respiratorysystemhxandphysicalexamination-240122180613-b865ad5e.pptx

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1. Respiratory system History & Physical examination Dr Aklilu M(MD, Internist)

2. Outline Anatomical structures Main symptoms of pulmonary disease Physical examination Reporting

3. Anatomical structures To describe physical signs in the chest accurately, you should understand the topographic landmarks of the chest wall. Sternum Clavicle Suprasternal notch Sternomanubrial angle Midsternal line Midclavicular lines Anterior axillary lines Midaxillary lines Posterior axillary lines Scapular lines Midspinal line

4. Anatomical structures

5. Anatomical structures Locating Findings on the Chest. Describe abnormalities of the chest in two dimensions: along the vertical axis and around the circumference of the chest.

6. The history Breathlessness /dyspnea It is not due simply to hypoxia or hypercapnia , although these may play a significant part. Lung,CVS Dyspnea related only to exertion? Is there variability in the symptom? Orthopnea, platypnea, trepopnea

7. • Positional Dyspnea Type Possible Causes Orthopnea Congestive heart failure Mitral valvular disease Severe asthma (rarely) Emphysema (rarely) Chronic bronchitis (rarely) Neurologic diseases (rarely) Trepopnea Congestive heart failure Platypnea Status post-pneumonectomy Neurologic diseases Cirrhosis (intrapulmonary shunts) Hypovolemia

8. The history… Cough May be dry or productive of sputum. Is sputum produced ? What does it look like? description of its Color consistency. How much is produced? How long has the cough been present? Is the cough worse at any time of day or night? Is the cough aggravated by anything, for example dust, pollen or cold air?

9. Appearance Possible Causes Mucoid/Mucopurulent Asthma, tumors, tuberculosis, emphysema, pneumonia Yellow- green, purulent Bronchiectasis, chronic bronchitis Rust- colored, purulent Pneumococcal pneumonia Red currant jelly Klebsiella pneumoniae infection Foul odor Lung abscess Pink, blood-tinged Streptococcal or staphylococcal pneumonia Gravel Broncholithiasis Pink, frothy Pulmonary edema Profuse, colorless (also known as bronchorrhea) Alveolar cell carcinoma Bloody Pulmonary emboli, bronchiectasis, abscess, tuberculosis, tumor, cardiac causes, bleeding disorders

10. The history… Haemoptysis Blood may be coughed up alone, or sputum may be bloodstained. Is there any blood in the sputum? Is it fresh or altered? How often has it been seen, and for how long? It is sometimes difficult to describe whether or not the blood has originated from the chest or other. always be asked about associated conditions such as epistaxis or melaena.

11. Qs "Do you smoke?" If yes, "How much, and for how long?" "Did the coughing up of blood occur suddenly ?" "Have there been recurrent episodes of coughing up blood?" "Is the sputum blood- tinged, or are there actual clots of blood ?" " How long have you noticed the blood?" "What seems to bring on the coughing up of blood? vomiting? coughing?" "Have you ever had tuberculosis?" "Do you take any 'blood thinners'?" "Are you aware of any bleeding tendency?" "Have you had night sweats? shortness of breath? palpitations? irregular heartbeats? hoarseness? weight loss? swelling or pain in your legs?"

12. Hemoptysis vs hematemesis Characteristics distinguishing hemoptysis from hematemesis Features Hemoptysis Hematemesis Prodrome Coughing Nausea and vomiting Past history Possible history of cardiopulmonary disease Possible history of gastrointestinal disease Appearance Frothy Not frothy Color Bright red Dark red, brown, or "coffee grounds" Manifestation Mixed with pus Mixed with food Associated symptoms Dyspnea Nausea

13. The history… Wheezing Wheezes are musical respiratory sounds that may be audible both to the patient and to others Suggests partial airway obstruction from secretions, tissue inflammation, or a foreign body. Sometimes stridor may be mistaken for wheezing by both patient and doctor

14. Qs "At what age did the wheezing begin?" "How often does it occur?" "Are there any precipitating factors, such as foods, odors, emotions, animals, etc.?" "What usually stops the attack?" "Have the symptoms worsened over the years?" "Are there any associated symptoms?" "Is there a history of nasal polyps?" "What is your smoking history?" "Is there a history of heart disease?"

