Respiratory Examination Dr Scarpa Schoeman Dept Internal Medicine

Respiratory Examination Dr Scarpa Schoeman – Dept Internal Medicine Slides of Dr JM Nel Department Critical Care

Respiratory Examination n 1. Positioning of the patient n 6. The chest n 7. The heart n 8. The abdomen n 9. Other 2. General Appearance 3. The hands n 4. The face n 5. The trachea

Positioning of the patient n Undress n Sitting to waist position n Acutely ill – Lying down

General appearance n 1. Dyspnoea n 2. Cyanosis n 3. Cough character – Signs of dyspnoea at rest – RR: 16 - 25/min – Central cyanosis: tongue

General appearance n 4. Sputum n 5. Stridor n 6. Hoarseness – Colour/volume/type – Hemoptysis – Loudest on inspiration

The hands n 1. Clubbing – P 51 -Table 4. 9

The hands n Clubbing – Cardiovascular § Congenital cyanotic heart disease § Infective endocarditis – Respiratory (80% the cause) § Lung carcinoma § Chronic pulmonary suppuration § Idiopathic lung fibrosis § Cystic fibrosis § Asbestosis § Pleural mesothelioma – Gastrointestinal § Cirrhosis § Inflammatory bowel disease § Coeliac disease n COPD/TB does not give clubbing

The hands HPO § Periosteal inflammation § Clubbing marked § Distal end of long bones, wrists, metacarpal, metatarsal bones, knees, ankles § Swelling/Tenderness

The hands n 2. Staining n 3. Wasting and weakness – Cigarette smoking – – – Wasting small muscles Weakness abduction Infiltration of brachial plexus by lung CA

The hands n 4. Pulse rate – Pulsus paradoxus § Systolic BP drop > 10 mm. Hg n 5. Flapping tremor(Asterixis) – Dorsiflex hands – CO 2 retention (COPD)

The face n 1. Horner’s syndrome – Constricted pupil – Partial ptosis – Loss of sweating – Apical lung tumour – Compression of sympathetic nerves

The face n 2. Skin changes – Connective tissue diseases

The face n 3. URTI n 4. Sinuses n 5. SVC obstruction – Look inside mouth – Facial plethora or cyanosis

The trachea n Position n Tracheal – COPD tug

The chest n Inspection n Palpation n Percussion n Auscultation

The chest: Inspection n 1. Shape and symmetry of chest shape – Barrel- shaped chest – Harrison’s sulcus – Pigeon chest – Kyphosis, scoliosis, kyphoscoliosis – Funnel chest – Lesions of chest wall – Movement of chest wall

The chest: Inspection n Barrel- shaped chest – Increased AP diameter – Severe asthma/COPD – Normal elderly people

The chest: Inspection n Pigeon chest(pectus carinatum) – Outward bowing sternum/costal cartilages – Chronic childhood resp infectons – Rickets n Funnel chest(pectus excavatum) – Developmental defect – Depression lower end of sternum – Severe: decreased lung capacity

The chest: Inspection n Harrison’s sulcus – Linear depression lower ribs just above costal margins – Severe asthma in childhood – Rickets

The chest: Inspection n Kyphosis, scoliosis, kyphoscoliosis – Severe: reduced lung capacity

The chest: Inspection n Lesions – Scars of chest wall § Previous surgery § Previous ICD – Radiotherapy § Erythema – Subcutaneous emphysema – Prominent veins § SVC obstruction

The chest: Inspection n Movement of chest wall – Expansion § Upper lobes – From behind – Look down at clavicles § Lower lobes – From behind – Unilateral § Localized fibrosis, consolidation, collapse, pleural effusion – Bilateral § COPD, diffuse pulmonary fibrosis

The chest: Inspection n Movement of chest wall – Asymmetry – Paradoxical inward movement abdomen during inspiration § Diaphragm paralysis

The chest: Palpation n 1. Chest expansion – Thumbs move symmetrical 5 cm on inspiration – Lower lobe § From back – Upper lobe § From front

The chest: Palpation n 2. Apex beat – Displacement § Towards side of lesion – Collapse lower lobe – Localized fibrosis § Away from lesion – Pleural effusion – Tension pneumothorax – Impalpable § COPD: hyperinflation

