Respiratory Exam History

Recent Previous weight loss, general malaise, lethargy Onset gradual/quick/traumatic, any associated fever or malaise TB reactivation Pneumonia/Pleurisy fr bronchiectasis hest in!uries/surgery abscess, "neumonia #llergy T disorders/R# fibrosis, effusion etc $c%ema/ hayfever asthma &' disorders res" fail Recent travel/immobility Pulmonary Thrombo embolism (evere measles/whoo"ing cough can be recogni%ed cause of current bronchiectasis )es"ecially if com"licated by "neumonia* TB, ancer, allergic disorders )Bronchial asthma*, hronic Bronchitis igarette smoking, drugs, e-"osure to allergies )e.g "ollen* /ork )even long time ago*, e-"osure dust, fumes, to-ins, asbestos, coal, silica, "igeons nasal dri", catarrh, sinus infect, "ersistent cough, obstruct, rhinitis, e"ista-is )nose bleed* 4aryngitis )sore*, Tumour, /hoo"ing cough grou", harsh, barking, "ainful, 4aryn"ersist, stridor, hoarse voice Tracheitis, "ainful,dry cough0non "roductive, (tridor, 5ys"noea, Trachea Bronchitis, OP5, bronchial # )bovine cough 6 hoarseness1 4 recurrent Bronchi laryngeal nerve*, "neumonia, bronchiectasis, "ulmonary oedema, interstitial fibrosis, dry, "roductive )s"utum*, any blood, daily "attern heck onset, frequency, duration, colour Bright/red nearer throat surface 5ark older from dee"er down/lungs #, trauma, infection, "ulm infarct

hildhood +amily ,abits Occu"ation

Symptoms ough 0acute1 2 weeks 0chronic1 3 weeks

Pharyn-

,aemo"tysis

("utum

#mount haracter

&ot v hel"ful as some is swallowed (erous )clear, watery,"ink* "ulmonary oedema.

+rothy/"ink over weeks alveolar cell # 'ucoid )7rey, white, black* OP5, chronic bronchitis, chronic asthma Purulent )yellow/green/brown* various bacterial infection, "neumonia, abscess, bronchiectasis

8iscosity

4ow serous ,igh mucoid/"urulent early stages asthma/"neumococcal "neumonia

Taste/odour hest "ain entral

&on0central

+oul smell/taste lung abscess, bronchiectasis, anaerobic infection )dee" in lungs* Res" ancer )dull, "oorly locali%ed*, trachea 8 '9, Pulm thromboembolism, aortic dissection 79T oeso"hagitis )"ain related to swallowing* '(:0 Triet% syndrome, sternum ; Pleuritic (har",stabbing, unilateral. #gg by dee" breath in/cough. '(:0 rib ; )(evere, shar" "ain *, costovertebral !oint, muscles related to s"ine or rib movement &erve0 (hingles ,er"es %oster )nerve root distribution 6 trigeminal nerve*

5ys"noea

On e-ertion &o e-ertion

Obstruction to airflow1 Trigger asthma )as cold weather, allergy etc*, em"hysema, chronic bronchitis
Ortho"noea )breathless su"ine due to hy"o-ia, so slee" sitting "ulm oedema/heart failure* ,y"erventilation dys"noea, tired )inefficient breathing, muscle use*, di%%y, "araesthesia )mouth/<$=*, fatigue, chest "ain #naemia0 Reduced carrying ca"acity of the blood /ith cough OP5, #sthma /ith central chest "ain '9, "ulmonary embolism/infarct /ith "leuritic chest "ain Pneumonia, "neumothora-, "ulmonary embolism /ith no chest "ain Pulmonary embolism, "neumothora-, metabolic acidosis, hy"ovolaemia/shock, acute 4 vent fail/"ulmonary oedema 'inutes Pulmonary embolism, "neumothora5ays Pneumonia, #sthma, "ulmonary oedema 'onths #naemia, Pleural effusion >ears OP5, Pulmonary fibrosis/tuberculosis On e-ercise asthma, )6 night wakening*, OP5 )6 after waking in morning* Partial occlusion of a large airway by tumour or foreign body

