2. The history
Most patients with respiratory disease will presentwith breathlessness, cough,
excess sputum, haemoptysis, wheeze or chest pain
Breathlessness
Everyone becomes breathless on strenuous exertion. Breathlessness
inappropriate to the level of physical exertion, or even occurring at rest, is
called dyspnoea.
People with cardiac disease and even non-cardiorespiratory conditions
such as anaemia, thyrotoxicosis or metabolic acidosis may become dyspnoeic
as well as those with primarily respiratory problems.
3. Cont…….
An important assessment is exercise tolerance, ask wether there are any times
of day or night that are usually worse than others. Variable airways
obstruction due to asthma is very often worse at night and in the early
morning.
By contrast, people with predominantly irreversible airways obstruction due
to chronic obstructive pulmonary disease (COPD) will often say that as long
as they are sitting in bed, they feel quite normal; it is exercise that troubles
them.
4. Cough
A cough may be dry or productive of sputum.
• How long has the cough been present?
A cough lasting a few days following a cold has less significance than one lasting several
weeks in a middle-aged smoker, which may be the first sign of a malignancy.
• Is the cough worse at any time of day or night?
A dry cough at night may be an early symptom of asthma, as may a cough that comes in
spasms lasting several minutes.
5. Cont…….
• Is the cough aggravated by anything? , eg. allergic triggers such as dust,
animals or pollen, or non-specific triggers like exercise or cold air? The
increased reactivity of the airways seen in asthma, and in some normal
people for several weeks after viral respiratory infections, may present in this
way.
Severe coughing, whatever its cause, may be followed by vomiting.
6. SPUTUM
Is sputum produced?
What does it look like?
ask for a description of its colour and consistency. Yellow or green sputum is
usually purulent. People with asthma may produce small amounts of very thick or
jelly-like sputum, sometimes in the shape of a cast of the airways. Eosinophils may
accumulate in the sputum in asthma, causing a purulent appearance even when no
infection is present.
How much is produced?
sputum produced daily in bronchiectasis often exceeded a cupful. chronic bronchitis
causes the production of smaller amounts of sputum.
7. HAEMOPTYSIS
Haemoptysis means the coughing up of blood in the Sputum.
• Ask if it is fresh or altered blood, how much is produced, when it started and
how often it happens.
• They should always be asked about associated conditions such as epistaxis
(nose bleeds), or the subsequent development of melaena (altered blood in
the stool), which occurs in the case of upper gastrointestinal bleeding.
8. WHEEZING
• Always ask whether the patient hears any noises coming from the chest. Even if a
wheeze is not present when you examine the patient, it is useful to know that he has
noticed it on occasions.
• Sometimes, wheezing will have been noticed by others (especially by a partner at
night, when asthma is worse) but not by the patient. Sometimes stridor may be
mistaken for wheezing by both patient and doctor. This serious finding usually
indicates narrowing of the larynx, trachea or main bronchi.
9. PAIN IN THE CHEST
• Consequent upon prolonged bouts of coughing, chest pain caused by lung disease usually
arises from the pleura. Pleuritic pain is sharp and stabbing, and is made worse by deep
breathing or coughing. It occurs when the pleura is inflamed, most commonly by infection in
the underlying lung.
• More constant pain, unrelated to breathing, may be caused by local invasion of the chest
wall by a lung or pleural tumour.
• A spontaneous pneumothorax causes pain which is worse on breathing but which may have
more of an aching character than the stabbing pain of pleurisy.
• If a pulmonary embolus causes infarction of the lung, pleurisy and hence pleuritic pain may
occur, but an acute pulmonary embolus can also cause pain which is not stabbing in nature.
A large pulmonary embolus causing haemodynamic disturbance may cause cardiac-type
10. Other aspects of the history that are particularly relevant to the respiratory
system
Ask Questions related to the ear, nose and throat are relevant
A change in the voice may indicate involvement of the left recurrent laryngeal nerve by a
carcinoma of the lung
Sometimes patients using inhaled corticosteroids for asthma develop oropharyngeal
candidiasis or even hoarseness or weakness of the voice
The smoking history
The family history
The occupational history
15. Pallor (Anemia)
The pallor of anemia is best seen in the
mucous membranes of the conjunctivae, lips
and tongue and in the nail beds
Anaemia may occur when there is
a. Haemoptysis
b.Excessive sputum production and protein
loss
c. Loss of appetite leading to malnutrition
16. Cyanosis
This is a blue discoloration of the skin and mucous membranes
caused by increased concentration of reduced hemoglobin (5g/dl)
Central cyanosis may result from the reduced arterial oxygen saturation
caused by cardiac or pulmonary disease. Intracardiac or extracardiac
shunting.
