ishraq elshamli respiratory unit tripoli medical center
TRANSCRIPT
Respiratory SystemPhysical Examination
Ishraq ElshamliRespiratory Unit
Tripoli Medical Center
Preparation for Examination
Privacy warm well-lighted quiet room Wash your hands Introduce yourself to the patient Seek permission for the examination and
be polite to the patient ldquoStop me at any time if it becomes
uncomfortable or I cause you any discomfort
Introduction
While seated or standing the patient should be exposed to the waist OR uncovered intermittently
Teach the patient how to breathe deeply and quietly slowly inhaling and exhaling through an open mouth
Physical Examination
Physical ExaminationInitial impression
Stand back to the right hand side of the patient
1 General appearance Thin Pink puffer cachexia Obese blue bloater cushinoid features Cyanosis Features of SVCO
Physical Examination (Initial Impression)
2 SOB Using accessory muscles of respiration Pursed lips Prolonged expiratory phase COPD 3 Count Respiratory rate Normal adult 12 - 20 breathsmin regular
and unlabored Tachypnea is an adult RRgt 24 breathsmin Bradypnea is an adult RRlt 10 breathsmin
Audible cough is it dry productive Is there a sputum pot If so look in it
Wheeze Stridor Hoarseness
Physical Examination (Initial Impression)
Note the intercostals retractions (especially at the base of the neck) and the position of the hands (a position known as tripodding)
Tri-Pod Position In patients with emphysema
Pink Puffer
Blue Bloater
Around the bed
Inhalers Oxygen CPAP machine (Obstructive sleep apnoea) Sputum Pots
Oximeter
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Preparation for Examination
Privacy warm well-lighted quiet room Wash your hands Introduce yourself to the patient Seek permission for the examination and
be polite to the patient ldquoStop me at any time if it becomes
uncomfortable or I cause you any discomfort
Introduction
While seated or standing the patient should be exposed to the waist OR uncovered intermittently
Teach the patient how to breathe deeply and quietly slowly inhaling and exhaling through an open mouth
Physical Examination
Physical ExaminationInitial impression
Stand back to the right hand side of the patient
1 General appearance Thin Pink puffer cachexia Obese blue bloater cushinoid features Cyanosis Features of SVCO
Physical Examination (Initial Impression)
2 SOB Using accessory muscles of respiration Pursed lips Prolonged expiratory phase COPD 3 Count Respiratory rate Normal adult 12 - 20 breathsmin regular
and unlabored Tachypnea is an adult RRgt 24 breathsmin Bradypnea is an adult RRlt 10 breathsmin
Audible cough is it dry productive Is there a sputum pot If so look in it
Wheeze Stridor Hoarseness
Physical Examination (Initial Impression)
Note the intercostals retractions (especially at the base of the neck) and the position of the hands (a position known as tripodding)
Tri-Pod Position In patients with emphysema
Pink Puffer
Blue Bloater
Around the bed
Inhalers Oxygen CPAP machine (Obstructive sleep apnoea) Sputum Pots
Oximeter
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Introduction
While seated or standing the patient should be exposed to the waist OR uncovered intermittently
Teach the patient how to breathe deeply and quietly slowly inhaling and exhaling through an open mouth
Physical Examination
Physical ExaminationInitial impression
Stand back to the right hand side of the patient
1 General appearance Thin Pink puffer cachexia Obese blue bloater cushinoid features Cyanosis Features of SVCO
Physical Examination (Initial Impression)
2 SOB Using accessory muscles of respiration Pursed lips Prolonged expiratory phase COPD 3 Count Respiratory rate Normal adult 12 - 20 breathsmin regular
and unlabored Tachypnea is an adult RRgt 24 breathsmin Bradypnea is an adult RRlt 10 breathsmin
Audible cough is it dry productive Is there a sputum pot If so look in it
Wheeze Stridor Hoarseness
Physical Examination (Initial Impression)
Note the intercostals retractions (especially at the base of the neck) and the position of the hands (a position known as tripodding)
Tri-Pod Position In patients with emphysema
Pink Puffer
Blue Bloater
Around the bed
Inhalers Oxygen CPAP machine (Obstructive sleep apnoea) Sputum Pots
Oximeter
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Physical Examination
Physical ExaminationInitial impression
Stand back to the right hand side of the patient
1 General appearance Thin Pink puffer cachexia Obese blue bloater cushinoid features Cyanosis Features of SVCO
Physical Examination (Initial Impression)
2 SOB Using accessory muscles of respiration Pursed lips Prolonged expiratory phase COPD 3 Count Respiratory rate Normal adult 12 - 20 breathsmin regular
and unlabored Tachypnea is an adult RRgt 24 breathsmin Bradypnea is an adult RRlt 10 breathsmin
Audible cough is it dry productive Is there a sputum pot If so look in it
Wheeze Stridor Hoarseness
Physical Examination (Initial Impression)
Note the intercostals retractions (especially at the base of the neck) and the position of the hands (a position known as tripodding)
Tri-Pod Position In patients with emphysema
Pink Puffer
Blue Bloater
Around the bed
Inhalers Oxygen CPAP machine (Obstructive sleep apnoea) Sputum Pots
Oximeter
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Physical ExaminationInitial impression
Stand back to the right hand side of the patient
1 General appearance Thin Pink puffer cachexia Obese blue bloater cushinoid features Cyanosis Features of SVCO