#ssociated sym"toms

Onset

(ounds

/hee%e )on out breath* (tridor )on in breath*1croaking ins"iratory noise, often agg by coughing ,issing Rhonchus

):ussmauls0air hunger* from ketoacidosis from uncontrolled ty"e ? 5iabetes oarse rattling/snoring, secretion in bronchial tube. Poss "al"able

Observation 7eneral ,ands

5emeanour, "osture, com"le-ion, s"eech, hoarseness, :y"hoscoliosis, Pectus e-cavatum/carinatum, @"ink "uffersA/Ablue bloatersA0 OP5 5u"utrens contracture 4iver, alcohol, diabetes, smoking #steri-is 8ent failure, OB retention )vasodilator, =( inhaler use*, #sthma, 4iver/kidney )+la""ing tremor of wrists* fail, /ilsonAs 5 )congenital loss of co""er metab u in body*

Blue )cyanosis* Tremor Parasthesia

&ails

>ellow/green lubbing

Test PT squee%e around your two fingers for 2C0DC sec or, arms abd EC dorsi fle-arms down B02 sec "eriods Peri"heral 8 "roblem, OB or ischemia, arterial blockage, local/general ,y"erthyroidism or commonly e-cess bronchodilator drugs #"ical/Pancost/lung carcinoma could com"ress lower brachial/(&( "le-us ),ornerAs* 4ym"hodema, e-udative "leural effusion +luctuation of1 F nail/bed angle, G nail curvature, G (T bulk ,eart (ubacute bact endocarditis, yanotic congenital heart disease 4ung Bronchial carcinoma, +ibrosing alveolitis, se"sis )bronchiectasis* 79 irrhosis, <lcerative colitis, rohnAs disease

+ace $yes

olour Ptosis on!unctiva

9dio"athic Pallor F O-ygenated ,b in skin Blue F OB in blood, yanosis 'alar flush Rosy cheeks
& 8 or Partial0,ornerAs (&( Hstellate ganglionI disturbance "artial "tosis,/meiosis)constricted "u"il*/ anhydrosis/ eno"thalmus )sunken eyeball* Possible a"ical carcinoma Pale #nemia Blue cyanosis

'outh &eck

Breathing "atterns
(ound

normal/"anting "ursed li"s em"hysema

5ifficulty in breathing eg whee%e, stridor, stertorus )ras"ing*

J8P1 raised, non0"ulsatile, abdomino0!ugular refle- is absent, "t has to be sitting u"right for it to be seen 4ym"h nodes

9tKs raised in R sided heart failure. OP5L"ulmonary hy"ertensionLR heart failureL raised J8P )cor "ulmonary*//increased intrathoracic "ressure1 "neumothora- and asthma//P$//obstruction (8 )cancer* $s"ecially ervical, #-illary, (u"ra clavicular
4arge/soft 9nfection (hotty Remains of old infection +irm/rubbery/irregular 'alignancy (ymmetry, scars etc. Barrel chest )#P6hy"erinflation*, :y"hoscoliosis, Pectoralis carinatum )1locali%ed "rominence of the sternum/asym"tomatic/"igeon chest/severe and "oorly controlled childhood asthma or Osteomalacia/rickets* Pectoralis e-cavatum )de"ression of the sternum/funnel chest/dis"lacement of the heart to the heart/reduced ventilator ca"acity* #symetrical "neumothara-, consolidation, effusion, unilateral fibrosis (ymmetrical #sthma, em"hysema, diffuse fibrosis (u"ine "arado-ical breathing )inward movement in ins"iration* severe OP5,

Thora-

(ha"e

RO'

