physical examination in RESPIRATORY SYSTEM
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Transcript of physical examination in RESPIRATORY SYSTEM
Wednesday, May 3, 2023Respiratory System.
Physical Examination in Respiratory System
D.RT.VENKATES
AN C.R.R.I
GYNMC.
Wednesday, May 3, 2023Respiratory System.
Anterior imaginary lines and landmarks
epigastric angle
Infraclavicular fossa
Anterior midline
Suprasternal fossa Supraclavicular fossa
Sternal line
Parasternal line
Midclavicular line
Wednesday, May 3, 2023Respiratory System.
Lateral imaginary lines
Anterior axillary line
Midaxillary line
Posterior axillary line
Wednesday, May 3, 2023Respiratory System.
Posterior imaginary lines and landmarks
Scapular line
Posterior midline
Infrascapular region
Interscapular region
Suprascapular region
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)
Wednesday, May 3, 2023Respiratory System.
Inspection
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
Wednesday, May 3, 2023Respiratory System.
Inspection
Palpation 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.Wednesday, May 3, 2023
1. Method
◦ Mediate Pleximeter: distal inter-phalangeal joint of left
middle finger Plexor: right middle finger tip
◦ Immediate◦ Order
Up to down, anterior to posterior
Respiratory System.Wednesday, May 3, 2023
◦ Thickness of thoracic wall◦ Calcification of costal cartilage ◦ Hydrothorax◦ Containing gas in alveoli ◦ Alveolar tension◦ Alveolar elasticity
Wednesday, May 3, 2023Respiratory System.
2. Affected factors
Resonance Normal
Hyperresonance Emphysema
Tympany Cavity or pneumothorax
Dullness Hydrothorax, atelectasis
Flatness Massive Hydrothorax
Wednesday, May 3, 2023Respiratory System.
3. Classification
Lung’s sound in percussion Resonance Slight dullness in some areas (upper, right,
back) due to thickness of muscles and skeletons
Wednesday, May 3, 2023Respiratory System.
4. Normal sound
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
Wednesday, May 3, 2023Respiratory System.
4. Normal sound
4. Normal sound
Respiratory System.Wednesday, May 3, 2023
sShifting 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
Percussing bottom of lung, marking
Asking the pat. to expire deeply and hold
Percussing bottom of lung, marking
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
Wednesday, May 3, 2023Respiratory System.
5. Abnormal sound
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
Wednesday, May 3, 2023Respiratory System.
5. Abnormal sound
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
Wednesday, May 3, 2023Respiratory System.
5. Abnormal sound
5. Abnormal sound
Special areas on percussion in moderate hydrothorax
Respiratory System.Wednesday, May 3, 2023
Damoiseau’s curve
Garland’s triangle area(tympanitic dullness)
Grocco’s triangle area(dullness)
1. Normal breath sound2. Abnormal breath sound3. Adventitious sound4. Vocal resonance
Wednesday, May 3, 2023Respiratory System.
Sound of auscultation
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
Wednesday, May 3, 2023Respiratory System.
1. Normal breath sound
Bronchovesicular
Bronchial
Bronchial
Bronchovesicular
Abnormal vesicular breath sound Abnormal bronchial breath sound Abnormal bronchovesicular breath sound
Wednesday, May 3, 2023Respiratory System.
2. Abnormal 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
Wednesday, May 3, 2023Respiratory System.
Abnormal vesicular breath sound(1)
3) Prolonged expiration Bronchitis Asthma emphysema
4) Cogwheel breath sound TB Pneumonbreath soundia
5) Coarse Early stage of bronchitis or pneumonia
Wednesday, May 3, 2023Respiratory System.
Abnormal vesicular breath sound (2)
Bronchial breath sound appears in supposed vesicular breath sound area
Consolidation: lobar pneumonia (consolidation stage) Large cavity: TB, lung abscess Compressed atelectasis: hydrothorax, pneumothorax
Wednesday, May 3, 2023Respiratory System.
Abnormal bronchial breath sound (tubular breath sound)
Bronchovesicular breath sound appears in supposed vesicular breath sound area
◦ The lesion is relatively smaller or mixed with normal lung tissue
Wednesday, May 3, 2023Respiratory System.