Impaired pulmonary function
a. Alveolar hypoventilation
b. Ventilation—Perfusion mismatch
c. Impaired oxygen diffusion.
17. Bulbous enlargement of the distal portion
of the digit due to increased subungual soft
tissue.
Clubbing
18. Grading of Clubbing
Grade I
Grade II
Positive nail bed fluctuation
Obliteration of the Lovibond angle
Grade III Parrot beak / Drumstick appearance
Grade IV Hypertrophic osteoarthropathy.
19. Pulmonary and Thoracic Causes
a. Bronchogenic carcinoma (rare in adenocarcinoma)
b. Metastatic lung cancer
c. Suppurative lung disease
1. Bronchiectasis
2. Cystic fibrosis
3. Lung abscess
4. Empyema
d. Interstitial lung disease
e. Longstanding pulmonary tuberculosis
f. Chronic bronchitis
g. Mesothelioma
h. Neurogenic diaphragmatic tumour
i. Pulmonary AV malformation
j. Sarcoidosis.
20. Hypertrophic Osteoarthropathy
It is a painful swelling of the wrist, elbow, knee, ankle,
with radiographic evidence of sub-periosteal new bone
formation. It can be familial or idiopathic.
common disorders that can produce it are:
a. Bronchogenic carcinoma
b. Cystic fibrosis
c. Neurofibroma
d. A-V malformation.
21. Lymphadenopathy
Scalene lymph node enlargement
1.Large and fixed in secondary involvement from a
primary lung malignancy
2.Hard and craggy, matted, with or without sinus
formation in healed and calcified tuberculous
lymphadenopathy.
22. Blood Pressure
Pulsus Paradoxus
Systolic blood pressure normally falls during quiet inspiration in
normal individuals.
Pulsus paradoxus is defined as a fall of systolic blood pressure of
>10 mmHg during the inspiratory phase.
severe acute asthma or exacerbations of chronic obstructive
pulmonary disease.
23. Examination of the Neck Veins
Jugular Venous Pulse
COPD/cor pulmonale
Bilateral non-pulsatile
SVC obstruction
Massive right sided pleural effusion
24. 2) Examination of the Chest
Inspection
Palpation
Percussion
Auscultation
The subject should be examined in the Standing or Sitting position in an
erect, and in good light.
25. All the findings in the clinical examination should
be compared on both sides in the following areas:
1. Supraclavicular area
2. Infraclavicular area
3. Mammary region
4. Inframammary region
5. Axillary region
6. Infra-axillary region
7. Suprascapular region
8. Interscapular region
9. Infrascapular region.
26. Inspection
Inspection for Position of trachea
Inspection for Symmetry of Chest
Inspection for Chest wall abnormalities
Inspection for Movement of the Chest
Inspection for Apex beat
Inspection for Dilated and engorged veins
Inspection for Surgical or any Scars or Sinuses
27. Inspection for Position of trachea
Trail’s sign: It is the undue prominence of the clavicular head of
sternomastoid on the side to which the trachea is deviated.
Position of Apex Beat
The apex beat is shifted to the side of mediastinal shift.
28. Inspection for Symmetry of Chest
Normal chest is symmetrical and elliptical in cross section.
The normal antero-posterior to transverse diameter ratio
(Hutchinson’s index) is 5 : 7.
The normal subcostal angle is 90°. It is more acute in
males than in females.
AP
T
AP:T = 5:7
29. Look for the following:
1. Drooping of the shoulder
2. Hollowness or fullness in the supraclavicular and infraclavicular fossa
3. Crowding of ribs
4. Kyphosis (forward bending of the spine)
5. Scoliosis (lateral bending of the spine).
30. Inspection for Chest wall abnormalities
1.Flat chest: The antero-posterior to transverse diameter ratio is 1 :
2.
Seen in pulmonary TB and fibrothorax
31. 2.Barrel chest: The anteroposterior to transverse diameter
ratio is 1 : 1.
Seen in physiological states like infancy and old age and in
pathological states like COPD (emphysema)
32. 3. Pigeon chest (Pectus carinatum) : It is forward protrusion of
sternum and adjacent costal cartilage,
seen in Marfan’s syndrome, in childhood asthma and rickets
33. 4.Pectus excavatum (funnel chest, cobbler’s chest)
It is the exaggeration of the normal hollowness over the
lower end of the sternum. It is a developmental defect.
The apex beat shifted further to the left and the ventilatory
capacity of the lung is restricted.
It is seen in Marfan’s syndrome
34. 5. Harrison’s sulcus: It is due to the indrawing of ribs to form
symmetrical horizontal grooves above the costal margin, along the line of
attachment of diaphragm
occurs in chronic respiratory
disease in childhood,
childhood asthma, rickets and
blocked nasopharynx due to
adenoid enlargement
35. 6. Scorbutic rosary: It is the sharp
angulation, with or without beading or
rosary formation, of the ribs, arising as
a result of backward displacement or
pushing in of the sternum,
e.g. Vitamin C deficiency.
