Clinical Examination of RS

Brief Presentation on clinical examination of Respiratory System with Report of Normal case
references:
macleod's clinical examination 13th edition
hutchinson clinical methods
R Alagappan - Manual of Practical Medicine, 4th Edition

1. Clinical Examination of the Respiratory System By, Dr.Prajwal

2. Different Lines

3. Vertebra prominence

4. Sternal angle and ICS Suprasternal Notch Sternal Angle

5. 2 nd Rib joins Arch of Aorta( beginning and the end) Trachea bifurcates into the two bronchi Pulmonary trunk bifurcation L eft recurrent laryngeal nerve looping under the arch of the aorta Azygous Vein draining into the superior vena cava. Thoracic duct emptying into the left subclavian vein

6. Lung fissure and Borders

7. Lung fissure and Borders Oblique fissure (Major interlobar fissure) Horizontal fissure (Minor interlobar fissure) T 2

8. EXAMINATION OF THE RESPIRATORY SYSTEM General Examination (RS) Examination of the Chest Upper Respiratory Tract Lower Respiratory Tract

9. General Examination P allor I cterus C yanosis C lubbing E dema L ymphadenopathy T emperature P ulse R espiratory Rate BP JVP

10. P allor (Anemia) The pallor of anemia is best seen in the mucous membranes of the conjunctivae, lips and tongue and in the nail beds Anaemia may occur when there is a. Haemoptysis b. Excessive sputum production and protein loss c. Loss of appetite leading to malnutrition

11. C yanosis This is a blue discoloration of the skin and mucous membranes caused by increased concentration of reduced hemoglobin (5g/dl) Central cyanosis may result from the reduced arterial oxygen saturation caused by cardiac or pulmonary disease . Intracardiac or extracardiac shunting. Impaired pulmonary function a. Alveolar hypoventilation b. Ventilation—Perfusion mismatch c. Impaired oxygen diffusion.

12. Bulbous enlargement of the distal portion of the digit due to increased subungual soft tissue. C lubbing

13. Grading of Clubbing Grade I Positive nail bed fluctuation Grade II Obliteration of the Lovibond angle Grade III Parrot beak / Drumstick appearance Grade IV Hypertrophic osteoarthropathy .

14. Pulmonary and Thoracic Causes a. Bronchogenic carcinoma (rare in adenocarcinoma) b. Metastatic lung cancer c. Suppurative lung disease 1. Bronchiectasis 2. Cystic fibrosis 3. Lung abscess 4. Empyema d. Interstitial lung disease e. Longstanding pulmonary tuberculosis f. Chronic bronchitis g. Mesothelioma h. Neurogenic diaphragmatic tumour i . Pulmonary AV malformation j. Sarcoidosis.

15. Hypertrophic Osteoarthropathy It is a painful swelling of the wrist, elbow, knee, ankle, with radiographic evidence of sub-periosteal new bone formation. It can be familial or idiopathic. common disorders that can produce it are: a. Bronchogenic carcinoma b. Cystic fibrosis c. Neurofibroma d. A-V malformation.

16. L ymphadenopathy Scalene lymph node enlargement 1. Large and fixed in secondary involvement from a primary lung malignancy 2. Hard and craggy, matted, with or without sinus formation in healed and calcified tuberculous lymphadenopathy.

17. B lood P ressure Pulsus Paradoxus Systolic blood pressure normally falls during quiet inspiration in normal individuals. Pulsus paradoxus is defined as a fall of systolic blood pressure of >10 mmHg during the inspiratory phase. severe acute asthma or exacerbations of chronic obstructive pulmonary disease.

18. Examination of the Neck Veins J ugular V enous P ulse COPD/ cor pulmonale Bilateral non-pulsatile SVC obstruction Massive right sided pleural effusion

19. Examination of the Chest Inspection Palpation Percussion Auscultation The subject should be examined in the Standing or Sitting position in an erect, and in good light.

20. All the findings in the clinical examination should be compared on both sides in the following areas: 1. Supraclavicular area 2. Infraclavicular area 3. Mammary region 4. Inframammary region 5. Axillary region 6. Infra-axillary region 7. Suprascapular region 8. Interscapular region 9. Infrascapular region.

21. Inspection Inspection for Position of trachea Inspection for Symmetry of Chest Inspection for Chest wall abnormalities Inspection for Movement of the Chest Inspection for Apex beat Inspection for Dilated and engorged veins Inspection for Surgical or any Scars or Sinuses

22. Inspection for Position of trachea Trail’s sign : It is the undue prominence of the clavicular head of sternomastoid on the side to which the trachea is deviated. Position of Apex Beat The apex beat is shifted to the side of mediastinal shift.