Oedema

Peri"heral +ace/neck

dia"hragm "aralysis 4ocal "arado-ical breathing double ; of a series of ribs or the sternum R ventricular failure )from "ulmonary hy"ertension/cor "ulmonary* /ith distended veins )!ugular/su"erficial chest wall* (8 obstruction. )cancer* Possibly with hemosis )con!unctival oedema* and "itting oedema of forearms/hands

Auscultation
Bell of stethosco"e )most breath sounds are low frequency, dia"hragm can catch hair noise*. PT breathe through mouth. over all lobes side/side, front/back. &ot too close to midline. &ote character, breath sound vol, added sounds, )changed voice sounds*. 8olume of ins"irationLe-"iration Bronchial )central* +rom larger airways you can hear ins"iration/e-"iration se"arately &ormal sounds 8esicular )"eri"heral* Over smaller airways. blurred and rustling. 9n/e-"iration together 8esicular Pleural effusion, airway obstruction 5iminished sounds 7eneral Bronchial asthma 4ocal tumour reaking from inflamed "leura #dded sounds Pleural rub @'usicalA sound from narrow airway /hee%es $-"losive, clicking from sudden o"ening of small airway. crackles #cute 4 heart fail Pulm ven Pa ,BO in alveoli Pulm oedema breathlessness, cough, frothy "ink s"utum 6 cre"itation at bases of lungs

Percussion
$very lobe, side to side. +ingers s"read, ta" middle "halan- of middle finger. #nt chest wall, infraclavicular region, B0D 9 (, lat wall, su" s"ine of sca"ula rib ?? Resonance air filled )normal* 5ull liver )R rib M at mid clavicular line cost margin* ,y"er resonant $m"hysema, "neumothora-, inflation below R rib M OP5, severe asthma )hy"erinflation* 5ull 6 vibration airless, consolidation, "ulmonary colla"se, severe fibrosis 5ull/AstonyA large "leural effusion, ,aemothora&B Basal dullness from elevated dia"hragm is easily confused with "leural fluid. <""er lobe mainly at front, lower lobe mainly at back Oblique fissure ("B rib D ,ori%ontal fissure )R only* Rib N mid a-illary line 4ungs T?C Pleura T?B #"e- above clavicle

Palpation (urface markings

2 lobes on R B lobes on 4

Thora-

Tracheal deviation )6heart beat dis"lacement1indicative

Pulling towards colla"sed lung, local fibrosis Pushing away from tumor, effusion, "neumothora-

of1shift of the lower mediastinum//heart beat1 ventricular enlargement, ky"hosis, scoliosis* Rib cage
B hands on low chest thumbs by midline

heck for movements, symmetry, de"th, any vibration $-"ansion normally M cm in ins"iration Rate should be a""ro- ?N/min Reduced e-"ansion in one side1 "leural effusion, lung/lobar colla"se, "neumothora-, unilateral fibrosis Reduced e-"ansion in both sides1 OP5, diffuse "ulmonary fibrosis Parado-ical inward mvmt of the abdomen1dia"hragmatic "aralysis, severe OP5

9ntercostals muscles Tenderness 8ocal fremitus )8ibration felt when

s"eaking*

Pain on "al"ation
+eel all lobes with ulnar borders. R/4, #/P, a-illa

&ormally suck inwards in inhalation Rib tenderness over fracture or areas of "ulmonary infarction

transmission consolidation transmission effusion, air )eg em"hysema* &B both dull on "ercussion

Additional tests
Pleuritic hest "ain #cute breathlessness ,aemo"tysis #lso check1 fever, confusion, res" rate )"neumonia*, vasculitic skin s"ots )"ulm vasculitis*, J8P )massive "ulm embolism*, 4$= for 58T )"ulm embolism* #lso check1 res" rate/min, weight loss, anaemia, "ulse ) ardiac 5, hy"o-ia*, J8P ) fail, or "ulmonale*, massive PT$, 4$= for "itting oedema bilateral )cor "ulm, heart fail*, unilateral)58T* #lso check1 /eight loss, anaemia, iron def, bruising, clubbing ) #, bronchiectasis*, 4ym"h nodes )es" scalenes* for lym"hadeno"thy )lym"homa, lung #*, scars from "revious resection )removal*

