Respiratory Examination

Methods of clinical examination of the respiratory system

1. Respiratory Examination
BY
ASHRAF OKBA
PROF. OF INTERNAL MEDICINE
AIN SHAMS UNIVERSITY

8. Personal History:
Stress on the following points
 Occupation: e.g.
– Silicosis may be complicated by pulmonary T.B.
– Asbestosis may be complicated by mesothelioma
Ask about the following:
1-Duration of exposure: several years needed for pneumoconiosis.
2-Adherence to safety measures as wearing special masks.
 Special Habits smoking cigarettes, shesha and goza.

9. The six cardinal symptoms of chest diseases are:
1- Cough
2- Expectoration (sputum)
3- Hemoptysis
4- Chest pain
5- Dyspnea
6- Wheezes
History of the present illness

10.  Other symptoms of importance in chest diseases :
1- Symptoms of mediastinal syndrome as dysphagia and
hoarseness of voice.
2- Symptoms of toxemia as night fever, night sweats, loss of
appetite and weight as in T.B.
3- Symptoms of RVF as LLs edema and pain in the RUQ of the
abdomen ( due to congested tender liver).
4- Fever as in upper and lower resp. tract infections.
 Finally any other symptoms related to other systems.
History of the present illness
2

11. Attack or disease similar to the present one: e.g. -
Asthma.
- Recurrent pneumonia
Allergic disorders: eczema, urticaria, angioedema and
hay fever.
Acute abdominal conditions.
Admission in any hospital before and why?
Bilharziasis: bilharzial cor pulmonale.
Past HistoryPast History
11

12. Chest injuries and operations.
Other Surgical Procedures.
Coma , convulsions….may predispose to
aspiration lung abscess
Cardiac diseases and history of rheumatic
fever.
Past HistoryPast History
22

13. Diabetes mellitus
Hypertension. Cough may result from ACE inhibitors
T.B and history of admission to a chest
hospital for treatment of T.B. medicines, duration of
the treatment and the adherence to it.
Previous radiological examination: comparison
with the current radiograph
Past HistoryPast History
33

14.  Similar condition in the family.
 History of T.B.
 History of allergy as eczema and hay
fever.
 History of DM
Family and Social HistoryFamily and Social History

15. Ask about the following:
 The frequency
 The severity
 Dry or productive
 Time of occurrence
 Relation to posture
Character of cough (better observed by the physician)
CoughCough
Analysis of Chest SymptomsAnalysis of Chest Symptoms
11

16. SputumSputum
Analysis of Chest SymptomsAnalysis of Chest Symptoms
22
Amount
Color
Character (seous, mucoid,purulent and mucopurulent)
Odor
Relation to posture
What increases or decreases it
Associated conditions

17. HemoptysisHemoptysis
11
::
Analysis of Chest SymptomsAnalysis of Chest Symptoms
33
The most important causes of hemoptysis are
•Mitral stenosis
•Pulm tuberculosis
•Pulm infarction
•Brochiectasis
•Bronchogenic carcinoma
•Bronchial adenoma
•Bleeding tendency

18.  Differentiate between hemoptysis and hematemesis
 Ask about :
•Type and Degree
•Frequency and Duration
 Ask about the preceding events e.g. DVT or chest
infection
HemoptysisHemoptysis
22
::
Analysis of Chest SymptomsAnalysis of Chest Symptoms
44

19. Type and Degree
HemoptysisHemoptysis
33
::
Analysis of Chest SymptomsAnalysis of Chest Symptoms
55
•Frank hemoptysis
•Blood-stained sputum
•Blood streaked sputum
•Rusty sputum
Frequency and duration

20.   Chest pain:
 The onset..
 Site.
Character.
 Radiation.
What increases the pain
 what relieves or decreases it.
Associated symptoms.
Analysis of Chest SymptomsAnalysis of Chest Symptoms
66

21. Wheeze
What dose the patient mean by wheezing?
differentiate between wheeze and stridor.
Wheezing may be intermittent as in asthma or
persistent as in chronic bronchitis.
Wheezing may be diffuse as in asthma and
chronic bronchitis or localized as in
bronchogenic carcinoma.
Analysis of Chest SymptomsAnalysis of Chest Symptoms
77

22. CHEST 
EXAMINATION

23. Inspection of anterior chest wall
1) Ask the patient to lie supine.
2) Ask the patient to lower his gown to waist
level.
3) Stand at the feet of patient.
4) Inspect the shape of the chest (ratio of
antero-posterior and transverse diameters).
5) Inspect the symmetry of the patient’s chest
on both sides with comparison.