The chest: Palpation n 3. Vocal fremitus – – Palm of hand “ 99” Differences Increased: Consolidation – Same as vocal resonance n 4. Ribs – Localized pain § Trauma, metastases, prolonged coughing

The chest: Percussion

The chest: Percussion n 1. Symmetrical – Ant/Post/Lat – Supraclavicular fossa over lung apex – Clavicle with finger

The chest: Percussion

The chest: Percussion n 2. Interpretation – Resonant § Normal – Dull § Solid structure (liver) § Consolidation – Stony dull § Fluid- filled area (pleural effusion) – Hyperresonant § Over hollow structures – Bowel, pneumothorax

The chest: Percussion n 3. Liver dullness – Upper level § 5 th / 6 th rib MCL § If lower: hyperinflation n 4. Cardiac dullness – Decreased § COPD § Asthma

The chest: Auscultation n 1. Breath sounds n 2. Vocal resonance

The chest: Auscultation n 1. Breath sounds – General – Quality of breath sounds – Intensity of breath sounds – Added sounds

The chest: Auscultation(Breath sounds) n General – Diaphragm of stethoscope – Compare sides – Axilla – Bell of stethoscope above clavicles § Lung apices

The chest: Auscultation(Breath sounds) n Quality of breath sounds p 125 – Normal breath sounds (vesicular) – Bronchial breath sounds – Amphoric breath sounds

The chest: Auscultation(Breath sounds) n Normal breath sounds (vesicular) – Most of chest – Breath through mouth – Inspiration § Longer and louder than expiration – No gap between inspiration and expiration

The chest: Auscultation(Breath sounds) n Bronchial breathing – Hollow, blowing sound – Audible in expiration – Gap between inspiration and expiration – Expiration § Higher intensity than inspiratory – Normal posteriorly over upper chest – CONSOLIDATION

The chest: Auscultation(Breath sounds) n Amphoric breathing – Exaggerated bronchial quality – Very hollow (blowing over bottle) – LARGE CAVITY

The chest: Auscultation(Breath sounds) n Intensity of breath sounds – Normal or reduced – Reduced § COPD § Pleural effusion § Pneumothorax § Pneumonia § Large neoplasm § Pulmonary collapse

The chest: Auscultation(Breath sounds) n Added sounds – Continuous sounds (wheezes) – Interrupted sounds (crackles)

The chest: Auscultation(Breath sounds) n Continuous sounds (wheezes) – Musical – Inspiration +/expiration – Airway narrowing – High pitched § Smaller bronchi § Asthma – Low pitched § Larger bronchi § COPD – Monophonic § Localized § Bronhial obstruction (Lung CA) – Stridor § Louder over trachea § Inspiratory

The chest: Auscultation(Breath sounds) n Interrupted sounds (crackles) – Non-musical – Early inspiratory § Small airway disease § COPD § Medium coarseness – Late/pan-inspiratory § Disease in alveoli § Fine – Pulmonary fibrosis § Medium – LV failure § Coarse – Bronchiectasis – Retention of secretions

The chest: Auscultation(Breath sounds) n Pleural friction rub § Thickened pleural surfaces rub together § Grating sound § Causes – Pleurisy § Secondary to pulmonary infarction – Pneumonia – Malignant involvement of pleura – Spontaneous pneumothorax

The chest: Auscultation n 2. Vocal resonance – Auscultation while patient speaks – Ability of lung to transmit sounds – Normal – Consolidation § Can hear “ 99” § Aegophony – Bee becomes bay § Whispering pectoriloquy – Can hear when whispers

The chest: Signs

The chest: Signs

The chest: Signs

The chest: Signs

The chest: Signs n Hyperinflation – Increased AP diameter – Trageal tug – Apex not palpable – Hyperressonant percussion – Liver displaced downwards – No cardiac dullness – Soft heart sounds

The Heart n Measure JVP – Increased in RV failure n Listen to P 2 – Loud in pulmonary hypertension

The Abdomen n Liver examination – Displaced downward in hyperinflation – Enlarged in metastases (Lung CA)

Other n Pemberton’s sign – Lift arms over head one minute – SVC obstruction § Facial plethora § Cyanosis § Inspiratory stridor § Non-pulsatile elevation of JVP

Other n Feet – Oedema § Cor pulmonale – DVT § PE