Examination of Respiratory System

Written by Dr.Md.Redwanul Huq (Masum)
Sunday, 23 December 2012 14:21

General assessment:

Appearance

Decubitus

Anemia

Polycythemia

Cyanosis

Clubbing

Edema

Pulse

Jugular venous pressure (JVP)

Lymph nodes (of neck & axilla)

Temperature

BP.

Examination of upper respiratory tract:

1) Examination of nose, mouth & throat.

2) Examination of sinuses- by giving pressure over frontal & maxillary sinuses and observing tenderness over the sinuses.

Examination of the chest:

1) Inspection:

During inspection the followings should be observed:

a) Appearance: 3 “S” – Shape, Symmetry, Skin condition (scar, superficial vein,

lesion, lump).

b) Movement of the chest:Type, rate, rhythm & depth of respiration.

c) Trachea- Position

d) Apex beat- Location.

2) Palpation:

a) Trachea: Palpation of trachea.

Procedure-

a) Placing of palm of hand over the chest & moving it up to trachea,

then patient is asked to deglutate & position of trachea is felt by one

of middle three fingers.

b) Then index finger on right side of patient and ring finger on left side

of patient is invaginated between trachea & corresponding sternal head

of sternecleidomastoid muscle.

b) Apex beat: Localization of apex beat.

c) Chest expansion:

- 3 areas in front

- 3 areas on back

(for accuracy of chest expansion measuring tape is used)

d) Vocal fremitus:-

It is done bilaterally in mid clavicular lines in front & in mid axillary lines laterally

& in sub scapular lines on the back over the areas of percussion or auscultation

by ulnar border of right hand. Vocal fremitus in mid axillary lines can also be

examined by whole palm of the right hand. The patient is asked to say

“ninety-nine” or “one, one” while examining vocal fremitus.

3) Percussion of chest:

Percussion of chest is done bilaterally over following areas from resonance to dull.

a) In front- in mid clavicular lines (chronologically):

above the clavicle, on the clavicle, below the clavicle, 2nd to 6th intercostal space.

b) Laterally- in mid axillary lines:

4th to 7thintercostals spaces.

c) On the back :

i) On supra clavicular fossa.

ii) Over trapezius muscles: 3 areas (intercostals spaces) above downwards from

medial to lateral.

iii) In sub scapular lines: Above, at & below the level of the spine of scapula

over the intercostal spaces up to 11th rib.

4) Auscultation of lung:

A) Auscultation of breath sounds: It is examined bilaterally over the areas

 of percussion (described earlier)

B) Vocal resonance:

It is done bilaterally in mid clavicular lines in front & in mid axillary lines laterally

& in sub scapular lines on the back over the areas of percussion or auscultation

by stethoscope. The patient is asked to say “ninety-nine” or “one, one” while

examining vocal resonance.

Verbal description of normal findings of examination of respiratory system(examination of the chest):

Size & shape of the chest are normal, chest expansibility is normal & symmetrical on both sides, there is no engorged vein, scar, lump or lesion in the chest, hair distribution is normal, respiratory rate is 16 breaths/min, type of respiration is abdomino-thoracic, depth of respiration is normal. Apex beat is found in Lt 5th intercostal space just medial to the mid-clavicular line, 9cm from the midline, trachea is central in position. Total chest expansion is 3cm, vocal fremitus is normal in mid-clavicular, in mid-axillary and in posterior sub-scapular lines. Percussion note is normal over the whole lung, breath sound is vesicular and there is no added sound over whole areas of both lungs. Vocal resonance is also normal over whole areas of both lungs.

Differences among respiratory sounds(pleural rub, crepitation & rhonchi):

Traits

Pleural rub

Crepitation

Rhonchi

1. Character of the sound

Leathery or creaking sounds

Non-musical crackling/ bubbling respiratory sounds

Musical sounds

2. Relation with respiration

Heard at the end of inspiration & just after beginning of expiration.

During inspiration

During inspiration (due to secretion in large bronchi) or during expiration (due to mucosal edema or bronchospasm).

3.Mechanism with cause

Friction of roughened pleural surfaces (e.g. pleurisy caused by pneumonia, TB, Ca, PI)

Re opening of occluded small airways (fibrosing alveolitis, pulmonary edema) or air bubbling through secretions (e.g. bronchiectasis)

Air passing through narrowed airways (e.g. Asthma)

4. Relation with cough

May be aggravated

May alter on coughing due to dislodgement of sputum

Disappeared or decreased after coughing.

5.Association with pleural pain

Usually associated

Not associated

Not associated

6. Effect of Pressureby stethoscope

Sound is increased

Not increased

Not increased

Differences between haemoptysis & haematemesis:

Haemoptysis

Haematemesis

1) Usually preceded by coughing

1) Usually preceded by vomiting

2) Color- bright red

2) Color-altered (dark red or coffee ground)

3) Blood may be associated with frothy sputum

3) Blood may be mixed with gastric content

4) Reaction- alkaline

4) Reaction- Acidic

5) H/O respiratory or cardiovascular diseases – positive

5) H/O gastrointestinal diseases- positive

6) Confirmation is done by bronchoscopy

6) Confirmation is done by endoscopy

Sings of lobar pneumonia:

1) On General Examination : Pyrexia, tachycardia, tachypnea, hypotension

2) On inspection: Restricted movement on affected side

3) On palpation: Sings of consolidation & pleural effusion

4) On percussion of chest: Sings of consolidation & pleural effusion

5) On auscultation of lung: High pitched bronchial breath sound, coarse crepitation,

pleural rub.

Co-ordination among respiratory findings:

Hyper resonance on percussion + Absent Breath sound on auscultation – Pneumothorax

Dull on percussion + Bronchial breath sound on auscultation – Consolidation

Dull on percussion + Absent Breath sound on auscultation – pleural effusion.


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