#sthama

5ef1 hronic common inflammatory condition of the bronchial wall. Patho"hysiology1 9ncrease in mucus secreting glands, increase in goblet cells in the bronchi, reduction in the number of cilia )and thus a reduced ability to remove mucus in the airways without coughing*, constriction and hy"ertro"hy of the bronchial smooth muscle, oedema6mucus lead to airway narrowing )reversible*. 9t increases the resistance to airflow. #lveolar e-change of gases is reduced, resulting in a build u" of OB and an OB deficit leading to an-iety. Pt begins to gas". (ym"toms1 #sthma may be e"isodic or chronic. $"isodes of chest tightness, whee%e, dys"noea on e-ertion, cough and whee%e at night. The "atient may develo" heavy mucoid cough with a res"iratory infection, similar to chronic bronchitis. (igns1 +orced e-"iratory volume )+$8?* and "eak e-"iratory flow )P$+* will be reduced during an attack, but characteristically these will im"rove after the use of a bronchodilator. ause1 a) #llergic/ato"ic. Often referred to as early onset asthma since it is usually seen in children. They will have "ositive reactions to skin testing. ommon triggers are "ollen, house dust mite, feathers, fungal s"ores etc. Occasionally certain foods have been im"licated

#cute bronchitis

hronic bronchitis

$m"hysema

b* 4ate onset or non0ato"ic, or intrinsic This is more usually triggered by cold air, tobacco smoke, dust, acid fumes, res"iratory infections and stress 'edical treatment1 a* Bronchodilators )B agonists*1 salbutamol, terbutaline, fenoterol b* 9nhaled steroids1 Beclometasone, budesonide, fluticasone 'anual ttt1 $ncourage e-"iration, accessory muscles, dia"hragm, #&(, inhale steam, breathing retraining 5ef1 Bacterial infection of the bronchial tree that is usually caused by viruses or bacteria and may last several days or weeks. (igns and sym"toms1 9nflammation of the mucous membrane during the infection, but when infection resolves inflammation of the mucous membrane returns to normal )with or without the aid of antibiotics*. ough 6 "urulent s"utum )yellow/green* 5ys"noea Ttt1 #ntibiotics for the infection, steam inhalation for the congestion, breathing e--, fresh air Osteo"athic ttt1 Tightness of res". muscles, rib ts" dysfunction. hest "ercussion for mucous. 5ef1 a chronic inflammation of the bronchi. 9t is generally considered one of the two forms of chronic obstructive "ulmonary disease ) OP5*, the other being em"hysema. 9t is defined clinically as a "ersistent cough that "roduces s"utum, for at least 2 months "er year in B consecutive years. Patho"hysiology1 9ncrease in mucus secreting glands 9ncrease in globet cells in the bronchi and bronchioles Reduction in the number of cilia, and thus reduced ability to remove mucus in the airway without coughing Oedema and mucus chronic airway narrowing occurs that is irreversible 9f air becomes tra""ed in the alveoli, this lead to gradual over0distension and em"hysema P.+1 (moker (igns and sym"toms1 Productive cough indicating infection. 7radual increase in severity, "rogressing to all year round cough /hee%e, dys"noea, chest tightness in the morning The day will almost always start with a good cough, which hel"s to clear the initial sym"toms. ("utum is often heavy mucous, slight streak of blood. Purulent indicative of infection. om"lications1 changes in cough can be indicative of carcinoma Test1 =0Ray relative normal TTT1 'ucolitics and s"ectorants 5ef1 5ilatation of the airs"aces distal to the terminal bronchioles. Over inflation of the alveoli. Patho"hysiology1 Ty"e1 4obular or alveolar. 9t usually affects to an res"iratory tree rather than a localised alveoli 5ef1 4ate stage lung disease resulting from the combination of em"hysema and chronic bronchitis Ty"es1 Blue bloater )cough, s"utum, infection, cyanosis )low o-ygenOcarbon dio-ide*, right heart failure, "eri"heral oedema*0choronic bronchitis /Pink "uffer )dys"noea*0em"hysema1 no cardiac failure/no cyanosis/no cough.

