resp.system examination

Compiled by: Dr.Ankit SrivastavB.H.M.S. (Gold Medalist), M.D. (PGR)Gorakhpur, U.P., IndiaEmail: [email protected]

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BREATHLESSNESS ; An unpleasant subjective

awareness of the sensation of breathing.


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


•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?


WHEEZING: Characterized by prolonged expiration

through an lower airways, bronchi, bronchioles.

E.g.. Asthma, COPD


• 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


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


1. PHYSIQUE

2. CLUBBING

3. CYANOSIS

4. NECK :THYROID SWELLING

5. PALLOR

6. LYMPHADENOPATHY

7. VENOUS PULSES

8. UPPER RESPIRATORY TRACT


• PHYSIQUE – Tall, short, thin or obese.


• 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


• CYANOSIS :Bluish discoloration of the nails due to increased amount of reduced Hb% (more than 5mg%) in capillary blood.


Central –

•COPD

•Collapse and fibrosis of lung

•Marked pulmonary destruction

Peripheral –

•Cold

•Inc. viscosity of blood

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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.


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

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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.


Funnel Chest Deformity:-Funnel Chest Deformity:-


• Depression in lower part of sternum.

• Congenital, in rickets, occupational deformity in cobblers.


Barrel Chest Deformity:-Barrel Chest Deformity:-


• Anterior-posterior diameter inc.,the sub costal angle is wide

• Angle of Louis unduly prominent, sternum more arched

• In emphysemaIn emphysema


Kyphosis:Kyphosis:


• Forward bending of spine

• Congenital, postural, neurological, pott’s spine, rheumatoid arthritis.


Kyphosis:Kyphosis:


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• Lateral bending of spine

• Congenital, postural, compensatory, neurological-poliomyelitis, muscular dystrophy, rickets


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.


• 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


• RESPIRATORY RHYTHM

Cheyne stokes respiration: alteration of apnea and hyperpnoea due to anoxemia.LVF

Neurological

Uremia

Deep sleep

Cardio respiratory embarassement


Kussmaul’s respiration : deep and rapid respirationDiabetes ketoacidosis

Uremia

Biot’s respiratory : irregularly irregular respirationMeningitis

Raised intracranial pressure


• STRIDOR-prolonged inspiration through an obstructed

upper airways, which produced a characteristic sound.

Laryngeal or tracheal obstruction

Laryngeal diphtheria

Mediastinal growth


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)


• THORACIC BREATHING- Diaphragmatic paralysis

Peritonitis

Severe ascitis

• ABDOMINAL BREATHING-

Pleurisy

Collapse of lung


• NORMALLY, uniformly, no bulging or in drawing of interspaces

• Accessory muscles of respiration not required

• Diminished in fibrosis ,emphysema, pleural effusion etc.


• LYMPH NODES

• SWELLINGS & TENDERNESS

• CHEST EXPANSION

• TRACHEA & HEART


• 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.


• 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.


• 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.


• 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.


Pushed away from the affected side

• Pleural effusion

• Pneumothorax

Pulled towards the affected side

• Collapse

• Fibrosis

• Pleural thickening.


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


• 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.


Reduce resonance Consolidation Pleural effusion Fibrosis Infiltration Collapse Pleural thickening

Hyper resonance Pneumothorax Emphysema Large cavity Congenital cyst Emphysematous bullae.


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


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


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.


• Vesicular breath sounds

• Bronchial breath sounds


• Vocal fremitus &resonanceBronchophony

Whispering pectoriloquy

egophony


• Added soundsPleural rub

Wheezes

Crackles


• 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.


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


• 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


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


• 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.


• 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

Diffuse interstitial fibrosis14/12/14Dr.Ankit Srivastav@copyright email:[email protected] 83

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


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


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.


• 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


NORMAL X -RAY DESCRIBED AS

View

Centralization

Exposure

Sex

Diaphragm

Cardiophrenic & costophrenic angles

Rib cage

Cardiac shadow

Lung shadow


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.


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


• Aortic knuckle prominent: in aortitis, atherosclerosis, aneurysm.

• Pulmonary artery prominent: in pulmonary hypertension

• Pulmonary artery shadow absent: in pulmonary stenosis. or pulmonary

atresia


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


Opaque Pneumothorax Pleural thickening Bullae Emphysema Bronchial asthma Pulmonary hypertension

Hyper translucent Pleural effusion Calcification Lung carcinoma Collapse Lung abscess


Pleural Effusion:Pleural Effusion:


Collapsed Left SideCollapsed Left Side


• 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


• Ventilation & perfusion scanning

• Helpful in case of pulmonary embolism

Magnetic resonance imaging (MRI)• Mediastinal abnormalities

• Chest wall tumors

Radio-isotope Imaging:


• Reveals less details than CT scan.

• Used in diaphragmatic movements

• Help to distinguished between pleural thickening from pleural fluid.

Ultra-Sonography:-


Fiber optic bronchoscopy

• For carcinoma of bronchus & for biopsy

LUNG BIOPSY

IMMUNOLOGICAL TESTS


• In pleural effusion

• Middle aged or old aged present in carcinoma

• Young aged in tuberculosis

Pleural Effusion & Biopsy:-


resp.system examination

Health & Medicine

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ankit srivastavb

cough worse

malignant disease

sensation of breathing

upper respiratory tract

diabetic ketoacidosis

previous history of