23. Inspection for Symmetry of Chest Normal chest is symmetrical and elliptical in cross section. The normal antero-posterior to transverse diameter ratio (Hutchinson’s index) is 5 : 7. The normal subcostal angle is 90°. It is more acute in males than in females. AP T AP:T = 5:7

24. Look for the following: 1. Drooping of the shoulder 2. Hollowness or fullness in the supraclavicular and infraclavicular fossae 3. Crowding of ribs 4. Kyphosis (forward bending of the spine) 5. Scoliosis (lateral bending of the spine).

25. Inspection for Chest wall abnormalities Flat chest : The antero-posterior to transverse diameter ratio is 1 : 2. Seen in pulmonary TB and fibrothorax

26. Barrel chest : The anteroposterior to transverse diameter ratio is 1 : 1. Seen in physiological states like infancy and old age and in pathological states like COPD (emphysema)

27. 3. Pigeon chest (Pectus carinatum ) : It is forward protrusion of sternum and adjacent costal cartilage, seen in Marfan’s syndrome, in childhood asthma and rickets

28. Pectus excavatum (funnel chest, cobbler’s chest) It is the exaggeration of the normal hollowness over the lower end of the sternum. It is a developmental defect. The apex beat shifted further to the left and the ventilatory capacity of the lung is restricted. It is seen in Marfan’s syndrome

29. 5. Harrison’s sulcus : It is due to the indrawing of ribs to form symmetrical horizontal grooves above the costal margin, along the line of attachment of diaphragm occurs in chronic respiratory disease in childhood, childhood asthma, rickets and blocked nasopharynx due to adenoid enlargement

30. 6. Scorbutic rosary: It is the sharp angulation, with or without beading or rosary formation, of the ribs, arising as a result of backward displacement or pushing in of the sternum, e.g. Vitamin C deficiency. 7. Rickety rosary: It is a bead like enlargement of costochondral junction, e.g. rickets

31. Spinal Deformity Kyphoscoliosis : It is a disfiguring or disabling deformity of the spine, producing a shift of the apex beat. It reduces the ventilatory capacity of the lung and increases the work of breathing.

32. Inspection for Movement of the Chest It is described in terms of rate, rhythm, equality and type of breathing Rate • The normal respiratory rate in relaxed adults is 14-18 breaths per minute • The type of breathing in women is thoraco-abdominal and in men is abdomino -thoracic • The ratio of pulse rate to respiratory rate is 4 : 1.

33. Tachypnoea : It is an increase in respiratory rate more than 20 per minute(Adult) . Conditions causing tachypnoea are: a. Nervousness b. Exertion c. Fever d. Hypoxia e. Respiratory conditions i . Acute pulmonary oedema ii. Pneumonia iii. Pulmonary embolism iv. ARDS v. Metabolic acidosis

34. Bradypnoea : It is a decrease in the rate of respiration. Conditions causing bradypnoea are: a. Alkalosis b. Hypothyroidism ( myxoedema ) c. Narcotic drug poisoning d. Raised intracranial tension. Hyperpnoea : It is an increase in depth of respiration. Conditions causing hyperpnoea are: a. Acidosis b. Brainstem lesion c. Hysteria.

35. Rhythm Inspiration : It is an active process brought about by the contraction of the external intercostal muscles and the diaphragm Expiration : It is a passive process and it depends upon elastic recoil of the lungs. Accessory muscles of inspiration are the scaleni , trapezius and pectoral muscles. Accessory muscles of expiration are abdominal muscles and latissimus dorsi .

36. Abnormal Breathing Patterns Abnormal breathing patterns may be regular or irregular Regular abnormal breathing patterns Cheyne-Stokes breathing : It is characterised by hyperpnoea followed by apnoea . It occurs in cardiac failure, renal failure, narcotic drug poisoning and raised intracranial pressure b. Kussmaul’s breathing : It is characterised by increase in rate and depth of breathing. It occurs in metabolic acidosis and pontine lesions.

37. Irregular abnormal breathing patterns a. Biots breathing : It is characterised by apnoea between several shallow or few deep inspirations. It occurs in meningitis b. Ataxic breathing : It is characterised by irregular pattern of breathing where both deep and shallow breaths occur randomly. It occurs in brainstem lesions c. Apneustic breathing : It is characterised by pause at full inspiration, alternating with a pause in expiration, lasting for 2 to 3 seconds. It occurs in pontine lesions

38. Palpation Palpation for Apex Beat (Position and Character) Palpation for Position of trachea Palpation for Measurement of the Chest Expansion Palpation for Assessing of Chest Expansion Palpation for Vocal fremitus (VF) Palpation for Direction of flow in veins Palpation for Tender points

