THE RESPIRATORY

SYSTEM EXAMINATION
1.COUGH- Coughing is a relatively
nonspecific symptom,resulting from irritation
anywhere from the pharynx to the lungs.The
character of a patients cough may , however,
give some clues to the underlaying cause.
Ask for- Duration
e.g. chronic cough- think of pertussis, TB,
foreign body, asthma.
Dry, chronic coughing may occur following acid
irritation of the lungs in oesophageal reflux and as
a side effects of ACE inhibitor.
Character
e.g.Loud, brassy coughing-suggests pressure on
the trachea e.g. by a tumour
Hollow,bovine coughing is associated with
recurrent laryngeal nerve palsy.
Barking coughs occur in acute epiglottis
W/F-Exacerbating factor, sputum ,haemoptysis
DYSPNOEA- Ask for Duration ,Steps climbed
/Distance walked before onset.
HOARSENESS- e.g Due to Laryngitis,Singers
Nodules or larengial tumour
FEVER/NIGHT SWEATS- Moderate night
sweating is common in anxiety states, but several
changes of night clothes is a more ominous
symptom associated with infection. e.g. TB,
lymphoproliferative disease or mesothelioma and
pneumonia.
CHEST PAIN- Pleuritic pain is exacerbated by
inspiration implies inflammation of the pleura
secondary to pulmonary infection, inflammation
or infarction.It causes the pt. to catch his breath.
WHEEZE- (RONCHI)- are caused by air passing
through narrowed airways.They may be
monophonic(a single note, signify partial
obstruction) or polyphonic signify widespread
narrowing of airways. Wheeze may also be heard
in LVF ( cardiac asthma).
STRIDOR- is a term used to describe a snoring
sound heard over extrathoracic airways.It ia an
inspiratory sound doe to partial obstruction of the
upper airways.
PAST HISTORY- W/F- Pneumonia, TB,
bronchitis, Atopy(eczema, asthma, hay fever).
Previous CXR abnormalities, lung surgery.
FAMILY HISTORY- Atopy, Emphysema, TB.
SOCIAL HISTORY- Ask for smoking and
occupational exposure.
DRUG HISTORY- Ask for respiratory drugs(e.g.
steroids, bronchdilators), any other drugs
especially those with respiratory side effects, e.g.
betablockers, ACE inhibitors.
EXAMINATION- Assess general health.
( INSPECTION)
Is he diseased? Cachectic? Using accessory
muscles in respiration? Are there signs of RDS?
Count the respiratory rate and breathing pattern.
Is there Kussmauls breathing?
(Rapid, deep respirstion)
It is deep, slow breathing that is principally
seen in metabolic acidosis and uraemia.
Is there Chyne-stokes breathing?
(Apnoea alternating with hyperapnoea)
Breathing becomes progressively deeper and then
shallower.
W/F- Chest wall deformities-
1. Barrel chest- AP diameter . seen in chronic
hyperinflation. e.g. asthma, COPD.
2. Funnel chest- (pectus excavatum)- it is
developmental defect involving local sternum
depression.
3. Pigeon chest(pectus carinatum)-
prominent sternum with a flat chest seen in
chronic childhood asthma and in ricket
W/F- Chest wall movement- Is it symmetrical?
If not, pathology is on restricted side. Is there
paradoxical respiration?( abdomen sucked in with
respiration, seen in diaphragmatic paralysis)
W/F- Deformities of the spine.
1. Kyphosis- Humpback from thoracic spine
curvature.
2. Scoliosis- Lateral curvature
Both may cause restrictive ventilatory defect.
3. Harrisons sulcus- is a groove deformity of
lower ribs at the diaphragm attachment site
suggesting chronic childhood asthma and rickets.
 Examine the hands-
W/F- 1. Clubbing- Finger nails have
exaggerated longitudinal curvature + loss of
angle between nail and nail folds and the nail fold
feels boggy.
W/F- 2. Peripheral cyanosis.
Inspect the face- check for ptosis and
constricted pupil.
W/F – Tongue and lips for central cyanosis.
 Palpation-
1. W/F- Lymphadenopathy- Check for cervical
Lymphadenopathy from behind with the pt.
sitting forward
2. W/F- Tracheal position- Is it central or
displaced to one side?
If deviated, concentrate to upper lobe for
pathology.
3. W/F- Chest exapansion- Use both hands to
compare chest exapansion on both
sides.Exapansion < 5 cm on deep inspiration is
abnormal.Reduced exapansion implies pathology
on that side.
 4. W/F- Tactile vocal fremitus- By asking the
pt. to repeat 99 while palpating chest wall over
different respiratory segments comparing similar
positions over each lung in turn.Increased vocal
fremitus implies consolidation.
5.W/F- Vocal resonance- is sound vibration of
the pts. Spoken or whispered voice transmitted
to the stethoscope.
 Percussion- Percuss symmetrical areas of the
Anterior, Posterior and Axillary regions of the
chest wall and note down the percussion note.
For the percussion of the chest, put the index
finger of the left hand in the intercostals apace
and stroke the index finger of the right hand on
this left index finger.The movement of the right
hand should be from the wrist joint.
 Percussion note-
1. Resonant note- is the normal.
2. Hyper resonant - suspect pneumothorax or
hyperinflation.
3. Stony dull- suspect lobe collapse.
Consolidation, fibrosis, pleural thickening, or
pleural effusion.
The cardiac dullness is usuallydetectable over
the left side of the chest.
The liver dullness usually extends up to the
fifth rib, right mid clavicular line, if the chest is
resonant below this level, it is a sign of lung
hyperexapansion.
Ascultation- Asculte over symmetrical areas of
the anterior, posterior and axillary regions of the
chest wall with the stethoscope and use the bell to
ascultate over the supraclavicular fossa. Consider
breath sounds in terms of quality, intensity and
the presence of additional sounds.
While ascultating, W/F-
1. Air entry ( AE=BS)
2. Ronchi ( wheeze, rales)
3. Crepitations( crackles)
Are caused by re-opening ,during inspiration,
of the small airways which have become occluded
during expiration.
4. Vesicular breathing- Normally heard all
over the lungs.It is a normal breath sounds
having a rustling quality.
5. Bronchial breathing- Normally heard over
the trachea and bronchus. It has hollow quality
and occur where lung tissue become firm , solid
due to consolidatuion, localized fibrosis etc.
6. Pleural rubs- are caused by movement of the
visceral pleura over the parietal pleural, when
both surfaces are roughened. E.g. by an
inflammatory exudate(pneumonia, pulmonary
infarction)
Further Examination- Look at the JVP.