15. The history… Chest pain If caused by lung disease usually arises from the pleura(infection, pneumothorax, tumor, effusion) Pleuritic pain is sharp and stabbing, and is made worse by deep breathing or coughing. Constant pain, unrelated to breathing

16. The history… Other symptoms /history Ear, nose and throat Smoking history: average consumption for both current and ex- smokers FAMILY HISTORY OCCUPATIONAL HISTORY

17. Physical examination A. General assessment Patient should be resting comfortably on a bed or couch Points to note in a general assessment Physique Voice Breathlessness Clubbing Cyanosis or pallor Intercostal recession – Use of accessory respiratory muscles Examine hands, lips and tongue, Central cyanosis vs peripheral cyanosis alone?

18. Physical examination A. Inspection Appearance of the chest/Deformities Scars, Kyphosis or scoliosis barrel- shaped masses or sinus tracts Impaired respiratory movement on one or both sides or a unilateral lag (or delay) in movement. Abnormal retraction of the interspaces during inspiration.

19. Physical examination B. Palpation Swellings and tenderness Tracheal position position of the mediastinum has been altered by disease of the lungs or pleura. pushed away from the affected side by a pleural effusion or pneumothorax. Fibrosis or collapse of the lung will pull towards the affected side. Chest expansion/Asymmetry Tactile fremitus

20. Physical examination B. Palpation Tactile fremitus Speech creates vibrations provides useful information about the density of the underlying lung tissue and chest cavity asks the patient to say "ninety-nine." Increased – Pneumonia Decreased Unilateral: Pneumothorax, Pleural effusion, Atelectasis, fibrosis(pleural thickening) Bilateral: Chronic obstructive lung disease, Chest wall thickening

21. Physical examination C. Percussion Sound heard and the tactile sensation felt depend on the air- tissue ratio Enable you to evaluate the lung tissue to a depth of only 5 to 6 cm, Evaluate Diaphragmatic Movement Points to note on percussion of the chest Resonance Reduction of resonance Increase in resonance /hyperresonance Dullness: relative dullness and stony dullness

22. Physical examination Percussion Notes and Their Characteristics Relative intensity Relative pitch Relative duration Example of Location Pathologic Examples Flatness Soft High Short Thigh Large pleural effusion Dullness Medium Medium Medium Liver Lobar pneumonia Resonance Loud Low Long Normal lung Simple chronic bronchitis Hyperreso nance Very loud Lower Longer None normally Emphysema, pneumothorax Tympany Loud High* * Gastric air bubble or Large pneumothorax, bowel obstruction

23. The difference between the inspiration and expiration levels represents diaphragmatic motion, which is normally 4 to 5 cm. An abnormally high level suggests pleural effusion, or a high diaphragm as in atelectasis or diaphragmatic paralysis.

24. Physical examination Auscultation Listen to the chest with the diaphragm, not the bell, of the stethoscope Listen in comparable positions to each side alternately. Auscultation involves listening to the sounds generated by breathing, listening for any adventitious (added) sounds, if abnormalities are suspected, listening to the sounds of the patient’s spoken or whispered voice as they are transmitted through the chest wall.

25. Physical examination Auscultation Breath Sounds (Lung Sounds). identify patterns of breath sounds by their intensity, their pitch, and the relative duration of their inspiratory and expiratory phases. Normal breath sounds are:

26. Physical examination Crackles:due to abnormalities of the lungs or of the airways Wheezes suggest narrowed airways Rhonchi suggest secretions in large airways. (pneumonia, fibrosis, CHF, bronchiecta

27. Physical examination D. Auscultation III. Transmitted Sounds. Ask the patient to say “ninety- nine.” Normally the sounds transmitted through the chest wall are muffled and indistinct. – Louder, clearer voice sounds are called bronchophony . Ask the patient to say “ee.” You will normally hear a muffled long E sound. When “ee” is heard as “ay,” an E- to- A change ( egophony ) is present, as in lobar consolidation from pneumonia. Ask the patient to whisper “ninety- nine” or “one-two- three.” The whispered voice is normally heard faintly and indistinctly, if at all. Louder, clearer whispered sounds are called whispered pectoriloquy .

28. Reporting Inspection: no cyanosis, no finger clubbing. Chest moves symmetrically with increased AP diameter, decreased expansion. Palpation: no tenderness, trachea located centrally, tactile fremitus decreased Purcussion: Lungs are hyperresonant , diaphragms descend 2 cm bilaterally. Auscultation: Breath sounds are distant with delayed expiratory phase and scattered expiratory wheezes .; no bronchophony, egophony, or whispered pectoriloquy.