7. Rickety rosary: It is a bead like
enlargement of costochondral junction,
e.g. rickets
36.
37. Spinal Deformity
Kyphoscoliosis : It is a disfiguring or
disabling deformity of the spine, producing a
shift of the apex beat. It reduces the
ventilatory capacity of the lung and
increases the work of breathing.
38. Inspection for Movement of the Chest
It is described in terms of rate, rhythm, equality and type of breathing
Rate
•The normal respiratory rate in relaxed adults is 14-18
breaths per minute
•The type of breathing in women is thoraco-abdominal
and in men is abdomino-thoracic
• The ratio of pulse rate to respiratory rate is 4 : 1.
39. Tachypnoea: It is an increase in respiratory rate more
than 20 per minute(Adult). Conditions causing tachypnoea
are:
a. Nervousness
b. Exertion
c. Fever
d. Hypoxia
e. Respiratory conditions
i. Acute pulmonary oedema
ii. Pneumonia
iii. Pulmonary embolism
iv.ARDS
v. Metabolic acidosis
40. Bradypnoea: It is a decrease in the rate of respiration.
Conditions causing bradypnoea are:
a. Alkalosis
b. Hypothyroidism (myxoedema)
c. Narcotic drug poisoning
d. Raised intracranial tension.
Hyperpnoea: It is an increase in depth of respiration.
Conditions causing hyperpnoea are:
a. Acidosis
b. Brainstem lesion
c. Hysteria.
41. Rhythm
Inspiration: It is an active process brought about by the
contraction of the external intercostal muscles and the
diaphragm
Expiration: It is a passive process and it depends upon
elastic recoil of the lungs.
Accessory muscles of inspiration are the scaleni,
trapezius and pectoral muscles.
Accessory muscles of expiration are abdominal
muscles and latissimus dorsi.
42. Abnormal Breathing Patterns
Abnormal breathing patterns may be regular or irregular
Regular abnormal breathing patterns
a. Cheyne-Stokes breathing: It is characterised by hyperpnoea
followed by apnoea.
It occurs in cardiac failure, renal failure, narcotic drug
poisoning and raised intracranial pressure
b. Kussmaul’s breathing: It is characterised by increase in rate and
depth of breathing.
It occurs in metabolic acidosis and pontine lesions.
43. Irregular abnormal breathing patterns
a.Biots breathing: It is characterised by apnoea between several
shallow or few deep inspirations. It occurs in meningitis
b.Ataxic breathing: It is characterised by irregular pattern of
breathing where both deep and shallow breaths occur randomly. It
occurs in brainstem lesions
c. Apneustic breathing: It is characterised by pause at
full inspiration, alternating with a pause in expiration,
lasting for 2 to 3 seconds. It occurs in pontine
lesions
44. Palpation
Palpation for Apex Beat (Position and Character)
Palpation for Position of trachea
Palpation for Measurement of the Chest Expansion
Palpation for Assessing of Chest Expansion
Palpation for Vocal fremitus (VF)
Palpation for Direction of flow in veins
Palpation for Tender points
45. The position of the trachea is confirmed by slightly flexing the neck
so that the chin remains in the midline.
The index finger is then inserted in the suprasternal notch and the
tracheal ring is felt.
Slight shift of trachea to the right is normal
Palpation for Position of trachea
46.
47.
48. Measurement of the Chest Expansion
The expansion of the chest should be measured with a tape
measure placed around the chest just below the level of the
nipples/inferior angle of scapula.
Chest circumference in full expiration
Chest circumference at full inspiration
Chest expansion
Right/Left Hemithorax
Normal expansion of the chest is 5-8 cm
In severe emphysema, it is less than 1 cm
49. General Restriction of Expansion
a. COPD
b. Extensive bilateral disease
c. Ankylosing spondylitis
d. Interstitial lung disease
e. Systemic sclerosis (hide bound chest).
Asymmetrical Expansion of the Chest
a. Pleural effusion
b. Pneumothorax
c. Extensive consolidation
d. Collapse
e. Fibrosis.
In all these above conditions, diminished
expansion occurs on the affected side.
52. It is a vibration felt by the hand when the patient is
asked to repeat ninety-nine or one-one-one, by putting
the vocal cord into action.
Identical areas of the chest are compared on both sides.
It is felt with the flat of the hand or with the ulnar
border of the hand for accurate localization.
It is increased in consolidation.
