EXAMINATION

MEDICINE

RESPIRATORY SYSTEM
CHAPTER

1 DR. MOHCEN AL. HAJ

 RESPIRATORY SYSTEM

The Possible Short Cases in Clinic Exam are:

1- COPD & Asthma. 2- Bronchiectesis.

3- Pleural Effusion. 4- Pneumothorax.
5- Pneumonia. 6- Interstitial Lung Disease (ILD).

Chest Examination Means  Examination On Chest From Front OR From the Back.
Respiratory Examination Means  Chest Examination & General Examination Related
to Respiratory System.

 CHEST EXAMINATION FROM THE BACK:

IN CHEST EXAMINATION FROM THE BACK PATIENT HAS TO BE IN

SETTING POSITION.

INTRODUCE YOUR SELF,, STAND ON THE RIGHT SIDE OF THE PATIENT &
TAKE PERMISSION FROM THE PATIENT FOR EXAMINATION & EXPOSURE.
.. ‫ أني (فالن فالن) طالب سنة خامسة في كلية الطب البشري‬.. ‫ صباح الخير يا حاج‬.. ‫السالم عليكم‬
‫ لو سمحت يا حاج ومن بعد إذنك لو تقدر تفتح السورية‬.. ‫من بعد إذنك يا حاج نبي اندير كشف على صدرك‬
... ‫وسامحني كثرت عليك‬

1 INSPECTION

1- Scars:
Look at the Chest From the Both Axilla For Any Scar Such as:
A- Small Axillary Scar  Indicate Chest Tube Insertion.
B- Large Axillary Scar (Lateral Thoracotomy Scar)  indicates Lobectomy or Pneumonectomy.

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 2- Chest Deformity:
Check the Chest From the Back and Observe If There is Any Deformity Like:
A- Scoliosis.
B- Kyphosis.
C- Kypho-Scoliosis.

Other Chest Deformity From Front are:

- Pectus Carinatum (Pigeon Chest)
- Pectus Excavatum (Funnel Chest)
- Barrel Chest (Increase Antero-Posterior Diameter Of Chest).
_____________________

3- Chest Movement:
Ask the Patient to Breath From His Mouth and Observe the Chest From the Back to Check Chest
Movement During Inspiration & Expiration.

Differential Diagnosis of Bilateral Differential Diagnosis of Unilateral

Decrease Chest Movement Decrease Chest Movement
-Asthma. -Pleural Effusion (Lower Zone).
-COPD. -Pneumothorax (Upper Zone).
-Bronchiectesis. -Lung Collapse.
-Interstitial Lung Disease (ILD). -Lobar-Pneumonia.
-Broncho-Pneumonia. -Pneumonectomy or Lobectomy.

4- OTHERS (S S):
Superficial Dilated Vein  Indicate Superior Vena Cava Obstruction in Case of Apical Lung Tumor.
Symmetry of The Chest  Bulging Or Retraction
- Bulging Indicate  Pleural Effusion & Pneumothorax.
- Retraction Indicate  Lung Collapse & Lung Fibrosis.

3 DR. MOHCEN AL. HAJ

 2 PALPATION

1- Chest Expansion:
Put The Palms of Your Both Hands On the Chest From the Back in Three Areas (1, 2, 3) as in the
Picture, Start From Area (1) , Then Ask the Patient to Breath From His Mouth and Check the
Expansion of the Chest in Both Sides in Area (1) ,, Do the Same Thing in Area (2) , Then Area (3):

4 DR. MOHCEN AL. HAJ

 2- Tactile Vocal Fremitus (TVF):
Use Ulnar Border of Your Hand and Put it On the Chest From the Back On Intercostal Space in Order
According to the Numbers in The Picture ,, and Ask the Patient to Say 44 In Each Area
(in English Say Ninety Nine) You are Going to Feel Simple Vibration (Transmitted Sound),
*Don’t Forget To Follow the Numbers in the Picture and Compare Between Both Lungs:

Differential Diagnosis of Decrease Differential Diagnosis of

Tactile Vocal Fremitus Increase Tactile Vocal Fremitus

- Asthma. - Consolidation in Pneumonia.

- COPD.
- Lung Fibrosis.
- Pleural Effusion.
- Pneumothorax.

Note:
Ask Permission From the Doctor to Palpate Tracheal Position, Because It is Useful In Case of Shifted
Mediastinum as in  Massive Pleural Effusion, Tension Pneumothorax, Lung Collapse, Pneumonectomy.