Physical Examination (Initial Impression)
2 SOB Using accessory muscles of respiration Pursed lips Prolonged expiratory phase COPD 3 Count Respiratory rate Normal adult 12 - 20 breathsmin regular
and unlabored Tachypnea is an adult RRgt 24 breathsmin Bradypnea is an adult RRlt 10 breathsmin
Audible cough is it dry productive Is there a sputum pot If so look in it
Wheeze Stridor Hoarseness
Physical Examination (Initial Impression)
Note the intercostals retractions (especially at the base of the neck) and the position of the hands (a position known as tripodding)
Tri-Pod Position In patients with emphysema
Pink Puffer
Blue Bloater
Around the bed
Inhalers Oxygen CPAP machine (Obstructive sleep apnoea) Sputum Pots
Oximeter
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Physical Examination (Initial Impression)
2 SOB Using accessory muscles of respiration Pursed lips Prolonged expiratory phase COPD 3 Count Respiratory rate Normal adult 12 - 20 breathsmin regular
and unlabored Tachypnea is an adult RRgt 24 breathsmin Bradypnea is an adult RRlt 10 breathsmin
Audible cough is it dry productive Is there a sputum pot If so look in it
Wheeze Stridor Hoarseness
Physical Examination (Initial Impression)
Note the intercostals retractions (especially at the base of the neck) and the position of the hands (a position known as tripodding)
Tri-Pod Position In patients with emphysema
Pink Puffer
Blue Bloater
Around the bed
Inhalers Oxygen CPAP machine (Obstructive sleep apnoea) Sputum Pots
Oximeter
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Audible cough is it dry productive Is there a sputum pot If so look in it
Wheeze Stridor Hoarseness
Physical Examination (Initial Impression)
Note the intercostals retractions (especially at the base of the neck) and the position of the hands (a position known as tripodding)
Tri-Pod Position In patients with emphysema
Pink Puffer
Blue Bloater
Around the bed
Inhalers Oxygen CPAP machine (Obstructive sleep apnoea) Sputum Pots
Oximeter
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Note the intercostals retractions (especially at the base of the neck) and the position of the hands (a position known as tripodding)
Tri-Pod Position In patients with emphysema
Pink Puffer
Blue Bloater
Around the bed
Inhalers Oxygen CPAP machine (Obstructive sleep apnoea) Sputum Pots
Oximeter
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Tri-Pod Position In patients with emphysema
Pink Puffer
Blue Bloater
Around the bed
Inhalers Oxygen CPAP machine (Obstructive sleep apnoea) Sputum Pots
Oximeter
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Pink Puffer
Blue Bloater
Around the bed
Inhalers Oxygen CPAP machine (Obstructive sleep apnoea) Sputum Pots
Oximeter
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Blue Bloater
Around the bed
Inhalers Oxygen CPAP machine (Obstructive sleep apnoea) Sputum Pots
Oximeter
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Around the bed
Inhalers Oxygen CPAP machine (Obstructive sleep apnoea) Sputum Pots
Oximeter
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Oximeter
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Venturi mask Provides controlled Oxygen therapy
24 28 35 60
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Ventolin Inhaler (mdi)Metered dose inhaler
Foradil (Formetrol)Powder inhaler
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Seretide diskhaler
Pulmicort and Oxis turbohaler
Metered dose inhalers(mdi) eg Becloforte (Beclomethasone)
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Hands and Pulse
Perfusion Nicotine staining Peripheral cyanosis Bruising thin skin steroid therapy Clubbing - lung cancer bronchiectasis CF
lung abscessempyema) pulmonary fibrosis mesothelioma (HPOA)
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Examination of the hands
Tremor (fine Β2 agonist) Flapping tremor (CO2 retention) Other conditions eg Yellow Nails RA hands
Scleroderma Wasting of the intrinsic muscles of the hands (cachexia pancoast tumour)
Pulse
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Finger clubbing
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Flapping tremor
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Pulse
Pulse palpate rate rhythm character
Tachycardia eg AF associated with
pulmonary disease
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Face and Neck
Central cyanosis Neck veins Lymphadenopathy Crepitus Neck muscles Indrawing Pursed lips
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Face Hornerrsquos Syndrome (MEAP Myosis
enophthalmos anhydrosis ptosis) Central Cyanosis (4g of Hb has to be
deoxygenated) Acneform eruptions associated with
immunosuppressive therapy Cushingoid appearance with long-term
steroid use
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Acneform eruptions
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Improves ventilation Releases trapped air Keeps the airways open
longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Pursed lip breathing
Relieves shortness of breath
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
The Neck
Position of the trachea Lymph node enlargement (tuberculosis
lymphoma malignancy sarcoidosis) Scars (phrenic nerve crush for old TB) Tracheostomy scar1048774previous ventilation in
COPD etc Central line scars Scar from LN biopsy JVP - right sided heart failure (cor
pulmonale as a result of chronic lung disease)
