Respiratory Examination

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Respiratory Examination
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History

• Dyspnoea
• Wheeze
• Cough
• Sputum
• Haemoptysis
• Chest pain

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History

• Acute/chronic disorder
• Preceding systemic disturbance
• Past medical history
• Drug history
• Social history
• Family history
• Occupational history

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Physical Examination

• Initial impression
• Audible cough
• Sputum sample
• Wheeze
• Stridor
• Hoarseness
• Dyspnoea
• TPR

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Hands and Pulse

• Perfusion
• Peripheral cyanosis
• Tremor
• Flap
• Finger clubbing
• Pulse

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Face and Neck

• Central cyanosis
• Neck veins
• Lymphadenopathy
• Trachea
• Crepitus
• Neck muscles
• Indrawing
• Pursed lips

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The Chest

• Inspection
• Palpation
• Percussion
• Auscultation

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Inspection

• Shape
• Scars
• Lesions
• Resp rate
• Resp depth
• Mode of breathing
• Abnormal inspiratory movements
• Abnormal expiratory movements
• Asymmetry of movement

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Chest wall

• Pectus carinatum

• Pectus excavatum

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Palpation

• Chest expansion
• Tactile vocal fremitus

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Percussion

• Illicit resonance
• Compare both sides
• Map out abnormal area

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Percussion

• Impaired(dull)resonance obtained
• Aerated lung tissue is separated from the chest
  wall e.g. fluid, pleural thickening
• Lung tissue is airless e.g. consolidation,
  collapse, fibrosis
• stony dullness- pleural effusion
• Hyperresonance - pneumothorax

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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

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Auscultation

• Breath sounds
• Added sounds
• Vocal sounds (vocal resonance)

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Breath Sounds

• Vesicular - normal
• Diminished - localised or diffuse
• Bronchial - consolidation

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Breath sounds

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Vesicular breath sounds

• Vibrations of the vocal cords caused by turbulent
  flow through the larynx
• Transmitted along trachea, bronchi to chest wall
• Rustling quality
• Inspiration continuous with expiration
• Intensity increases during inspiration fades
  during first 1/3rd expiration

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Diminished breath sounds

• Conduction limited by
• Airflow limitation
• e.g. diffusely asthma, emphysema
• localised tumour, collapse
• Something separating chest wall from lung
• e.g. effusion, fibrosis

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Bronchial breathing

• blowing inspiratory expiratory sounds
• Expiratory phase as long as inspiration
• Distinct pause between phases
• High-pitched e.g. consolidation
• Low-pitched e.g. fibrosis

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Added sounds

• Rhonchi (wheeze)
• Crepitations (crackles)
• Pleural sounds

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Rhonchi

• Due to passage of air through narrowed bronchus
  e.g. bronchospasm, mucosal oedema
• Musical quality
• High or low pitched
• Usually expiratory
• Expiration prolonged

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Crepitations

• Inspiratory noises, usually 2nd half
• Non-musical
• Due to explosive reopening of peripheral small
  airways during inspiration which have become
  occluded during expiration

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Pleural Rub

• Creaking noise
• Movement of visceral pleura over parietal pleura
• Surfaces roughened by exudate
• 2 separate phases at end inspiration and early
  expiration

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Vocal sounds

• Vocal resonance
• Increased when voice sounds are louder and more
  distinct e.g. consolidation
• Reduced when transmission impeded e.g. effusion,
  collapse

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Information from auscultation

• Type and amplitude of breath sounds
• Type of added sounds and their location
• Quality and amplitude of conducted sounds

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Auscultation technique

• Diaphragm of stethoscope
• Mouth open
• Breathing deeply and fairly rapidly
• Systematic approach over several areas, comparing
  both sides
• Repeat asking patient to say 9,9,9 for vocal
  resonance
• Whispering pectoriloquy

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Other physical signs

• Peak flow
• Oedema
• Pulsatile liver

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Interpretation of findings

• Breath sounds locally reduced or absent over
  pleural effusion, thickened pleura, collapsed
  area
• Breath sounds diffusely reduced in emphysema,
  asthma
• Rhonchi heard in asthma, COPD
• Crepitations may be widespread in COPD, LVF
• Crepitations localised in area of consolidation
• Pleural rub in pleurisy

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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

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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

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• Pleural effusion

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• pneumothorax

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Cardiovascular Examination
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History

• Chest pain
• Dyspnoea
• Palpatations
• Oedema
• Syncope/ presyncope

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Chest pain

• Site
• Radiation
• Character
• Severity
• Frequency
• Duration
• Aggravating factors
• Relieving factors
• Associated features

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Dyspnoea

• Onset
• Severity
• Related to effort
• Orthopnoea
• Paroxysmal nocturnal dyspnoea

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Other symptoms

• Cough
• Haemoptysis
• Tiredness
• Nausea/ vomiting
• Bowel upset
• Oliguria
• Visual loss

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Other aspects of history

• Past medical history
• Drug history
• Family history
• Social history
• Occupational history

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Physical examination

• Initial impression
• TPR
• Audible cough
• Breathlessness
• Distress

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Hands and face

• Perfusion
• Colour
• Peripheral cyanosis
• Finger clubbing
• Nicotine stains
• Splinter haemorrhages
• xanthomata