39. The position of the trachea is confirmed by slightly flexing the neck so that the chin remains in the midline. The index finger is then inserted in the suprasternal notch and the tracheal ring is felt. Slight shift of trachea to the right is normal Palpation for Position of trachea

40. Measurement of the Chest Expansion The expansion of the chest should be measured with a tape measure placed around the chest just below the level of the nipples/inferior angle of scapula. Chest circumference in full expiration Chest circumference at full inspiration Chest expansion Right/Left Hemithorax Normal expansion of the chest is 5-8 cm In severe emphysema, it is less than 1 cm

41. General Restriction of Expansion a. COPD b. Extensive bilateral disease c. Ankylosing spondylitis d. Interstitial lung disease e. Systemic sclerosis (hide bound chest). Asymmetrical Expansion of the Chest a. Pleural effusion b. Pneumothorax c. Extensive consolidation d. Collapse e. Fibrosis. In all these above conditions, diminished expansion occurs on the affected side.

42. Assessing Symmetry of Chest Expansion anterior thoracic expansion upper thoracic expansion posterior thoracic expantion

43. It is a vibration felt by the hand when the patient is asked to repeat ninety-nine or one-one-one, by putting the vocal cord into action. Identical areas of the chest are compared on both sides. It is felt with the flat of the hand or with the ulnar border of the hand for accurate localization. It is increased in consolidation. It is decreased in pleural effusion Palpation for Vocal fremitus (VF)

44. Tenderness over the Chest Wall It may be due to: 1. Empyema 2. Local inflammation of parietal pleura, soft tissue and osteomyelitis 3. Infiltration with tumor 4. Non-respiratory cause (amoebic liver abscess).

45. Percussion Percussion for the Lung fields

46. Cardinal Rules of Percussion a. The pleximeter : The middle finger of the examiner’s left hand should be opposed tightly over the chest wall, over the intercostal spaces . The other fingers should not touch the chest wall. Greater pressure should be applied over a thick chest wall to remove air pockets b. The plexor : The middle or the index finger of the examiner’s right hand is used to hit the middle phalanx of the pleximeter c. The percussion movement should be sudden, originating from the wrist . The finger should be removed immediately after striking to avoid damping d. Proceed from the area of normal resonance to the area of impaired or dull note, as the difference is then easily appreciated e. The long axis of the pleximeter is kept parallel to the border of the organ to be percussed.

47. Direct percussion—clavicle Anterior Chest Wall Clavicle: Direct percussion is used and percussion is done within the medial 1/3rd of the clavicle Supraclavicular region ( Kronig’s isthumus ): It is a band of resonance 5-7 cm size over the Supraclavicular fossa. The percussion is done by standing behind the patient and the resonance of the lung apices is assessed by this method. Second to sixth intercostal spaces. However, the percussion note cannot be compared due to relative cardiac dullness on the left side. Liver dullness can be percussed from the right 5 th rib downwards in the midclavicular line.

48. Lateral Chest Wall Fourth to seventh intercostal spaces. Liver dullness can be percussed from the right 8 th rib downwards in the midaxillary line. Posterior Chest Wall a. Suprascapular (above the spine of the scapula) b. Interscapular region c. Infrascapular region up to the eleventh rib. Liver dullness can be percussed from the right 10 th rib downwards in the midscapular line.

49. Tidal Percussion This is done to differentiate upward enlargement of liver or subdiaphragmatic abscess from right sided parenchymal or pleural disorder. If on deep inspiration, the previous dull note in the fifth right intercostal space on the mid clavicular line becomes resonant, it indicates that the dullness was due to the liver, which had been pushed down by the right hemidiaphragm with deep inspiration. If the dullness persists on the other hand, it indicates underlying right sided parenchymal or pleural pathology, in the absence of diaphragmatic paralysis. Shifting Dullness This is done to demonstrate the shift of fluid in hydropneumothorax. The immediate shift of fluid can be demonstrated by the dull area percussed in the axilla in the sitting posture, becoming resonant on lying down on the healthy side.

50. Auscultation Auscultation for Breath Sounds Auscultation for Vocal Resonance

51. Listen with the patient relaxed and breathing deeply through his open mouth. Auscultate each side alternately, comparing findings over a large number of equivalent positions to ensure that you do not miss localised abnormalities. Listen: ■ anteriorly from above the clavicle down to the sixth rib ■ laterally from the axilla to the eighth rib ■ posteriorly down to the level of the 11th rib. ■ Assess the quality and amplitude of the breath sounds. Identifyany gap between inspiration and expiration, and listen for added sounds. Avoid auscultation within 3 cm of the midline anteriorly or posteriorly, as these areas may transmit soundsdirectly from the trachea or main bronchi.

