physical examination in RESPIRATORY SYSTEM

Friday, August 5, 2016Respiratory System.
D.RT.VENKATESAN
C.R.R.I
GYNMC.

epigastric angle
Infraclavicular fossa
Anterior midline
Suprasternal fossa Supraclavicular fossa
Sternal line
Parasternal line
Midclavicular line

Anterior axillary line
Midaxillary line
Posterior axillary line

Scapular line
Posterior midline
Infrascapular region
Interscapular region
Suprascapular region

Pectus excavatum
Barrel chest
Kyphosis

1. Respiratory movement
◦ Abdominal breathing: male adult and child
◦ Thoracic breathing: female adult
2. Respiratory rate: 16-18 f/min
◦ Tachypnea: >20 f/min
◦ Bradypnea: <12 f/min
◦ Shallow and fast
 respiratory muscular paralysis, elevated
intraabdominal pressure, pneumonia, pleurisy
◦ Deep and fast
 Agitation, intension
◦ Deep and slow
 Severe metabolic acidosis (Kussmaul’s breathing)

3. Respiratory rhythm
 Cheyne-Stokes’ breathing
 Biot’s breathing
_____Decreased excitability of respiratory
center
 Inhibited breathing
◦ Sudden cessation of breathing due to chest pain
 Pleurisy, thoracic trauma
 Sighing breathing
◦ Depression, intension

 Thoracic expansion
◦ Massive hydrothorax, pneumonia,
pleural thickening, atelectasis
 Vocal fremitus (tactil fremitus)
 Pleural friction fremitus
◦ Cellulose exudation in pleura due to
pleurisy
◦ Holding breathing disappeared
◦ Tuberculous pleurisy, uremia, pulmo
embolism
Respiratory System.Friday, August 5, 2016

◦ Mediate
 Pleximeter: distal inter-phalangeal joint of left
middle finger
 Plexor: right middle finger tip
◦ Immediate
◦ Order
 Up to down, anterior to posterior

◦ Thickness of thoracic wall
◦ Calcification of costal cartilage
◦ Hydrothorax
◦ Containing gas in alveoli
◦ Alveolar tension
◦ Alveolar elasticity

 Resonance
 Normal
 Hyperresonance
 Emphysema
 Tympany
 Cavity or pneumothorax
 Dullness
 Hydrothorax, atelectasis
 Flatness
 Massive Hydrothorax

 Lung’s sound in percussion
 Resonance
 Slight dullness in some areas (upper, right,
back) due to thickness of muscles and
skeletons

Border of lungs in percussion
 Apex of lungs
 Kronig’s isthmus: 5cm in width
 Narrow: TB, fibrosis
 wider: emphysema
 Anterior border
 absolute cardiac dullness area
 Lower border
 6th, 8th, 10th intercostal space in midclavicular line,
midaxillary line, scapular line, respectively
 Down: emphysema
 Up: atelectasis, intraabdominal pressure goes up

s
Shifting range of
bottom of lung
6-8 cm
 Shifting range of bottom of lung
Along the scapular line
Percussing bottom of lung, marking
Asking the pat. to inspire deeply and hold
Asking the pat. to expire deeply and hold
Measuring the dist. between upper and lower lines
 Decreased: emphysema, atelactasis,
fibrosis, pulmo. edema, pneumonia
 Detected impossibly: pleura adhesion,
massive hydrothorax, pneumothorax,
diaphragmatic paralysis

 Dullness, flatness, hyperresonance or
tympany appear in the area of supposed
resonance.
 Unchanged sound (resonance)
◦ The depth of the lesion > 5 cm
◦ The diameter of the lesion  3 cm
◦ Mild hydrothorax

Dullness or flatness
 Decreased containing gas in alveoli
◦ Pneumonia
◦ Atelectasis?
◦ TB
◦ Pulmo. embolism
◦ Pulmo. edema
◦ Pulmo. fibrosis
 No gas in alveoli
◦ Tumor
◦ Pulmo. Hydatid
◦ Pneumocystis
◦ Non-liquefied lung abscess
 Others
◦ Hydrothorax
◦ Pleural thickness

 Hyperresonance
 Emphysema
 Tympany
 Pneumothorax
 Large cavity (TB, lung abscess, lung cyst)
 Amphorophony
 Large and shallow cavity with smooth wall
 Tension pneumothorax
 Tympanitic dullness
 Decreased tension and gas in alveoli
 Atelectasis
 Congestive or resolution stage of pneumonia
 Pulmo. edema

 Special areas
on percussion
in moderate
hydrothorax
Damoiseau’s curve
Garland’s triangle area
(tympanitic dullness)
Grocco’s triangle area
(dullness)

1. Normal breath sound
2. Abnormal breath sound
3. Adventitious sound
4. Vocal resonance

 Tracheal breath sound
 Bronchial breath sound
◦ Larynx, suprasternal fossa,
around 6th, 7th cervical
vertebra, 1st, 2nd thoracic
vertebra
 Bronchovesicular breath
sound
◦ 1st, 2nd intercostal space
beside of sternum, the level
of 3rd, 4th thoracic vertebra
in interscaplar area, apex of
lung
 Vesicular breath sound
◦ Most area of lungs
Bronchovesicular
Bronchial
Bronchial
Bronchovesicular

 Abnormal vesicular breath sound
 Abnormal bronchial breath sound
 Abnormal bronchovesicular breath sound

1) Decreased or disappeared
 Movement of thoracic wall
 Respiratory muscle weakness
 Obstruction of airway
 Hydrothorax or pneumothorax
 Abdominal diseases: ascites, large tumor
2) Increased
 Movement of respiration

