities are suspected, listening to the
sounds of the patient's spoken or whispered
voice as they are transmitted through the
chest wall.
Normal breath sounds:
-vesicular: soft, low pitched. They are heard
through inspiration, continue without pause
through expiration, then fade away one third
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...of the way through expiration. Heard over most

of both lungs.
-bronchovesicular: equal in length in inspiratory
and expiratory phase, at times separated by a
silent interval heard ofetn in the 1st and 2nd
interspace anteriorly and between the scapulae.
-bronchial: louder and higher in pitch- short
silence between inspiratory and expiratory
sounds.Expiratory sounds last loner than
inspiratory. Heard over the manubrium, if heard
at all.
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If bronchovesicular and brochial breath

sounds are heard distant to the above listed
locations, suspect that air-filled lung has been
replaced by fluid-filled or solid lung tissue.
Listen to the breath sounds with the
diaphragm of the stethoscope after instructing
the patient to breath deeply through an open
mouth.
When auscultating, compare similar locations
over the right and left sides.
When patients don't breath deeply enough or
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...sounds may be diminished.

Breath sounds may be decreased when air
flow is decreased or when transmission is
poor-pleural effusion, pneumothorax or
emphyema.
Adventitious(added) sounds: listen for any
adventitious sounds that are added on the
usual breath sounds.
-crackles(rales): are intermittent, non musical and
brief.Fine crackles: soft, high pitch and very
brief 5-10 sec, may be due to pneumonia,
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...coarse crackles:louder, lower in pitch, not quite

so brief 20-30sec
-wheezes: relatively high pitch and have a hissing
or shrill quality. May be due to narrowed
airways e.g. asthma.
-rhonci: relatively low pitched and have a snoring
quality. Suggests secretion in large airways.
Bronchophony: louder clearer voice sounds, if
vocal resonance seems nearer the ear piece
of the stethoscope.
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When ee is heard as ay and E to A

change-egophony, presents in lobar
consolidation in pneumonia. The quality
sounds nasal.
Auscultate the chest anteriorly, laterally and
posteriorly comparing the right and left sides.
Percuss on clavicles to assess the apical
aspect of the lungs over the right and left.
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Recording the physical examination

Eg of a report of respiratory system
Thorax is symmetrical with moderate kyphosis,
increased AP diameter, decreased chest
expansion. Tactile fremitus is decreased.
Lungs are hyper resonant. Breath sounds are
distant with delayed expiratory phase and
scattered expiratory wheezes. No
bronchophony, egophony. Diaphrams
descend 2cm bilaterally.
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Chest x-ray
Standard chest x-ray is AP view which is
taken with the film against the front of the
patient's chest.
X-ray examined systematically as follows:
1.check if the name, card number on the x-ray film
corresponds with the patient.
2. The bony skeleton: is the chest symmetrical? Is
scoliosis present? Are the ribs crowded or
widely spaced? Is there an
absent/traumatized/fractured rib?
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3. Position of the Patient: is the patient straight or

rotated? If straight, the inner ends of the clavicle
will be disposed symmetrically with reference to
the vertebral column Any rotation will alter the
appearance of the mediastinum.
4. Position of trachea: seen as a dark column
representing the air within the trachea. The
cartilaginous rings are not visible. Is the trachea
centrally placed or deviated?
5. Outline of the Heart: A+B<0.5(C)
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6. The diaphragm: normally the anterior end of the

6th or 7th rib crosses the mid-part of the
diaphragm on each side although the
diaphragm on the right side may be a little
higher than the left.
The costophrenic and cardiophrenic angles.
Can the diaphragm be seen on each side and
is it normal shape and position.
7. The lung fields: inspect the lung parenchyma
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...on the right and left.

Normally seen as darkened area but if fluid is
present would be opacified. The costophrenic
angles obliterated with presence of pleural
effusion.
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