OP5

#lthough the lung is damaged, by increasing the res"iratory rate they can maintain adequate o-ygen levels in the blood and hence retain their "ink colour. Both these states involve quite late stage res"iratory dysfunction due to structural damage and thus all treatment is su""ortive. 5ef1 9nfection "redominantly affecting the lung tissue and the alveoli. 9t more commonly occurs as a secuelae of u""er res"iratory tract infection that then s"reads to the lower res"iratory tract. #s"iration of food or fluid. 9ncidence1 vulnerable "atients )the young and old and immuno0com"romised* (igns and sym"toms1 feeling markedly unwell, it can be life threatening Ttt1 ,os"italisation om"lications1 (carring leading to bronchiectasis and lung fibrosis 5ef1 Bronchial distension secondary to bronchial infection )"neumonia, TB* Patho"hysiology1 The distension may develo" because of an obstruction due to residual scarring and narrowing of the bronchus. The wall of the bronchus beyond/distal the obstruction then becomes vulnerable to re"eated infections which lead to scarring and weakening of the wall, and hence the dilatation (igns and sym"toms1 o"ious and "ersistent "urulent s"utum, malodorous breath due to "ersistent infection Test1 =0Ray no visible, BRO& ,O( OP> 5ef1 breathing in e-cess of metabolic requirements

Pneumonia

Bronchiectasis

,y"erventilati on

P.+1 #n-iety, fear, "anic Patho"hysiology1 "atient breathe too ra"idly O-ygen increases but carbon dio-ide reduces The blood becomes more alkaline because there is less carbonic acid haemoglobin binds o-ygen more strongly and therefore does not release it when it reaches target tissues )nervous tissue, '(: system* Because of alkalosis the body attem"ts to "roduce more acid in the form of lactic acid. This then causes muscle aching, cram"s (igns1 ventilation rate is too high LBM, accessory muscle use, u""er rib breather (ym"toms1

Res"iratory

Breathlessness at rest for no a""arent reason +requent dee" sighs or yawning hest wall tightness inability to breath dee"ly +ast breathing hest wall "ains Pal"itations old hands and feet

8(

&eurologica 4ight0headedness and feeling s"aced out/di%%iness l Tingling or numbness in li"s or e-tremities/finger0ti"s ,eadaches Blurred vision onfusion, lost touch with environment 79 5ry throat, heartburn, regurgitation, Tight around mouth 9B( Bloating from air swallowing #chy muscles /!oints or even tremors (tiffness in fingers and arms )due to build u" of lactic acid* +eeling tense, tiredness, weakness, broken slee", nightmares lammy hands and high anxiety level