5 DR. MOHCEN AL. HAJ

 3 PERCUSSION

Put the Palm of Your Left Hand on Intercostal Space of the Chest From the Back in Order According
to the Numbers in The Picture ,, and Use The Middle Finger of Your Right Hand and Tap it On Distal
Interphalangeal Joint of Your Left Hand.

Listen to the Sound that Will Occur Due to Percussion Which May Be:

 Resonant  Means  Normal.

 Hyper-Resonant (Tympanic)  Means  Pneumothorax OR Obstructive Lung

Diseases (Asthma, COPD, Broncheictesis).

 Dull  Means  Consolidation (Pneumonia).

 Stony Dull  Means  Pleural Effusion.

6 DR. MOHCEN AL. HAJ

 4 AUSCULTATION

1- Air Entery:

Put Your Stethoscope On the Chest From the Back On Intercostal Space in Order According to the
Numbers in The Picture ,, and Ask the Patient to Breath From His Mouth ,, Then Auscultate;;
and Check If the Air Entry Equal in Both Lungs OR If there is Any Decrease of Air Entry:

Differential Diagnosis of Bilateral Differential Diagnosis of Unilateral

Air Entry Decrease Air Entry Decrease
- Asthma. - Pleural Effusion.
- COPD. - Pneumothorax.
- Bronchiectesis. - Lung Collapse.
- Interstitial Lung Disease. - Pneumonectomy or Lobectomy.

2- Type of Breathing:

*Harsh Vesicular Breathing  Means  Normal (Inspiration More Than Expiration).

*Broncho-Vesicular Breathing  Means  Obstructive Lung Diseases

(Expiration More Than Inspiration) as in Asthma, COPD, Bronchiectesis.

*Bronchial Breathing  Means  Consolidation of Pneumonia (Gap Between Inspiration & Expiration).

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 3- Added Sound:

Rhonchi: Crepitation or Crackles:

It is a Musical Sound Caused by Air Way It is a Non Musical Sound Heard Mainly During
Obstruction Heard Mainly During Expiration. Inspiration.

*If Rhonchi Heard Locally or Unilaterally & There are Two Types of Crepitation:
Low Pitched, it is Called  Monophonic
Fine Crackles Coarse Crackles
Which Occurs Due to Local Obstruction to
Not Disappear By Cough. Disappear By Cough.
Major Air Way.
Occurs in: Occurs in:
*If Rhonchi Heard Bilaterally & High
Pitched, it is Called  Polyphonic Which * Interstitial Lung * Bronchiectesis.
Occurs in Asthma & COPD. Disease (ILD). * Chronic Bronchitis.
* Pulmonary Edema. * Late Pneumonia.
Note: * Early Pneumonia.
Wheeze is  Audible Rhonchi.

4- Vocal Resonance:

Similar to Tactile Vocal Fremitus But By Using Stethoscope, Put It in Same Areas of Intercostal
Space in Order According to Numbers in The Picture ,, and Ask Patient to Say (44) in Each Area.

Note:
In Case of Consolidation; You Have to Add Two Steps:

* Whispered Pecterloquy  Similar to Vocal Resonance But Ask the Patient to

Whispered (44) in Each Area;; It Will Be Heard Loud in Area with Consolidation.

* Ego phony  Put Your Stethoscope On the Chest From the Back On
Intercostal Space in Order According to the Numbers in The Picture ,, and
Ask the Patient to Say (E) ;; It Will Be Heard (AA) in Area with Consolidation.

*Finally: Cover the Patient and Thank The Patient and Say  .. ‫ سامحني وان شاء هللا الباس عليك‬, ‫شكرا يا حاج‬

8 DR. MOHCEN AL. HAJ

  CHEST EXAMINATION FROM THE FRONT:

IN CHEST EXAMINATION FROM THE FRONT PATIENT HAS TO BE LAYING

IN SUPINE POSITION (FLAT OR 45 DEGREE).

INTRODUCE YOUR SELF,, STAND ON THE RIGHT SIDE OF THE PATIENT &
TAKE PERMISSION FROM THE PATIENT FOR EXAMINATION & EXPOSURE.
.. ‫ أني (فالن فالن) طالب سنة خامسة في كلية الطب البشري‬.. ‫ صباح الخير يا حاج‬.. ‫السالم عليكم‬
‫ لو سمحت يا حاج ومن بعد إذنك لو تقدر تفتح‬.. ‫من بعد إذنك يا حاج نبي اندير كشف على صدرك من القدام‬
... ‫السورية وسامحني كثرت عليك‬

1 INSPECTION

*First Stand at the End of the Bed and Check the Symmetry of Chest From Both Sides;
- Bulging Indicate  Pleural Effusion & Pneumothorax.
- Retraction Indicate  Lung Collapse & Lung Fibrosis.

