resp.system examination
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Compiled by: Dr.Ankit SrivastavB.H.M.S. (Gold Medalist), M.D. (PGR)Gorakhpur, U.P., IndiaEmail: ankitsrivastav183@gmail.com
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BREATHLESSNESS ; An unpleasant subjective
awareness of the sensation of breathing.
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Cardiac diseases :• pulmonary thromboembolism
• chronic cardiac failure,
• congenital heart diseases
Respiratory diseases:•COPD
•Asthma
• bronchial carcinoma
• interstitial diseases
• pleural effusion
Also in Diabetic
Ketoacidosis (kussmaul (kussmaul
breathing)breathing)
severe Anemia
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•COUGH :Dry or productive
How long has cough been present ?
Is the cough worse at any time of day or night?
Is the cough aggravated by anything for e.g. dust, pollen or cold air?
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WHEEZING: Characterized by prolonged expiration
through an lower airways, bronchi, bronchioles.
E.g.. Asthma, COPD
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• HAEMOPTYSIS: coughing of blood in the sputum.
Bronchial carcinoma-repeated small haemoptyses
Tuberculosis –chronic fever & wt. Loss
Pneumoccocal pneumonia- rusty colored sputum
Bronchiectasis-catastrophic bronchial hemorrhage with previous history of T.B. & whooping cough
Pulmonary thromboemoblism- major risk factors include immobilization, malignant disease,cardiac failure, pregnancy
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CHEST PAIN :more common presentation of cardiac disease but also signify diseases of the lungs , musculoskeletal system.
Location
Radiation
Provocation
Character of the pain
Pattern of onset
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1. PHYSIQUE
2. CLUBBING
3. CYANOSIS
4. NECK :THYROID SWELLING
5. PALLOR
6. LYMPHADENOPATHY
7. VENOUS PULSES
8. UPPER RESPIRATORY TRACT
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• PHYSIQUE – Tall, short, thin or obese.
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• CLUBBING –Bulbous enlargement of soft parts of the terminal phalanges with both transverse and longitudinal curving of the nails.
Bronchogenic carcinoma
Lung abscess
Bronchiectasis
Tuberculosis
Diffuse fibrosing alveolitis
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• CYANOSIS :Bluish discoloration of the nails due to increased amount of reduced Hb% (more than 5mg%) in capillary blood.
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Central –
•COPD
•Collapse and fibrosis of lung
•Marked pulmonary destruction
Peripheral –
•Cold
•Inc. viscosity of blood
•shock 14/12/14Dr.Ankit Srivastav@copyright email:ankitsrivastav183@gmail.com 20
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• SHAPE OF THE CHEST:scar of previous surgery ,lumps visible beneath
the skin.
Normal chest –bilaterally symmetrical, ellipitical in cross section,
transverse :anteroposterior diameter = 7:5
Subcostal angle = 70
Interspaces are broader anteriorly than posteriorly.
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Shapes deformities
Pigeon chest or pectus carinatum: in severe asthma, rickets.
Funnel chest or pectus excavatum : congenital,an occupational deformity in cobblers (cobbler’s chest).
Barrel shaped chest: emphysema
Spinal deformities
Kyphosis
Scoliosis14/12/14Dr.Ankit Srivastav@copyright email:ankitsrivastav183@gmail.com 24
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• Depression on either side of the sternum
• A transverse groove passing Xiphistrenum to the midaxillary line (Harrison sulcus)
• Sternum unduly prominent.
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Funnel Chest Deformity:-Funnel Chest Deformity:-
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• Depression in lower part of sternum.
• Congenital, in rickets, occupational deformity in cobblers.
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Barrel Chest Deformity:-Barrel Chest Deformity:-
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• Anterior-posterior diameter inc.,the sub costal angle is wide
• Angle of Louis unduly prominent, sternum more arched
• In emphysemaIn emphysema
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Kyphosis:Kyphosis:
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• Forward bending of spine
• Congenital, postural, neurological, pott’s spine, rheumatoid arthritis.
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Kyphosis:Kyphosis:
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ScoliosisScoliosis14/12/14Dr.Ankit Srivastav@copyright email:ankitsrivastav183@gmail.com 38
• Lateral bending of spine
• Congenital, postural, compensatory, neurological-poliomyelitis, muscular dystrophy, rickets
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Bulging:
one side bulging
Pleural effusion, pneumothorax, tumors, aneurysm, emphysema
Localized bulging- aortic aneurysm, pericardial effusion, liver abscess, chest wall tumors
Depression or flattening :one side affected in fibrosis, collapse, pleural adhesions.
Flat chest: chronic nasal obstruction, bilateral T.B.