'uscular Psychologic al

Pleurisy

Pleural effusion 4ung cancer1 BRO& ,9#4 #R 9&O' #

Pulmonary embolism

5ef1 Pain arising from any disease of the "leura Patho"hysiology1 5ry "leural irritation without effusion (igns and sym"toms1 shar", stabbing, unilateral "ain. Reduced breath sounds in the affected side and "leural rub. (econdary of "ulmonary infection 5ef1 $-cessive accumulation of fluid in the "leural s"ace (igns and sym"toms1 Pleurisy sym"toms, dys"noea )reduced si%e of the affected lung* Billateral1 Pneumonia, R#,(4$,TB, "ulmonary carcinoma, "ulmonary infarction 5ef1 ommon site for metastatic disease )breast, kidney, uterus, ovaries, testes, thyroid* and secondaries Prevalence1 MCP of male deaths from cancer are from lung cancer, age1 MC0QM. NCtimes more frequent among cigarette smokers Patho"hysiology1 narrowing of the bronchus, reducing airflow to the lung. &o "ain unless it reaches the chestwall (ym"toms1 ough )dry or with s"utum,changes in quality or relative new, lasting more than 2 weeks*, dys"noea )obstruction, colla"se, "neumonia/infection due to obstruction*, weight loss, chest "ain )"leurisy, s"read to the chest wall*, haemo"tysis )breakdown of the tissue in the centre of the bronchial tumour* Pleuratic s"read direct or by lym"hatic s"read affecting intercostals nerves, brachial "le-us ) 30T?* 'ediastinal s"read affecting "hrenic nerve )dia"hragmatic "aralysis* and recurrent laryngeal nerve )vocal chord0 usually unilateral* 'etastasic s"read )liver, brain1 changes in mental or emotional behaviour, bone "ain)"ain during the night, unrelated to mvmt or "osition** Test1 =0Ray 5ef1 A pulmonary embolism is a blood clot in the pulmonary artery, which is the blood vessel that transports blood from the heart to the lun s! "his meanly develops as a result of a thrombus brea#in off from a peripheral vein or less commonly the R heart $R atrial fibrillation and valvular heart disease* 58T causes1 slow blood flow, blood vessel damage, blood that clots too easily om"lications1 Severe% &eath Patho"hysiology1 bloc#a e of the pulmonary artery leads to infarction of the lun tissue supplied by the pulmonary vessel! (igns and sym"toms1 &i''iness or li ht(headed, tachycardia, central cyanosis, pyrexia, secondary infection, pleural pain $pain in breathin in, stabbin , shrap), cou h with haemoptysis

Ttt1 Anticoa ulant therapy $warfarin ) Heparin) Test1 &oppler ultrasound, *+R $*nternational +ormalised Ratio) to monitor warfarin ttt, to "rovide the benefits of anticoagulation, while avoiding the risks of haemorrhage. C.30?.B in normal individuals/ B02 with "t taking warfarin

(arcoidosis

Pneumothora-

5ef1 ,un sarcoidosis is the result of multisystem ranuloma! "his usually resolves spontaneously in a year! -ost commonly affects mediastinum.sup lymph nodes, spleen, s#in $erythema nodosum), eyes, parotid, arthral ya $phalan es, phalan eal cysts) Ttt1 Steroids om"lication1 /ibrosis 5ef1 is an abnormal collection of air or gas in the "leural s"ace Ty"es1 0Primary1 &#R. Tiny tear of an outer "art of the lung 0 usually near the to" of the lung. 9t is often not clear why this occurs. 0(econdary1 as a com"lication of an e-isting lung disease. This is more likely to occur if the lung disease weakens the edge of the lung in some way. 0 "raumatic in0ury to the chest wall om"lications1 Primary1 The small tear that caused the leak usually heals within a few days, es"ecially in cases of "rimary s"ontaneous "neumothora-. 1losed once air has entered the "leural s"ace the hole closes u". #ir is reabsorbed and the lung gradually inflates. (ym"toms of breathlessness )which is rarely severe* tend to subside over a few days. (econdary1 Open 0hole stays o"en, the lung remains small and em"ysema commonly develo"s )"us in "leural s"ace from infection*. Breathlessness does not tend to im"rove and sym"toms of underlying cause then develo"

Tension "neumothora- )rare com"lication*1 air enters through a small hole, and the damage around the hole means that air can enter the "leural s"ace but can e-it, acting as a one0way valve. Thus air enters the s"ace but can not esca"e, leading to a large volume of air entering. &ot only does the lung colla"se on the affected side, but also the mediastinum is then "ushed to the o""osite side, com"ressing the o""osite lung. This can to lead to severe res"iratory distress and occasional even death. Test1 =0Ray

*nvesti ation% 0P# =0Ray )frontal "lane*1 #, tuberculosis 0("utum e-amination 0#rterial blood gas analysis1 #rterial o-ygen saturation 0 ("irometry1 OP5, asthma 0Peak e-"irometry flow 0Pleural as"iration1 effusions 0Pleural bio"sy1 #, tuberculosis