It is decreased in pleural effusion
Palpation for Vocal fremitus (VF)
53. Tenderness over the Chest Wall
It may be due to:
1. Empyema
2.Local inflammation of parietal pleura, soft tissue and
osteomyelitis
3. Infiltration with tumor
4. Non-respiratory cause (amoebic liver abscess).
55. Cardinal Rules of Percussion
a. The pleximeter: The middle finger of the examiner’s left hand should
be opposed tightly over the chest wall, over the intercostal spaces. The
other fingers should not touch the chest wall. Greater pressure should be
applied over a thick chest wall to remove air pockets
b.The plexor: The middle or the index finger of the examiner’s right
hand is used to hit the middle phalanx of the pleximeter
c.The percussion movement should be sudden, originating from the
wrist. The finger should be removed immediately after striking to avoid
damping
d.Proceed from the area of normal resonance to the area of impaired or
dull note, as the difference is then easily appreciated
e.The long axis of the pleximeter is kept parallel to the border of the
organ to be percussed.
56. Direct percussion—clavicle
Anterior Chest Wall
Clavicle: Direct percussion is used and percussion is
done within the medial 1/3rd of the clavicle
Supraclavicular region (Kronig’s isthumus):
It is a band of resonance 5-7 cm size over the
Supraclavicular fossa. The percussion is done by
standing behind the patient and the resonance of the
lung apices is assessed by this method.
Second to sixth intercostal spaces. However, the percussion
note cannot be compared due to relative cardiac dullness on
the left side.
Liver dullness can be percussed from the right 5th rib
downwards in the midclavicular line.
57. Lateral Chest Wall
Fourth to seventh intercostal spaces.
Liver dullness can be percussed from the right 8th rib
downwards in the midaxillary line.
Posterior Chest Wall
a. Suprascapular (above the spine of the scapula)
b. Interscapular region
c. Infrascapular region up to the eleventh rib.
Liver dullness can be percussed from the right 10th rib
downwards in the midscapular line.
58.
59. Tidal Percussion
This is done to differentiate upward enlargement of liver or
subdiaphragmatic abscess from right sided parenchymal or pleural
disorder.
If on deep inspiration, the previous dull note in the fifth right
intercostal space on the mid clavicular line becomes resonant, it
indicates that the dullness was due to the liver, which had been
pushed down by the right hemidiaphragm with deep inspiration.
If the dullness persists on the other hand, it indicates underlying
right sided parenchymal or pleural pathology, in the absence of
diaphragmatic paralysis.
Shifting Dullness
This is done to demonstrate the shift of fluid in hydropneumothorax.
The immediate shift of fluid can be demonstrated by the dull area
percussed in the axilla in the sitting posture, becoming resonant on
lying down on the healthy side.
61. Listen with the patient relaxed and breathing deeply
through his open mouth.
Auscultate each side alternately, comparing findings over a
large number of equivalent positions to ensure that you do
not miss localised abnormalities.
Listen:
■ anteriorly from above the clavicle down to the sixth rib
■ laterally from the axilla to the eighth rib
■ posteriorly down to the level of the 11th rib.
■Assess the quality and amplitude of the breath sounds.
Identifyany gap between inspiration and expiration, and
listen for added sounds.
Avoid auscultation within 3 cm of the midline anteriorly or
posteriorly, as these areas may transmit soundsdirectly from
the trachea or main bronchi.
62. Vesicular breath sounds
low pitched, rustling in
nature
produced by attenuating and
filtering effect of the lung
parenchyma.
Duration of the inspiratory
phase is longer than the
expiratory phase in a ratio of
3 : 1.
There is no pause between
the end of inspiration and the
beginning of expiration.
Bronchial breath sounds
It is loud and high pitched,
with an aspirate or guttural
quality.
It is produced by passage of
air through the trachea and
large bronchi
The duration of inspiration is
shortened whereas that of
expiration is prolonged or
equal
There is a pause between
inspiration and expiration.
63.
64.
65. INVESTIGATIONS
1. Sputum examination
Mucoid sputum is characteristic in patients with chronic bronchitis when there is no active
infection. It is clear and sticky and not necessarily produced in a large volume. Sputum may
become mucopurulent or purulent when bacterial infection is present in patients with bronchitis,
pneumonia, bronchiectasis or a lung abscess. In these last two conditions, the quantities
may be large and the sputum is often foul
smelling.
66. INVESTIGATIONS
Lung function tests
Arterial blood sampling
The chest X-ray
The computed tomography scan
Magnetic resonance imaging
Ultrasound
Radioisotope imaging
Positron emission tomography (PET)
scanning
Flexible bronchoscopy
Immunological tests
67. References
Breath Sounds Made Incredibly Easy (2005)– Lippincott
Williams and Wilkins
Gleadle J(2012)History and Clinical Examination at a
Glance Wiley Blackwell
Hogan-Quigley, Palm, Bickley (2012) Bates Nursing Guide
to Physical Examination and History Taking Lippincott
Williams and Wilkins