26. Chest wall
Pectus carinatum Pectus excavatum

28. Inspection of anterior chest wall
6) Inspect patient’s chest normal breathing
movement.
7) Inspect patient’s chest for accessory muscle use.
8) Inspect patient’s chest for retraction of lower
intercostal spaces.
9) Stand again to the right of patient and look
tangentially for apical and epigastric pulsation.
10) Inspect the chest wall and skin for swelling,
scars, skin eruption or engorged veins.

29. Palpation of anterior chest wall
1) Stand to the right of the patient.
2) Ask the patient to lie supine.
3) Palpate upper lung zone to confirm the movement by placing
the palms in the infraclavicular fossa and the two thumbs in
the midline at the level of suprasternal notch. Let the patient
inspire deeply and let your thumbs follow chest movement.
4) Palpate middle lung zone by putting the palm in the middle
part with tips of thumbs in the midline. Let the patient inspire
deeply and let your thumbs follow chest movement.

31. Palpation of anterior chest wall
5) Palpate lower lung zone by putting the palm in the lower part
with tips of thumbs in the midline. Let the patient inspire
deeply and let your thumbs to follow chest movement.
6) Palpate for palpable rhonchi, pleural rub or chest wall
tenderness by putting the palm on various areas of chest
wall.
7) Palpate for Tactile vocal fremitus
a) Place the palm of hand over various area of chest wall in the
direction of bronchial tree away from midline with
comparison.
b) Ask the patient to repeat the words “44” in arabic

32. TVF
2
Increased TVF Decreased TVF
Consolidation
Cavitation
Collapse with patent main
bronchus
Thick chest wall
Pleural effusion
Pleural fibrosis
Pneumothorax
Emphysema
Collapse

33. Tracheal examination:
a) Stand to the right of the patient.
b) Ask the patient to sit up with the head straight.
c) Inspect for tracheal position “Trill’s sign”.
d) Tracheal shift: Insert the index finger in horizontal position in
the pouch between the medial end of sternomastoid and the
lateral aspect of trachea with comparison.
e) Check the cricosternal distances. This is the distance
between the cricoid cartilage and the suprasternal notch. If it
is less than 3 finger breadths, this indicates hyperinflation of
the lung.
f) Tracheal descent: place the tip of the index finger on the
thyroid cartilage during inspiration to observe its descent.

35. Percussion technique
Place left hand on chest wall, palm
downwards with fingers separated
2
nd
phalanx over area of intercostal space
Right middle finger strikes the 2nd phalanx
producing hammer effect
Entire movement comes from wrist

37. Percussion of the chest
anterior chest wall
1- Stand to the right of the patient.
2- Ask the patient to lie supine.
3- Use light percussion.
4- Krönig’s isthmus: Percuss both areas right and left from dullness to
resonance (start from the neck) with comparison.
5- Percuss both clavicles directly (over medial third)
6- Percuss the infraclavicular regions.
7- Percuss both parasternal lines right and left, from the second space
to the sixth space with comparison.
8- Spare bare area to be percussed late with special areas percussion.
9- Percuss both midclavicular lines right and left, from the second
space to the sixth space with comparison.
10-Comment on dullness found.

38. Percussion of the lateral chest wall
1-Stand to the right of the patient.
2-Ask the patient to lie supine and raise his hands above his
head.
3-Use light percussion.
4-Percuss both anterior axillary lines right and left, from the
fourth space to the eighth space with comparison.
5-Percuss both middle axillary lines right and left, from the
fourth space to the eighth space with comparison.
6-Percuss both posterior axillary lines right and left, from the
fourth space to the eighth space with comparison.
7-Comment on dullness found.

39. Upper border of the liver
1- Stand to the right of the patient.
2- Ask the patient to lie supine.
3- Use heavy percussion.
4- Start in the right midclavicular line from
second space down to the first dullness.
5- Decide the upper border of the liver.

40. Bare area of the heart
1- Stand to the right of the patient.
2- Ask the patient to lie supine.
3- Place the left hand in the left 4th and the
5th spaces between midline and
parasternal line.
4- Percuss lightly with right hand.
5-Comment.

41. Tidal percussion
1- Stand to the right of the patient.
2- Ask the patient to sit.
3- After percussing the back using heavy
percussion if any infrascapular dullness
was found, fix the left hand over it and ask
the patient to take a deep breath and hold it
then percuss again.
4- Comment on whether it changed to be
resonant or not and explain.

42. Percussion of the lateral chest wall
1- Stand to the right of the patient.
2- Ask the patient to lie supine and raise his hands above his
head.
3- Use light percussion.
4- Percuss both anterior axillary lines right and left, from the
fourth space to the eighth space with comparison.
5- Percuss both middle axillary lines right and left, from the
fourth space to the eighth space with comparison.
6- Percuss both posterior axillary lines right and left, from the
fourth space to the eighth space with comparison.
7- Comment on dullness found.