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Tracheostomy Scar
Thyroidectomy Scar
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Chest Traditional Sequence
1 Inspection
2 Palpation
3 Percussion
4 Auscultation
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Remember
Always describe the chest in terms of anterior and posterior
Describe the lungs as zones not lobes ie Upper middle lower zones
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Posterior View
Anterior View
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Right Lateral View
Left Lateral View
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
InspectionInspection is performed to1 Scars pneumonectomy lobectomy Chest drains thoracocentesis Radiation tattoorsquos (previous radiotherapy) 2 Shape or Chest wall deformity ndash pectus
excavatum carinatum(pigeon chested) Barrel chest (Hyper-inflated) Kyphosis Scoliosis
3 Resp rate depthamp Mode of breathing
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Inspection
3 Movements Equal symmetry or reduced on one side Respiratory effort intercostal indrawing or
use of accessory muscle
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Kyphosis Causes the patient to bend forward X-Ray shows curvature of the spine
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Pectus excavatum Congenital posterior displacement of lower sternum The x-ray shows a concave appearance of the lower sternum
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Barrel chest In chronic lung hyperinflation (egAsthma COAD)Due to increased AP diameter of the chest
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Scoliosis Is an increased lateral curvature of the spine (ie Like the shape of the Letter ldquoSrdquo)
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Intercostal retraction
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
ANTERIOR EXAMPalpation
1 Trachea palpate for tracheal position midline or deviated Rt or Lt
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Position of the Trachea
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
A Apex Beat
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Chest expansion
Place your palms on the patientrsquos chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath observe for bilateral expansion
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Tactile Vocal fremitus
Place the ulnar side of your hand on the patientrsquos chest
Instruct the patient to say ldquo44rdquo each time they feel your hand on their back
Comment on the tvf increased or decreased
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Percussion
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Percussion technique
Place left hand on chest wall palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Percussionbull Technique bull Compare like with like
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Percussion Do not forget the apices of the lungs
Compare both sides1 Impaired(dull)resonance obtained ndashLung tissue is airless eg consolidation collapse fibrosis
2 Hyper resonant = pneumothorax COPD
3 Stony Dull = Pleural effusion
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Percussion
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Auscultation
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open Systematic approach over several areas
comparing both sides listen to one complete respiration Repeat asking patient to say ldquo999rdquo for vocal
resonance Whispering pectoriloquy
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Auscultation
The auscultatory assessment includes (1) breath sounds audible or not (2) Character of breath sounds(3) Abnormal sounds or added sounds (4) Examination of the sounds produced by the
spoken voice Use a zigzag approach comparing the finding at Each point with the corresponding point on the Opposite hemithorax
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
inspiration expiration
inspiration expiration
expirationinspiration
Vesicular ndash Normal Or Diminished localised or diffuse
Bronchial Breathing
Vesicular with prolonged expiration
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration amp
fades during first 13rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Diminished breath sounds
Conduction limited by Airflow limitation eg diffusely ndash asthma emphysema localised ndash tumour collapse
Something separating chest wall from lung eg effusion fibrosis
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Bronchial breathing
ldquoblowingrdquo inspiratory amp expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched eg consolidation
Low-pitched eg fibrosis
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Rhonchi
Due to passage of air through narrowed bronchus eg bronchospasm mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Crepitations
Inspiratory noises usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Pleural Rub
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Vocal sounds
Vocal resonance
Increased when voice sounds are louder and
more distinct eg consolidation
Reduced when transmission impeded eg
effusion collapse
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Whisper pectoriloquy With your stethoscope the over area of
possible pathology have the patient whisper
the phrase lsquoone-two-threersquo Listen to hear if
the sound is distorted
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Egophony With your stethoscope over the area of
