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Physical Examination Physical Examination in Respiratory Systemin Respiratory System
Zhao Li, M.D.Zhao Li, M.D.
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Skeletal landmarksSkeletal landmarks
Sternal angle
subscapular angle
Intercostal space
Spinous process
xiphoid
Costalspinal angle
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Anterior imaginary lines and Anterior imaginary lines and landmarkslandmarks
epigastric angle
Infraclavicular fossa
Anterior midline
Suprasternal fossa Supraclavicular fossa
Sternal line
Parasternal line
Midclavicular line
Sternal angle
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Lateral imaginary lines Lateral imaginary lines
Anterior axillary line
Midaxillary line
Posterior axillary line
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Posterior imaginary lines and Posterior imaginary lines and landmarkslandmarks
Scapular line
Posterior midline
Infrascapular region
Interscapular region
Suprascapular region
Scapular region
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Anterior view of lobesAnterior view of lobes
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Posterior view of lobesPosterior view of lobes
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Right lateral view of lobesRight lateral view of lobes
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Left lateral view of lobesLeft lateral view of lobes
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Thoracic deformity Thoracic deformity
Pectus excavatumBarrel chest
Kyphosis
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Inspection(1) Inspection(1)
1. Respiratory movement
Abdominal breathing: male adult
and child
Thoracic breathing: female adult
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Inspection(2)Inspection(2)
2. Respiratory rate: 16-18 f/min
Tachypnea: >20 f/min
Bradypnea: <12 f/min
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Inspection(2)Inspection(2)
Shallow and fast
respiratory muscular paralysis, elevated intr
aabdominal pressure, pneumonia, pleurisy
Deep and fast
Agitation, intension
Deep and slow
Severe metabolic acidosis (Kussmaul’s breat
hing)
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Inspection (3)Inspection (3)
3. Respiratory rhythm Cheyne-Stokes’ breathing Biot’s breathing
_____Decreased excitability of respiratory center Inhibited breathing
Sudden cessation of breathing due to chest pain Pleurisy, thoracic trauma
Sighing breathing Depression, intension
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Palpation Palpation
Thoracic expansion
Massive hydrothorax, pneumonia, pleural
thickening, atelectasis
Vocal fremitus (tactil fremitus)
Pleural friction fremitus
Cellulose exudation in pleura due to pleur
isy
Holding breathing disappeared
Tuberculous pleurisy, uremia, pulmo emb
olism
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PercussionPercussion
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1. Method1. Method
Mediate Pleximeter: distal inter-phalangeal j
oint of left middle finger Plexor: right middle finger tip
Immediate Order
Up to down, anterior to posterior
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2. Affected factors2. Affected factors
Thickness of thoracic wall
Calcification of costal cartilage
Hydrothorax
Containing gas in alveoli
Alveolar tension
Alveolar elasticity
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3. Classification3. Classification
Resonance Normal
Hyperresonance Emphysema
Tympany Cavity , pneumothorax
Dullness Hydrothorax, atelectasis
Flatness Massive Hydrothorax, massive atelectasis
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4. Normal sound4. Normal sound
Lung’s sound in percussion
Resonance
Slight dullness in some areas (upper, right,
back) due to thickness of muscles and
skeletons
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4. Normal sound4. Normal sound
Border of lungs in percussion Apex of lungs
Kronig’s isthmus: 5cm in width Narrow: TB, fibrosis wider: emphysema
Anterior border absolute cardiac dullness area
Lower border 6th, 8th, 10th intercostal space in midclavicular line, midaxillary
line, scapular line, respectively Downward: emphysema Upward: atelectasis, intraabdominal pressure increased
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4. Normal sound4. Normal sound
Shifting range of bottom of lung
Decreased: emphysema, atelactasis, fibrosis, pulmo. edema, pneumonia
Detected impossibly: pleura adhesion, massive hydrothorax, pneumothorax, diaphragmatic paralysis
Shifting range of
bottom of lung
6-8 cm
Along the scapular line
To percuss bottom of lung, marking
To ask the pat. to inspire deeply and hold
To percuss bottom of lung, marking
To ask the pat. to expire deeply and hold
To percuss bottom of lung, marking
To measure the dist. between upper and lower lines
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5. Abnormal sound5. Abnormal sound
Dullness, flatness, hyperresonance or tympa
ny appear in the area of supposed resonanc
e.