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• RESPIRATORY RATE : normal 16-20 respiration per mins
Inc. rate (tachypnoea) –
Fevers e.g. pneumonia
Anoxaemia & acidosis
Pleurisy
Dec. rate (bradypnoea) –
Narcotic poisoning
Brain tumour
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• RESPIRATORY RHYTHM
Cheyne stokes respiration: alteration of apnea and hyperpnoea due to anoxemia.LVF
Neurological
Uremia
Deep sleep
Cardio respiratory embarassement
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Kussmaul’s respiration : deep and rapid respirationDiabetes ketoacidosis
Uremia
Biot’s respiratory : irregularly irregular respirationMeningitis
Raised intracranial pressure
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• STRIDOR-prolonged inspiration through an obstructed
upper airways, which produced a characteristic sound.
Laryngeal or tracheal obstruction
Laryngeal diphtheria
Mediastinal growth
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WHEEZING-prolonged expiration through an obstructed
lower airways bronchi, bronchioles
Cardiac & renal asthma
STERTOR –occurs in coma or deep sleep or in dying
person (death rattles)
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• THORACIC BREATHING- Diaphragmatic paralysis
Peritonitis
Severe ascitis
• ABDOMINAL BREATHING-
Pleurisy
Collapse of lung
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• NORMALLY, uniformly, no bulging or in drawing of interspaces
• Accessory muscles of respiration not required
• Diminished in fibrosis ,emphysema, pleural effusion etc.
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• LYMPH NODES
• SWELLINGS & TENDERNESS
• CHEST EXPANSION
• TRACHEA & HEART
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• Supraclavicular fossae, cervical regions and axillary's region.
• Enlarged lymph nodes secondary to the spread of malignant diseases from chest.
• Tuberculosis often affects the upper deep cervical nodes.
• Normally on palpation surface is smooth but matted in T.B. and irregular in malignancy.
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• Palpate part of the chest presents an swelling or where the patient complains of pain.
CAUSES OF PAIN &TENDERNESS
A recent injury or inflammatory conditions.
Intercostal muscular pain.
A painful costochondral junction.
Secondary malignant deposits in the rib.
Herpes zoster before the appearance of the rashes.
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• The positions of cardiac impulse and trachea helps to assess mediastinum position.
Tracheal palpation: Feel trachea in the suprasternal notch decide whether it is central or deviated to one side by its relation to the suprasternal notch and insertion of sternomastoids.
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• APEX Beat: Is examined with palm of the hand and its position is noted. Normally the apex beat is in 5th left intercostal space just inside the mid clavicular line.It may be shifted inward or outward depending upon the shift of the mediastinum.
• Apex beat alone may be shifted in:
Scoliosis
Funnel shaped depression of the sternum in enlargement of L.V.
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Pushed away from the affected side
• Pleural effusion
• Pneumothorax
Pulled towards the affected side
• Collapse
• Fibrosis
• Pleural thickening.
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Chest expansion- As well as by simple inspection possible asymmetrical expansion of the chest may be further explored by palpation.
Unilateral diminished movements
• Obstruction to the main bronchus
• Consolidation
• Fibrosis
• Collapse
• Hydropneumothorax
• Pleural effusion.
Bilateral diminished movements
• Emphysema
• Bilateral fibrosis, collapse,consolidation, hydropneumothorax.
• Bronchial asthma
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• Auenbrugger applied percussion to the chest first.
• Points to be noted on percussion of the chest:
Resonance
Dullness
Pain & tenderness.
• Normally resonance present below clavicle anteriorly , below scapula posteriorly.
• Normally dullness present right side inferiorly as the liver encountered left side stomach.
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Reduce resonance Consolidation Pleural effusion Fibrosis Infiltration Collapse Pleural thickening
Hyper resonance Pneumothorax Emphysema Large cavity Congenital cyst Emphysematous bullae.
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Liver dullness: right 5th intercostal space in the mid clavicular line, in 7th space in the anterior axillary line and in 9th space in the scapular line.
Abnormally in 4th space in the mid clavicular line in : Amoebic or pyogenic abscess of liver. Diaphragmatic paralysis or collapse of the lower lobe of the lung
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It may be pushed down to the 6th space in the mid clavicular line:
Emphysema Right sided pneumothorax air in the peritoneal cavity Terminal cirrhosis
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Cardiac dullness: This area of dullness decreasing in emphysema and left
pneumothorax. Increase in cardiomegaly and push of the heart to the left
side.
Shifting dullness In hydro pneumothorax in sitting position hyper resonant
note above followed by dullness below.
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• Vesicular breath sounds
• Bronchial breath sounds
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• Vocal fremitus &resonanceBronchophony
Whispering pectoriloquy
egophony
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• Added soundsPleural rub
Wheezes
Crackles
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• VESICULAR BREATH SOUNDS : normal lung tissue make the sound quieter & selectively filter out some of the higher
frequency this result vesicular sounds. No distinct pause between the end of inspiration and the beginning of expiration.
• BRONCHIAL BREATH SOUNDS :In consolidation, the sounds generated in the large airways are transmitted more
efficiently/so they are louder & less filtering of the high frequency.
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TACTILE VOCAL FREMITUS – Perception of vibration communicated to the
chest wall from the larynx via the bronchi and lungs during the act of phonation
TVF inc. in-consolidation, pulmonary infraction, malignant lesion.