• Malar flush
• Xanthelasma
• Corneal arcus
• Central cyanosis
• Dentition
• Anaemia
• Chemosis

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Pulse and blood pressure

• BP both arms

• Radial artery
• rate
• rhythm
• volume
• Character (collapsing)
• Central pulse

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Venous pressure

• JVP right atrial pressure
• Indicator of filling pressure
• Equivalent to column of blood 7cm above right
  atrium with patient at 45 degrees
• Falls during inspiration
• Fixed in SVCO
• High in fluid overload e.g. right heart failure
• Low in dehydration / fluid depletion

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Jugular venous pulse

• a wave atrial contraction
• c wave transient increase in atrial pressure
  as atrium contracts against closed tricuspid
  valve
• x descent atrial relaxation
• v wave max venous return to atrium
• y descent ventricular relaxation

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Examination of the heart

• Inspection
• Palpation
• (percussion)
• Auscultation

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Inspection

• Skeletal abnormalities
• Scars
• Pulsations
• Pacemaker
• Resp rate

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Palpation

• Apex beat
• Abnormal pulsations
• Thrills
• Parasternal heave

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Position of apex beat

• Defined as furthest point downwards and outwards
  where cardiac impulse is palpated
• Normally 5th interspace in mid-clavicular line
• Right hand is placed on left chest wall with
  middle finger over approx site
• Finger is lifted during ventricular contraction
• Once located position defined by counting down
  rib spaces
• Displacement suggests cardiac enlargement
• May be impalpable

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Quality of apex beat

• Forceful/heaving/thrusting LV hypertrophy
• Diffuse LV dysfuction
• Tapping mitral stenosis

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Other palpable abnormalities

• Thrills palpable murmurs
• Diastolic or systolic
• Palpable with right hand at apex, aortic,
  pulmonary and lower left sternal edge
• Accentuated by leaning forward in fixed
  expiration
• Right ventricular heave

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Auscultation

• Diaphragm high pitched sounds
• Bell low pitched sounds
• Heart sounds
• Added sounds

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Heart sounds

• 1st 2nd heart sounds usually audible at apex
• lub-dup
• Time with carotid pulse
• Ventricular systole occurs
• between 1st 2nd heart sounds

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First heart sound

• Mitral valve closure principally, at end of
  atrial systole
• Tricuspid valve usually quiet
• lub in lub-dup
• Immediately precedes
• Apical pulse
• Immediately precedes carotid wave pulse
• Usually loudest at apex
• Bell or diaphragm

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First heart sound

• Loudness depends on position of the cusps at
  onset of systole
• If wide apart a loud S1 is heard e.g. heart
  failure
• Variation in intensity with AF/AV dissociation
• Loud in mitral stenosis

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Second heart sound

• Closure of aortic and pulmonary valves at end of
  ventricular systole
• dup in lub- dup
• Immediately follows apical impulse
• Immediately follows carotid wave pulse
• Upper left sternal edge with diaphragm

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Second heart sound

• Physiological splitting. Delayed closure of
  pulmonary valve due to increased venous return on
  deep inspiration
• Exaggerated splitting e.g. RV dilatation in pul
  stenosis
• Fixed splitting in ASD
• Reverse splitting in delayed left ventricular
  ejection e.g. HOCM

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Third heart sound

• Normal in young healthy
• Impaired LV function
• Raised end diastolic pressure
• Low pitched at apex bell
• gallop or triple rhythm when tachycardic

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Fourth heart sound

• Accompanies and is due to atrial systole
• Only heard in sinus rhythm
• Loud in left atrial hypertrophy i.e. IHD,
  hypertension
• Low pitched at apex bell
• Triple or gallop rhythm

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Heart sounds

• Rate
• Rhythm
• Sinus arrhythmia
• Ectopic beats premature
• Intermittent heart block dropped beats
• Atrial fibrillation

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Murmurs

• Arise from turbulent flow across valves
• Leaking or narrowed valve
• Timing
• Intensity
• Grade 1 - very quiet
• Grade 2 - quiet
• Grade 3 - mod loud
• Grade 4 - loud thrill
• Grade 5 - very loud
• Grade 6 - audible without stethoscope

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Systolic murmurs

• Heard between 1st 2nd heart sounds
• Pan systolic
• Ejection systolic

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Pan systolic murmurs

• Start with S1
• Extend through systole continue to S2
• Mid systolic accentuation
• Escape of blood from ventricle to low pressure
  atrium through leaking valve
• Mitral regurgitation apex, low pitched
• Triscuspid regurg- left sternal edge to apex (
  JVP pulsatile liver)
• VSD rough, tearing with thrill

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Ejection systolic murmurs

• Turbulent flow across narrowed valve
• Onset after SI - distinct and separate
• Intensity increases to crescendo in middle of
  systole
• Aortic stenosis aortic area (carotid)
• Pulmonary stenosis pulmonary area

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Diastolic murmurs

• Heard between 2nd 1st heart sounds
• Aortic regurgitation
• Pulmonary regurgitation
• Mitral stenosis
• Pericardial friction rub

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Other findings

• Carotid bruits
• Pitting oedema (ankles sacrum)
• Chest auscultation
• Abdo exam
• Peripheral pulses
• Urinalysis

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