Unchanged sound (resonance) The depth of the lesion > 5 cm
The diameter of the lesion 3 cm
Mild hydrothorax
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5. Abnormal sound5. Abnormal sound
Dullness or flatness
Decreased containing gases in alveoli Pneumonia Atelectasis? TB Pulmo. embolism Pulmo. edema Pulmo. fibrosis
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5. Abnormal sound5. Abnormal sound
Dullness or flatness No gases in alveoli
Tumor Pulmo. Hydatid (肺包虫 ) Pneumocystis (肺囊虫 ) Non-liquefied lung abscess
Others Hydrothorax Pleural thickness
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5. Abnormal sound5. Abnormal sound
Hyperresonance Emphysema
Tympany Pneumothorax Large cavity (TB, lung abscess, lung cyst)
Amphorophony (空瓮音 ) Large and shallow cavity with smooth wall Tension pneumothorax
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5. Abnormal sound5. Abnormal sound
Tympanitic dullness (浊鼓音 ) Decreased tension and gases in alveoli
AtelectasisCongestive or resolution stage of pneumonia
Pulmo. edema
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5. Abnormal sound5. Abnormal sound
Special areas on percussion in moderate hydrothorax Damoiseau’s curve
Garland’s triangle area
(tympanitic dullness)
Grocco’s triangle area
(dullness)
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AuscultationAuscultation
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Order of auscultation Order of auscultation
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Sound of auscultationSound of auscultation
1. Normal breath sound
2. Abnormal breath sound
3. Adventitious sound
4. Vocal resonance (语音共振 )
5. Pleural friction rub
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1. Normal breath sound1. Normal breath sound
Tracheal breath sound Bronchial breath sound
Larynx, suprasternal fossa, around 6th, 7th cervical vertebra, 1st, 2nd thoracic vertebra
Bronchovesicular breath sound 1st, 2nd intercostal space be
side of sternum, the level of 3rd, 4th thoracic vertebra in interscaplar area, apex of lung
Vesicular breath sound Most area of lungs
Bronchovesicular
Bronchial
Bronchial
Bronchovesicular
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2. Abnormal breath sound2. Abnormal breath sound
Abnormal vesicular breath sound
Abnormal bronchial breath sound
Abnormal bronchovesicular breath sound
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Abnormal vesicular breath Abnormal vesicular breath soundsound(1)(1)
1) Decreased or disappeared Limited movement of thoracic wall Respiratory muscle weakness Obstruction of airway Compressed atelectasis
Hydrothorax or pneumothorax Abdominal diseases: ascites, large tumor
2) Increased Increased movement of respiration
Exercise, fever, anemia, metabolic acidosis, compensation (single lung)
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Abnormal vesicular breath sound Abnormal vesicular breath sound (2)(2)
3) Prolonged expiration
___ uncompleted obstruction and / or
decreased alveolar elasticity
Bronchitis
Asthma
emphysema
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Abnormal vesicular breath sound Abnormal vesicular breath sound (3)(3)
4) Cogwheel breath sound TB Pneumonia
5) Coarse breath sound
____ not smooth in airway due to swollen or exudation bronchitis Early stage of pneumonia
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Abnormal bronchial breath soundAbnormal bronchial breath sound (tubular breath sound)(tubular breath sound)
Bronchial breath sound appears in the area where vesicular breath sound is supposed to appear because of increased sound transmission or resonance.
Consolidation: lobar pneumonia (consolidati
on stage)
Large cavity: TB, lung abscess
Compressed atelectasis: hydrothorax, pneu
mothorax
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Abnormal bronchovesicular breatAbnormal bronchovesicular breath soundh sound Bronchovesicular breath sound appears in t
he area where vesicular breath sound is supposed to appear. The lesion is relatively smaller, deeper or
mixed with normal lung tissue.bronchopneumonia TBEarly stage of lobar pneumoniaUpper area of hydrothorax
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3. Adventitious sound3. Adventitious sound
moist Crackles
Rhonchi (wheezes)
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Moist crackles Moist crackles
Mechanism
During inspiration, air flow passes thin secre
tion in the airway to rupture the bubbles, or t
o open the collapse of bronchioli due to adh
esion by secretion.
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Characteristics of cracklesCharacteristics of crackles
1. Adventitious sound
2. Intermittent
3. Appeared in phase of inspiration or early expiration
4. Constant in site
5. Unchanged in character
6. Medium and fine crackles exist meantime
7. Less or disappeared after cough sometimes
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Classification of moist crackles(1)Classification of moist crackles(1)
According to intensity of the sound
1. Loud moist crackles
2. Slight moist crackles
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Classification of moist crackles(2)Classification of moist crackles(2)
According to diameter of the airway crackles
appeared
1. Coarse: trachea, main bronchi, or cavity
Bronchiectasis, pulmo. edema, TB, lung
abscess,
coma (wheezy phlegm, 痰鸣 )
2. Medium: bronchi
bronchitis, bronchopneumonia
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Classification of moist crackles(3)Classification of moist crackles(3)
3. Fine: bronchioli Bronchiolitis, Pneumonia, pulmo. congestion,
pulmo. embolism
4. Velcro: Interstitial lung disease
5. Crepitus: Bronchiolitis, alveolitis, early pneumonia (co
ngestion),
elder subject, pat. lying in bed for long time
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Site of cracklesSite of crackles
1. Local: local lesion Pneumonia TB Bronchiectasis
2. Both bases Pulmo. congestion Bronchopneumonia,
3. Full fields Acute pulmo. Edema Severe bronchopneumonia
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Rhonchi (wheezes)Rhonchi (wheezes)
Mechanism
The turbulent flow is formed in trachea, bronchi or bronchioli due to airway narrow or incomplete obstruction.