52. Vesicular breath sounds low pitched, rustling in nature produced by attenuating and filtering effect of the lung parenchyma. Duration of the inspiratory phase is longer than the expiratory phase in a ratio of 3 : 1. There is no pause between the end of inspiration and the beginning of expiration. Bronchial breath sounds It is loud and high pitched, with an aspirate or guttural quality. It is produced by passage of air through the trachea and large bronchi The duration of inspiration is shortened whereas that of expiration is prolonged or equal There is a pause between inspiration and expiration.

53. Types of Bronchial Breathing a. Tubular b. Cavernous c. Amphoric .

54. Added sounds Added sounds are abnormal sounds that arise in the lung itself or in the pleura. The added sounds most commonly arising in the lung are best referred to as wheezes and crackles. Pleural rub is a “creaking” or “rubbing” sound produced by friction between the two layers of inflamed and roughened pleura. NEW Terms OLD Terms Definations coarse crackles râles non-musical, interruptedshort , explosive sounds often described as bubbling or clicking. fine crackles crepitations wheezes rhonchi Continuous musical sounds associated with airway narrowing.

55. Vocal resonance is the detection of vibrations transmitted to the chest from the vocal cords as the patient repeats a phrase, usually the words ‘ ninetynine ’ assess the quality and amplitude of vocal resonance. Types Bronchophony : Voice sounds appear to be heard near the earpiece of stethoscope and words are unclear, e.g. consolidation, cavity communicating with a bronchus, Aegophony : Voice sound has a nasal or bleating quality. On saying ‘E’, it will be heard as ‘A’ (E to A sign), e.g. consolidation, cavity. c. Whispering pectoriloquy : The patient is asked to whisper words at the end of expiration, and this whispered voice individual syllables are recognised clearly, e.g. pneumonic consolidation, cavity communicating with a bronchus

56. Examination of RS Name: Age: Sex: Address: Occupation: 1) General Physica l Examination: Young patient moderately built and moderately nourished, well oriented to time place and person, conscious and cooperative P allor I cterus C yanosis C lubbing E dema L ymphadenopathy T emperature P ulse R espiratory Rate BP JVP

57. Examination of the Chest Inspection: Trachea appears Central in Position Shape of the chest is elliptical, Bilaterally symmetrical Movement of the chest is equal on both sides and normal Respiratory Movement Rate : 14 – 18 Breaths per minute Rhythm : Regular Depth : Normal Type : Abdominothoracic / Thoracoabdominal Accessory muscles of Respiration not in use No skeletal deformity seen Apical impulse not seen/seen at Left 5 th ICS medial to MCL No dilated or engorged veins present No scars or swelling or other visible pulsations seen

58. Palpation: Apical Impulse felt at Left 5 th ICS medial to MCL and is of Normal Character Trachea centrally Placed (slightly deviated to right side) Expansion of the chest is normal and symmetrical, expansion is more at the base compared to apex and sides of chest Measurement of the Chest Expansion Transverse Diameter : ___cm Anteroposterior Diameter : ___cm Right/Left Hemithorax : ___cm Chest circumference in expiration : ___cm Chest circumference at full inspiration : ___cm Chest expansion : ___cm No tenderness present

59. Area Right Left Supraclavicular area Equal on both sides Infraclavicular area Equal on both sides Mammary region Equal on both sides Inframammary region Equal on both sides Axillary region Equal on both sides Infra-axillary region Equal on both sides Suprascapular region Equal on both sides Interscapular region Equal on both sides Infrascapular region Equal on both sides Vocal fremitus (VF)

60. Percussion : Area Right Left Supraclavicular area Resonant Resonant Infraclavicular area Resonant Resonant Mammary region Resonant Dullness Inframammary region Dullness(5 th ICS onwards) Dullness Axillary region Resonant Resonant Infra-axillary region Resonant Resonant Suprascapular region Resonant Resonant Interscapular region Resonant Resonant Infrascapular region Resonant Resonant

61. Auscultation Breath Sounds Area Right Left Supraclavicular area Vesicular Vesicular Infraclavicular area Vesicular Vesicular Mammary region Vesicular Vesicular Inframammary region Vesicular Vesicular Axillary region Vesicular Vesicular Infra-axillary region Vesicular Vesicular Suprascapular region Vesicular Vesicular Interscapular region Vesicular Vesicular Infrascapular region Vesicular Vesicular No added Sounds

62. Area Right Left Supraclavicular area Equal on both sides Infraclavicular area Equal on both sides Mammary region Equal on both sides Inframammary region Equal on both sides Axillary region Equal on both sides Infra-axillary region Equal on both sides Suprascapular region Equal on both sides Interscapular region Equal on both sides Infrascapular region Equal on both sides Vocal Resonance (VR) Report : Examination of the respiratory system of the subject is clinically normal