Abnormal bronchovesicular breath sound
(moist) Crackles Rhonchi (wheezes) Pleural friction rub
Wednesday, May 3, 2023Respiratory System.
3. Adventitious sound
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.
Wednesday, May 3, 2023Respiratory System.
Moist crackles
1. Adventitious sound2. Intermittent 3. Appeared in phase of inspiration or early
expiration4. Constant in site5. Unchanged in character6. Medium and fine crackles exist meantime7. Less or disappeared after cough
Wednesday, May 3, 2023Respiratory System.
Characteristics of crackles
According to intensity of the sound1. Loud moist crackles2. Slight moist crackles
According to diameter of the airway crackles appeared1. Coarse: trachea, main bronchi, or cavity
Bronchiectasis, pulmo. edema, TB, lung abscess, coma2. Medium: bronchi
bronchitis, pneumonia3. Fine: bronchioli
pneumonia4. Crepitus:
Bronchiolitis, alveolitis, early pneumonia (pulmo. Congestion), elder subject, pat. bed rest for long time
Wednesday, May 3, 2023Respiratory System.
Classification of crackles
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
Wednesday, May 3, 2023Respiratory System.
Site of crackles
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
Wednesday, May 3, 2023Respiratory System.
Rhonchi (wheezes)
1. Adventitious sound2. High pitch3. Dominance in phase of expiration4. Variable intensity of character or site 5. Wheezing
Wednesday, May 3, 2023Respiratory System.
Characteristics of rhonchi
1. Sibilant ◦ Bonchioli, bronchi
2. Sonorous ◦ Trachea, main bronchi
Wednesday, May 3, 2023Respiratory System.
Classification of rhonchi
1. Both fields◦ Asthma◦ Chronic bronchitis◦ Acute left heart failure
2. Local site◦ Tumor◦ Endobronchial TB
Wednesday, May 3, 2023Respiratory System.
Site of rhonchi
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 breath4. Friction rub appeared both breath and heart beat: mediastinal pleurisy5. Causes
Tuberculous pleurisy Pulmo. embolism Uremia Pleural mesothelioma
Wednesday, May 3, 2023Respiratory System.
Pleural friction rub
Bronchophony ◦ Consolidation
Pectoriloqny ◦ Massive consolidation
Egophony ◦ Upper area of hydrothorax
Whispered ◦ Consolidation
Wednesday, May 3, 2023Respiratory System.
Vocal resonance
Chill Continued fever: 39-40ºC Chest pain Tachypnea Cough Rusty sputum
Wednesday, May 3, 2023Respiratory System.
Symptoms
General signs◦ Acute facial features, blushing ◦ Nares flaring (dyspnea)◦ Cyanosis◦ Tachycardia◦ Simple herpes around lips
Wednesday, May 3, 2023Respiratory System.
Signs (1)
Congestion Inspection Decreased respiratory movement Palpation Increased vocal r
Wednesday, May 3, 2023Respiratory System.
Signs (2)
Chronic productive cough White mucous sputum or pus sputum
(infection) Exertional dyspnea Breathlessness (dyspnea) Chest depression
Wednesday, May 3, 2023Respiratory System.
Symptoms
Wednesday, May 3, 2023Respiratory System.
Signs 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 Orthopnea Cyanosis Severe sweat Decreased movement of respiration Decreased vocal fremitus Hyperresonance Rhonchi in full fields of lungs
Wednesday, May 3, 2023Respiratory System.
Signs
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
Wednesday, May 3, 2023Respiratory System.
Symptoms
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
Wednesday, May 3, 2023Respiratory System.
Signs (Moderate to massive effusion)
Sudden chest pain Dyspnea Forced sitting position Unaffected side lying Dry cough
Tension pneumonia◦ Progressive dyspnea◦ Tyckycardia◦ Cyanosis◦ Respiratory failure
Wednesday, May 3, 2023Respiratory System.
Symptoms
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
Wednesday, May 3, 2023Respiratory System.
Signs