43. Kronig’s isthmus
1- Stand to the right of the patient.
2- Ask the patient to sit and stand behind him.
3- Use light percussion.
4- Percuss both areas right and left from
dullness to resonance with comparison.
5- Comment on dullness found.

44. Auscultation of the chest
anterior chest wall
1) Stand to the right of the patient
2) Ask the patient to lie supine.
3) Auscultate both midclavicular lines right & left,
from the second space to the sixth space with
comparison.
4) Ask the patient to say ‘ 44 ’ and auscultate both
midclavicular lines right & left, from the second
space to the sixth space with comparison

45. Anterior Auscultation

46. Auscultation of the lateral chest wall
1) Auscultate both midaxillary lines right & left, from the fourth space to
the eighth space with comparison
2) Ask the patient to say ‘ 44 ’ and auscultate both midaxillary lines
right & left, from the fourth space to the eighth space with
comparison
Comment on :
a) Breath sounds (character, intensity)
b) Adventitious sounds (wheeze, crepitations)
c) Type of wheeze if present ( inspiratory or expiratory, localized or
generalized )
d) Type of crepitations if present (fine or coarse, change with cough)
e) Vocal resonance

47. Breathing Patterns

48. Examination of
posterior chest wall

49. Inspection of posterior chest wall
1) Stand behind the patient in a midline position.
2) The patient should be sitting with the posterior
thorax exposed.
3) Inspect the cervical, thoracic and upper lumbar
spine for deformity.
4) Assess for costovertebral tenderness by placing
the ball of one hand in the costovertebral angle
and strike it with the ulnar surface of your fist
5) Inspect for scars.

51. Palpation of posterior chest wall
1) Stand behind the patient in a midline position.
2) The patient should be sitting with the posterior
thorax exposed.
3) Assess extent and symmetry of lower thoracic
expansion by
a) Place your thumbs at the level of the 10th ribs with your
fingers loosely grasping the rib cage and gently slide
them medially.
b) Ask the patient to inhale deeply and observe whether
your thumbs move apart symmetrically.
4) With palms of hands, assess symmetry of
fremitus throughout lung fields.

53. Percussion of the posterior chest wall
1-Stand to the right of the patient.
2-Ask the patient to sit and his hands folded across
the anterior chest wall.
3-Use heavy percussion.
4-Percuss suprascapular area with comparison
5-Percuss both scapulae directly.
6-Percuss both infrascapular areas to the 10th
space comparing right and left sides.
7-Percuss interscapular area on the right and left
sides with comparison
8-Comment on dullness found.

54. Auscultation of the posterior chest wall
1) Stand to the right of the patient.
2) Ask the patient to sit and his hands folded
across the anterior chest wall
3) Auscultate both scapular lines right & left,
from the apex to the tenth space with
comparison.
4) Ask the patient to say ‘44 ’ and auscultate
both scapular lines right & left, from the
apex to the tenth space.

55. Posterior Auscultation

56. 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

57. 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

58. Technique of Auscultation
1
•Patient relaxes and breathes normally with mouth open, auscultate
lungs, apices and middle and lower lung fields posteriorly, laterally
and anteriorly.
•Alternate and compare both sides at each site.
•Listen at least one complete respiratory cycle at each site.
•Listen to quiet respiration. If sounds are inaudible, then ask him take
deep breaths.
•First describe the breath sounds and then the adventitious sounds.

59. Technique of Auscultation
2
•Note intensity of breath sounds and compare with opposite side.
•Assess length of inspiration and expiration.
•Listen for a pause between inspiration, expiration and the quality
of pitch of sound
•compare intensity of breath sounds between upper and lower chest
in upright position.
•Compare intensity of breath sounds from dependent to top lung in
decubitus position.
•Note the presence or absence of adventitious sounds.

60. Normal Breath Sounds
1
The normal breath sounds over lung tissue are vesicular
breathing.
The vesicular breathing is lower pitched and softer than bronchial
breathing.
Expiration is shorter (I > E) and no pause between inspiration and
expiration.
The breath sounds are symmetrical and louder in intensity in bases
compared to apices in erect position and dependent lung areas in
decubitus position.
 No adventitious sounds are heard.

61. Normal Breath Sounds
2

The breath sounds over tracheobronchial tree are bronchial
breathing.
only place where tracheobronchial trees are close to chest wall
without surrounding lung tissue are
 Trachea
 right sternoclavicular joints
 posterior right interscapular space.
These sites where bronchial breathing can be normally heard.
bronchial breath sounds have a higher pitch, louder, inspiration and
expiration are equal and pause between inspiration and expiration.

62. prolonged expiratory phase (E > I)
indicates airway narrowing, as in:
Vesicular breathing with prolonged
expiration
Bronchial asthma.
Chronic bronchitis