Causes Congestion Secretion Spasma Tumor Foreign subject Compression (lymph node, mediastinal tumor)
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Characteristics of rhonchi Characteristics of rhonchi
1. Adventitious sound
2. High pitch
3. Dominance in phase of expiration
4. Variable intensity, character, site or spread
5. Wheezing (appeared in main bronchi)
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Classification of rhonchiClassification of rhonchi
1. Sibilant (哨笛音,高调 )
Bonchioli, smaller bronchi
2. Sonorous (鼾音,低调 )
Trachea, main bronchi
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Site of rhonchi Site of rhonchi
1. Both fields Asthma Chronic bronchitis Acute left heart failure (cardiac asthma)
2. Local site Tumor Endobronchial TB
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Vocal resonanceVocal resonance
Increased sound transmission due to changed density of lung tissue
Bronchophony (支气管语音) Consolidation
Pectoriloqny (胸语音 ) Massive consolidation
Egophony (羊语音 ) Upper area of hydrothorax
Whispered (耳语音 ) Consolidation Increased density
of lung tissue:
Consolidation vs Atelectasis
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Pleural friction rubPleural friction rub
1. Cellulose exudation in pleurisy (rough pleura)2. Area of auscultation
inferolateral thoracic wall (maximal shifting area of lung)
3. Friction rub disappeared if holding breath4. Friction rub appeared both breath and heart beat: mediastinal pleurisy5. Causes
Tuberculous pleurisy Pulmo. embolism Uremia Pleural mesothelioma
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Main symptoms and signs in Main symptoms and signs in common respiratory diseasescommon respiratory diseases
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Labor pneumoniaLabor pneumonia
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Symptoms Symptoms
Chill Continued fever: 39-40ºC Chest pain Tachypnea Cough Rusty sputum
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Signs (1)Signs (1)
General signs Acute facial features, blushing (颜面潮红 )
Nares flaring (dyspnea)
Cyanosis
Tachycardia
Simple herpes around lips
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Signs (2)Signs (2)
Congestion stage Decreased movement of respiration in affected
area
Increased vocal fremitus
Dullness
Crepitus
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Signs (3)Signs (3)
Consolidation stage Obviously increased vocal fremitus (resonanc
e) Dullness or flatness Abnormal bronchial breath sound (tubular breat
h sound) Pleural friction rub
Resolution Moist crackles
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Chronic bronchitis with Chronic bronchitis with emphysemaemphysema
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Symptoms Symptoms
Chronic productive cough White mucous sputum or pus sputum (infect
ion) Usually exacerbation in winter Morning cough To last more than 3 months Exertional dyspnea Breathlessness (dyspnea) Chest depress
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Signs Signs
Barrel chest Movement of respiration Vocal fremitus Hyperresonance The lower border of lungs downward Shifting range of bottom of lung Cardiac dullness area Decreased vesicular breath sound Prolonged expiration Moist crackles and/or rhonchi (acute episode)
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Bronchial asthmaBronchial asthma
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Symptom Symptom
Expiratory dyspnea with wheezing
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Signs Signs
Expiratory dyspnea with wheezing Orthopnea Cyanosis Severe sweat Decreased movement of respiration Decreased vocal fremitus Hyperresonance Rhonchi in full fields of lungs
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HydrothoraxHydrothorax(pleural effusion)(pleural effusion)
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Symptoms Symptoms
Dry cough Chest pain
Disappeared with growing of pleural effusion Reappeared with the fluid decreasing
Affected side lying Dyspnea, orthopnea, palpitation The symptoms of underlying disease
300ml: no obvious symptoms
>500ml: breathlessness, chest depress
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Signs Signs (Moderate to massive effusion)(Moderate to massive effusion)
Tachypnea Limited movement of affected side Costal interspaces of affected side are wider Trachea shifts to opposite side Decreased vocal fremitus Dullness or flatness Decreased or disappeared vesicular breath sound Decreased or disappeared vocal resonance Pleural friction rub Abnormal bronchial breath sound in upper area of t
he fluid
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Pneumothorax Pneumothorax
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Symptoms Symptoms
Sudden chest pain Dyspnea Forced sitting position Unaffected side lying Dry cough
Tension pneumothorax Progressive dyspnea Severe sweat Tyckycardia Tension, agitated Cyanosis Respiratory failure
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Signs Signs
Costal interspaces in affected side are wider Limited movement of affected side Decreased or disappeared vocal fremitus Trachea and heart shift to opposite side Tympany Vesicular breath sound decreased or disapp
eared