possible pathology have the patient vocalize
the vowel lsquoEEEErsquoListen for the sound to be
distorted into the sound lsquoAHHHrsquo
Confirm that a similar change is absent
over the identical location on the
contralateral chest
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
I would like to complete my examination by
1 Reviewing the temperature and blood
pressure
2 Examine for features of cor pulmonale
(Inspect the JVP look for peripheral
oedema other signs of right heart failure)
3 Check the patientrsquos peak flow and forced
expiratory time
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Forced expiratory time
Instruct the patient to
take in as deep breath in as deep as you can and
then hold it Then breathe out as forcefully and
as quickly as possible
Or
blow as hard as you can until all the air has
emptied from your lungs
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
If you canrsquot empty your lungs in 6 seconds this suggests a degree of obstruction ie COPD
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Finishing off the examination
At this stage say to the patient
ldquoThank-you you may sit back nowrdquo
And to cover them up with the blanket
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Interpretation of findings
Breath sounds locally reduced or absent over pleural
effusion thickened pleura collapsed area
Breath sounds diffusely reduced in emphysema asthma
Rhonchi heard in asthma COPD
Crepitations may be widespread in COPD LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
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
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
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
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Pleural effusion
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
pneumothorax
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
A candidate was asked to examine the respiratory system
EXAMPLE
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Examiner observations
1 A reasonable method2 She did commence examination of the
chest from the posterior aspect3 The findings The patient was breathless at rest Was using oxygen via nasal prongs There were no peripheral signs The chest was normal apart from bilateral
basal crepitations
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
What is your Diagnosis
Fibrosing alveolitis
What are other causes of bilateral basal
crepitations
1 Heart failure
2 Brocnhiectasis
3 Atypical pneumonia
JVP
sputum pots or inhalers
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Patient re-examined
General Examination The patient was propped up in bed
suggesting dyspnoea The face was flushed flaring of the alae nasi OE No clubbing but the peripheries were
warm with high volume pulse not collapsing neck we noted a raised JVP almost to the ear
lobe with no predominant waveform
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
On examination of the chest
Barrel shaped There was little movement of the chest wall
with respiration being predominantly abdominal
Respiratory rate was 26 per minute The apex beat was difficult to palpate Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular There were a few crepitations at both bases
but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
Diagnosis
COPD Respiratory failure
Cor pulmonale
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
This case demonstrate
A methodical examination
Evaluation of the findings at each step
Makes diagnosis much easier
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-
THANK YOU
- Respiratory System Physical Examination
- Preparation for Examination
- Introduction
- Physical Examination
- Physical Examination Initial impression
- Physical Examination (Initial Impression)
- Physical Examination (Initial Impression) (2)
- Note the intercostals retractions (especially at the base of th
- Slide 9
- Slide 10
- Slide 11
- Around the bed
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Hands and Pulse
- Examination of the hands
- Slide 20
- Slide 21
- Slide 22
- Finger clubbing
- Slide 24
- Flapping tremor
- Pulse
- Face and Neck
- Face
- Slide 29
- Acneform eruptions
- Slide 31
- Slide 32
- Slide 33
- The Neck
- Slide 35
- Tracheostomy Scar
- Slide 37
- Chest Traditional Sequence
- Remember
- Slide 40
- Slide 41
- Inspection
- Inspection (2)
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Intercostal retraction
- ANTERIOR EXAM Palpation
- Position of the Trachea
- A Apex Beat
- Chest expansion
- Slide 55
- Slide 56
- Slide 57
- Tactile Vocal fremitus
- Slide 59
- Slide 60
- Percussion
- Percussion technique
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Percussion (2)
- Percussion (3)
- Slide 70
- Auscultation
- Auscultation technique
- Auscultation (2)
- Auscultation (3)
- Slide 75
- Vesicular breath sounds
- Diminished breath sounds
- Bronchial breathing
- Added sounds
- Rhonchi
- Crepitations
- Pleural Rub
- Vocal sounds
- Information from auscultation
- Whisper pectoriloquy
- Egophony
- I would like to complete my examination by
- Forced expiratory time
- Slide 89
- Finishing off the examination
- Interpretation of findings
- Interpretation of findings (2)
- Interpretation of findings (3)
- Slide 94
- Slide 95
- Slide 96
- A candidate was asked to examine the respiratory system
- Examiner observations
- What is your Diagnosis
- Patient re-examined
- On examination of the chest
- Slide 102
- Diagnosis
- This case demonstrate
- THANK YOU
-