TVF dec. in-pleural effusion, pneumothorax, hydrothorax, bronchial asthma, emphysema, fibrosis, collapse
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• Vocal resonance: Resonance in the chest made by the voice when testing vocal resonance you are detecting vibration transmitted to the chest from the vocal cord as the patient repeats a phrase “ninety nine”.
Inc. In consolidation
Dec . in pneumothorax
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BRONCHOPHONY: Inc vocal resonance where the sounds are loud & clear but the
words are not distinguished. Found in consolidation
EGOPHONY: When spoken voices are auscultated over the chest, nasal quality is imparted
to the sound which resembles the bleating goat.
WHISPERING PECTORILOQUY- When the patient whispers a phrase (eg. One
,two, three) the sounds may be heard clearly. Found in consolidation
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• WHEEZES/RHONCHI- Musical sounds associated with
airways narrowing
Widespread POLYPHONIC– Heard in expiratory eg.Asthma,
COPD.
Fixed MONOPHONIC- May be inspiratory or expiratory eg.
Tumors foreign bodies.
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• CRACKLES/RALES- Short,explosive as bubbling or
clicking. Produced by sudden change of gas pressure related
to sudden opening of previously closed small airways.
COPD
Bronchiectasis
Pulmonary edema
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Pleural infflammation with pleuritic pain.
More prominent in lateral & posterior bases of the lung and dec. Superiorly
Best heard at the bases in the axillary lines
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SPUTUM EXAMINATION
LUNG FUNCTION TEST
X-RAYS
CT –SCAN
RADIOISOTOPES IMAGING
MAGNETIC RESONANCE IMAGING(MRI)
ULTRASOUND (USG)
FIBRE OPTIC BRONCHOSCOPY
PLEURAL ASPIRATION & BIOPSY
LUNG BIOPSY
IMMUNOLOGICAL TESTS
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Measuring the size of the lungs.
Measuring how easily air flows into & out of the airways.
Measuring how efficient the lungs are in the process of gas exchange.
• VITAL CAPACITIES (VC): How much air can be exhaled after a maximal inspiration.
• TOTAL LUNG CAPACITY(TLC): Amount of air can be exhaled after a maximal inspiration.
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• Residual vol.(RV)- Air still remain in the lungs after full expiration.
• Forced vital capacity (fvc)-Vital capacity is measured after the patient has blown as hard and fast as possible into the spiro meter
• FORCED EXPIRATORY VOLUME (fev)-Vol. Of the air expired in the first second
normally, FEV is 70% of FVC.
-In copd fev/fvc is reduced
-In pulmonary fibrosis FFEV/FVC is normal but absolute value reduced
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NORMAL X -RAY DESCRIBED AS
View
Centralization
Exposure
Sex
Diaphragm
Cardiophrenic & costophrenic angles
Rib cage
Cardiac shadow
Lung shadow
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NORMAL X- RAY
Clavicle should be at same level .
If breast shadows are visualized the plate is of a female
patient.
Rt. Diaphragm slightly higher than the left ,with clear
costophrenic & cardiophrenic angles.
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Cardiac shadow consists of
Smooth right border-superior vena cava,right atrium
&inferior vena cava
Left border-aortic knuckles,pulmonary artery, left
arterial appendage, right ventricle &left ventricle from
above downwards
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• Aortic knuckle prominent: in aortitis, atherosclerosis, aneurysm.
• Pulmonary artery prominent: in pulmonary hypertension
• Pulmonary artery shadow absent: in pulmonary stenosis. or pulmonary
atresia
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Ratio of chest wall and cardiac shadow is 2:1.
Cardiac enlargement it dec.
Emphysema it inc.
LUNGS SHADOWS
Normally: TRANSLUCENT
Abnormally: OPAQUE HYPER TRANSLUCENT
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Opaque Pneumothorax Pleural thickening Bullae Emphysema Bronchial asthma Pulmonary hypertension
Hyper translucent Pleural effusion Calcification Lung carcinoma Collapse Lung abscess
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Pleural Effusion:Pleural Effusion:
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Collapsed Left SideCollapsed Left Side
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• A thoracic CT scan comprises a series of the cross sectional slices through the thorax at various levels.
• Help in diagnosing
• Carcinoma lung
• Bronchiectasis
• Diffuse pulmonary fibrosis
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• Ventilation & perfusion scanning
• Helpful in case of pulmonary embolism
Magnetic resonance imaging (MRI)• Mediastinal abnormalities
• Chest wall tumors
Radio-isotope Imaging:
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• Reveals less details than CT scan.
• Used in diaphragmatic movements
• Help to distinguished between pleural thickening from pleural fluid.
Ultra-Sonography:-
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Fiber optic bronchoscopy
• For carcinoma of bronchus & for biopsy
LUNG BIOPSY
IMMUNOLOGICAL TESTS
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• In pleural effusion
• Middle aged or old aged present in carcinoma
• Young aged in tuberculosis
Pleural Effusion & Biopsy:-
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