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Physical Examination
Initial Survey
Inspection
Palpation
Percussion
Auscultation
I. INTRODUCTION
A. Review of Respiratory Anatomy
Conducting System
Made out of tubes
Nasal cavity and pharynx (upper airways) larynx
trachea main bronchi distal bronchioles (lower
airways)
Bulk of respiratory system
Disturbance would result in a physical complaint
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Gas Exchange
Primary function of the respiratory system
Exchange of oxygen (O2) and carbon dioxide (CO2)
between the alveoli and pulmonary circulation
Anything that disrupts this function leads to pulmonary
symptoms
Breathing
Largely an automatic act controlled in the brainstem
and mediated by the muscles of respiration
o In a spinal cord injury there may be a problem in
breathing even though anatomy of respiratory
system is normal
Dome-shaped diaphragm is the primary muscle of
respiration
Inspiration is an active process while expiration is a
passive process
o During inspiration, as these muscles contract, the
thorax expands intrathoracic pressure decreases
draws air into the tracheobronchial tree into the
alveoli lungs expand gas exchange takes
place in the alveoli
o
o During inspiration, air enters the upper airway,
travels through the lower airways until it reaches
the alveoli
After inspiratory effort stops, the expiratory phase
begins
o The chest wall and the lungs recoil
o The diaphragm relaxes and rises passively, air
flows outward and the chest and abdomen return
to their resting positions
Any disruption at the level of C3-C4 / (C5) of the spinal
cord leads to disruption of pulmonary function
(remember: C345 keeps the diaphragm alive!)
II. HISTORY TAKING
Systematic investigation surrounding patients chief
complaint (backbone of how you will ask
subsequent questions)
Main task: to land on a valid diagnosis
Basically asking a series of questions in a logical order
so as to pay more attention to the relevant/pertinent
findings
o Relevance of given data is determined based on
experience
o Need to probe deeper with follow-up questions to
clarify the validity of information obtained
Classify uncovered data to pertinent positives and
negatives, and relate all retrieved data to chief
complaint
A good history and PE clinches the diagnosis in 80-90%
of cases (so added labs and maneuvers will only add
10-20%)
Past
medical
history,
family
history,
personal/social history, occupational history
Always ask WHAT, WHEN, HOW in the history of
present illness
Aims of History Taking
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Anong nagpapalala?
e.g. asthma (usually patient is aware of the trigger) in
the Philippines, house dust mite (cleaning the house)
remains the #1 trigger of asthma; change of weather
can also trigger
o Relieving factors
o Phlegm
o Fever
Coughing Sounds
Etiology cannot be determined by the sound of the
cough
o Although, in pediatric cases etiology may be
determined by the sound
Sound does not dictate severity
Character and timing of cough are not helpful in
predicting its cause in adults
ACTIVITY: Are you going to use a mucoactive agent?
o Non-specific
o With eheck eheck eheck
o High pitch eheck
o Waaheeeeck: mahalak yung ubo
o With wheezing: mahuni na ubo
o It would seem that last two are worse, but
actually all came from cancer patients
B. Dyspnea
Subjective complaint so mainly determined by
patients threshold
Duration
o Filipinos tend to underestimate dyspnea, which is
why it is important for patients to quantify their
dyspnea
o Most of the time dyspnea is secondary to chronic
disease
o Acute dyspnea may be more life threatening than
chronic type
o You might have to challenge the patient because
Filipinos tend to deny their symptoms
Precipitating/relieving factors/timing
o Principally important in association with other
symptoms, such as chest pain
o The degree of activity that precipitates it
o Compensatory activities should be asked
Cardiac Etiology.
Cardiac
Relieved with certain
meds (nitrates) and rest
Other associated
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symptoms
Awakens after several
hours (since pressure
changes first before loss
of breath)
Orthopnea, PND
Worsens at the end of
the day
If frothy = congestion
If pinky = secretions in congestive heart failure)
D. Abnormal Laboratory
Usually asymptomatic (according to patients) but
there are incidental findings on tests
Why was lab/investigation done in the first
place?
o Was it because the patient sought for consult
because he/she is not feeling well?
o Was it because the physician has already
suspected an abnormality?
o For the purpose of pre-employment or abroad
clearance?