3) Prolonged expiration
 Bronchitis
 Asthma
 emphysema
4) Cogwheel breath sound
 TB
 Pneumonbreath soundia
5) Coarse
 Early stage of bronchitis or pneumonia

 Bronchial breath sound appears in supposed
vesicular breath sound area
 Consolidation: lobar pneumonia (consolidation stage)
 Large cavity: TB, lung abscess
 Compressed atelectasis: hydrothorax, pneumothorax

 Bronchovesicular breath sound appears in
supposed vesicular breath sound area
◦ The lesion is relatively smaller or mixed with
normal lung tissue

 (moist) Crackles
 Rhonchi (wheezes)
 Pleural friction rub

Mechanism
During inspiration, air flow passes thin
secretion in the airway to rupture the
bubbles, or to open the collapse of
bronchioli due to adhesion by secretion.

2. Intermittent
3. Appeared in phase of inspiration or early
expiration
4. Constant in site
5. Unchanged in character
6. Medium and fine crackles exist meantime
7. Less or disappeared after cough

 According to intensity of the sound
1. Loud moist crackles
2. Slight moist crackles
 According to diameter of the airway crackles appeared
1. Coarse: trachea, main bronchi, or cavity
 Bronchiectasis, pulmo. edema, TB, lung abscess, coma
2. Medium: bronchi
 bronchitis, pneumonia
3. Fine: bronchioli
 pneumonia
4. Crepitus:
 Bronchiolitis, alveolitis, early pneumonia (pulmo.
Congestion), elder subject, pat. bed rest for long time

1. Local: local lesion
◦ Pneumonia, TB, bronchiectasis
2. Both bases
◦ Pulmo. edema, bronchopneumonia,
chronic bronchitis
3. Full fields
◦ Acute pulmo. edema, severe bronchopneumonia,
chronic bronchitis with severe infection

Mechanism
The turbulent flow is formed in trachea, bronchi
or bronchioli due to airway narrow or incomplete
obstruction.
Causes
◦ Congestion
◦ Secretion
◦ Spasma
◦ Tumor
◦ Foreign subject
◦ Compression

2. High pitch
3. Dominance in phase of expiration
4. Variable intensity of character or site
5. Wheezing

1. Sibilant
◦ Bonchioli, bronchi
2. Sonorous
◦ Trachea, main bronchi

1. Both fields
◦ Asthma
◦ Chronic bronchitis
◦ Acute left heart failure
2. Local site
◦ Tumor
◦ Endobronchial TB

1. Cellulose exudation in pleurisy (rough pleura)
2. Area of auscultation
 Anterolateral thoracic wall (maximal shifting area of
lung)
3. Friction rub disappeared if holding breath
4. Friction rub appeared both breath and heart beat:
mediastinal pleurisy
5. Causes
 Tuberculous pleurisy
 Pulmo. embolism
 Uremia
 Pleural mesothelioma

 Bronchophony
◦ Consolidation
 Pectoriloqny
◦ Massive consolidation
 Egophony
◦ Upper area of hydrothorax
 Whispered
◦ Consolidation

 Chill
 Continued fever: 39-40ºC
 Chest pain
 Tachypnea
 Cough
 Rusty sputum

 General signs
◦ Acute facial features, blushing
◦ Nares flaring (dyspnea)
◦ Cyanosis
◦ Tachycardia
◦ Simple herpes around lips

 Congestion
 Inspection
 Decreased respiratory movement
 Palpation
 Increased vocal r

 Chronic productive cough
 White mucous sputum or pus sputum
(infection)
 Exertional dyspnea
 Breathlessness (dyspnea)
 Chest depression

 Barrel chest
 Movement of respiratory
 Vocal fremitus
 Hyperresonance
 The lower border of lungs downward
 Shifting range of bottom of lung
 Cardiac dullness area
 Decreased vesicular breath sound
 Prolonged expiration
 Moist crackles and/or rhonchi (acute episode)

 Expiratory dyspnea with wheezing

 Expiratory dyspnea with wheezing
 Orthopnea
 Cyanosis
 Severe sweat
 Decreased movement of respiration
 Decreased vocal fremitus
 Hyperresonance
 Rhonchi in full fields of lungs

 Dry cough
 Chest pain
◦ Disappeared with growing of pleural effusion
◦ Reappeared with the fluid decreasing
 Affected side lying
 Dyspnea, orthopnea
 The symptoms of underlying disease

 Tachypnea
 Limited movement of affected side
 Costal interspaces of affected side are wider
 Trachea shifts to opposite side
 Decreased vocal fremitus
 Dullness or flatness
 Decreased or disappeared vesicular breath sound
 Pleural friction rub
 Abnormal bronchial breath sound in upper area of
the fluid

 Sudden chest pain
 Dyspnea
 Forced sitting position
 Unaffected side lying
 Dry cough
 Tension pneumonia
◦ Progressive dyspnea
◦ Tyckycardia
◦ Cyanosis
◦ Respiratory failure

 Costal interspaces in affected side are wider
 Limited movement of affected side
 Decreased vocal fremitus
 Trachea and heart shift to opposite side
 Tympany
 Vesicular breath sound decreased or
disappeared

THANK YOU

physical examination in RESPIRATORY SYSTEM

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (18)

Similar to physical examination in RESPIRATORY SYSTEM

Similar to physical examination in RESPIRATORY SYSTEM (20)

Recently uploaded

Recently uploaded (20)

physical examination in RESPIRATORY SYSTEM