Duration of symptoms
Previous labs or medical advice
o Comparison of CXR (4-6 mo interval)
o Without change in lesion within the said interval
can be a stable lesion that has progressed already
to fibrosis and calcification
IV. PHYSICAL EXAMINATION
Note that these are from Bates (in preparation for
OSCE so we know how to position the patient)
For men, arrange the gown so that you can see the
chest fully
For women, cover the anterior chest when you
examine the back and for the anterior examination,
drape the gown over each half of the chest as you
examine the other half
With the patient sitting, examine the posterior thorax
and lungs
o The patient's arms should be folded across the
chest with hands resting, if possible, on the
opposite shoulders
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Normal
during
infancy,
often
Chest
From a midline position
symmetry
of
the
rib
cage
accompanies COPD, chronic bronchitis
as
it
expands
and
behind the patient (expose
Sternum is displaced anteriorly,
contracts
the patient well and ask
increasing the AP diameter
Pectus
permission),
note
the
Any pathology can lead
Carinatum Costal cartilages adjacent to the
shape of the chest and the
to chest lag something
(Pigeon
way it moves, including:
interferes with air going
protruding
Chest)
o Abnormal retraction of
out of the lungs
sternum are depressed
interspaces
during
o
Accumulation of air
Most often secondary to trauma
inspiration
(note
(pneumothrorax), fluid,
supraclavicular retraction)
mucus and inflammation (in pneumonia)
o Impaired respiratory movement on one or both
sides or unilateral lag or delay in movement
Figure 4. From left to right: Pigeon chest; typical
chest of COPD patient; kyphoscoliosis (spinal
deformity)
C. Palpation
Palpate to test respiratory excursion, especially
posteriorly
Palpate for tracheal position
Palpate for any soft tissue masses/tenderness (which
students usually miss)
Palpate for rib/costochondral tenderness
Palpate for tactile fremitus, using base of fingers or
edge of your hand, comparing the two sides of the
chest
Palpate from posterior (Pxs back) to anterior
Tracheal Position
Very important
If trachea is displaced ipsilaterally to the affected
lung volume loss problem
Use the clavicular head of SCM as take-off point
Palpation of the Chest
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E. Auscultation
(A)
(B)
(C)
(D)
Insp =
Exp
Intermedi
ate
Intermed
iate
Normal
location
Both
lung
fields
1st and
2nd ICS
anteriorl
y;
between
scapulae
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Insp <
Exp
Loud
Relativel
y high
Trache
al
Insp =
Exp
Very loud
Relativel
y high
Over
manubri
um
At
sternal
notch
with
nasal
twang;
scratching/rasping sound
o Egophony voice sound with a nasal or bleating
quality heard over the chest wall over
consolidated/atelectatic lung tissue, also seen in
upper border of a large pleural effusion
Adventitious Sounds (ATS, 1977)
Crackles (Rales) discontinuous sounds and heard
more in inspiration
o Coarse crackles loud & low pitched (pus-filled or
phlegm, usually due to infection, e.g. pneumonia,
inflammatory condition)
o Fine crackles less intense, higher pitch & short
duration (hemorrhage, congestion, or fluid-filled)
o Sound produced when you rub hair strands
together
o Not required to be differentiated during OSCE,
identifying the presence or absence of crackles will
suffice
o 2015: accdg. to Sir, parang straw sa softdrinks
pag ubos na
o Any fluid filled alveoli will have a respiratory sound
with crackles , wherein the fluid is thinner so
sound is finer
Wheezes
END
Marky: Im so boring na I dont have any message in
particular. BUUUT Ray just gave me an idea. I would
like to greet Mich. I love you and I miss you! More
drama soon. Heehee! To Lee Tan, I love you too. To Erik,
Im sad that you hate me
James: Malapit na mag-sembreak! Nag-aaya kami ni
Terence ng surf trip this weekend sa LU since long
weekend naman. Tara!
Allie: It wasnt a dark and stormy night. It should
have been but thats the weather for you. (Gaiman &
Pratchett, 1990)
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