*Now Do Inspection For:

1- Scars:
*Look at the Chest From the Both Axilla For Any Scar Such as:
A- Small Axillary Scar  Indicate Chest Tube Insertion.
B- Large Axillary Scar (Lateral Thoracotomy Scar)  indicates Lobectomy or Pneumonectomy.

*Then Look at the Chest From Front For Any Scar Such as:
C- Mid-Line Sternotomy Scar  Indicate Open Heart Surgery, (Valve Replacement OR Coronary
Artery Bypass Graft “CABG”).
D- Left Infra-Clavicular Scar  indicates Pacemaker or Implantable Cardiac Defibrillator (ICD).
E- Left Infra-Mammary Scar  indicates Valvotomy of Mitral Stenosis.

9 DR. MOHCEN AL. HAJ

 2- Chest Deformity:
Check the Chest From Front and Observe if There is Any Deformity Like:
A- Pectus Carinatum (Pigeon Chest)  Bulging of Sternum (Due to Childhood Asthma OR Rickets).
B- Pectus Excavatum (Funnel Chest)  Depression of Sternum.
C- Barrel Chest (Increase Antero-Posterior Diameter Of Chest) in COPD.

Then Check the Chest From the Back and Observe If There is Any Deformity Like:
A- Scoliosis.
B- Kyphosis.
C- Kypho-Scoliosis.

10 DR. MOHCEN AL. HAJ

 3- Chest Movement:
Ask the Patient to Breath From His Mouth and Observe the Chest From the Front to Check Chest
Movement During Inspiration & Expiration.

4- OTHERS:
Superficial Dilated Vein  Indicate Superior Vena Cava Obstructon in Case of Apical Lung Tumor.
Gyneacomastia, Cauthery Mark.

2 PALPATION

1- Chest Expansion:
Put The Palms of Your Both Hands On the Chest From the Front in Three Areas (1, 2, 3) as in the
Picture, Start From Area (1) , Then Ask the Patient to Breath From His Mouth and Check the
Expansion of the Chest in Both Sides in Area (1) ,, Do the Same Thing in Area (2) , Then Area (3):

------------------------------------------------------------------

2- Tactile Vocal Fremitus (TVF):

First Use the Tip of Your Fingers and Put Them in Supra-Clavicular Area [Number 1 as in the
Picture], Then Ask the Patient to Say 44, and Feel the Vibration,
After That Use Ulnar Border of Your Hand and Put it On the Chest From the Front On Intercostal
Space in Order According to the Numbers in The Picture Starting From Number 2 Until Number 6,
and Ask the Patient to Say 44 In Each Area (in English Say Ninety Nine) You are Going to Feel Simple
Vibration (Transmitted Sound),

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 *Don’t Forget To Follow the Numbers in the Picture and Compare Between Both Lungs:

----------------------------------------------------------------------

3- Tracheal Position:
First Say to the Examiner; (I Would Like to Examine Mediastinal Structures By Examining Tracheal
Position) and Ask the Patient to Sit,
Then Put Your Index Finger On the Medial End of the Right Clavicle and Put Your Ring Finger On the
Medial End of the Left Clavicle as in the Picture,
Then Use Your Middle Finger and Try to Palpate the Trachea as in the Picture and Check If It
Centralized OR Not,
(Normally the Distance Between the Index Finger and Middle Finger is Equal to the Distance Between
Ring Finger and Middle Finger  Equi-Distance).

12 DR. MOHCEN AL. HAJ

 3 PERCUSSION

Put the Palm of Your Left Hand on Intercostal Space of the Chest From the Front in Order According
to the Numbers in The Picture,, and Use The Middle Finger of Your Right Hand and Tap It On Distal
Interphalangeal Joint of Your Left Hand.

Listen to the Sound that Will Occur Due to Percussion Which May Be:

 Resonant  Means  Normal.

 Hyper-Resonant (Tympanic)  Means  Pneumothorax OR Obstructive Lung

Diseases (Asthma, COPD, Brochiectesis).

 Dull  Means  Consolidation (Pneumonia).

 Stony Dull  Means  Pleural Effusion.

13 DR. MOHCEN AL. HAJ

 4 AUSCULTATION

1- Air Entery:
Put Your Stethoscope On the Chest From the Front On Intercostal Space in Order According to the
Numbers in The Picture ,, and Ask the Patient to Breath From His Mouth ,, Then Auscultate;;
and Check If the Air Entry Equal in Both Lungs OR If there is Any Decrease of Air Entry:

2- Type of Breathing:
Harsh Vesicular Breathing, Broncho-Vesicular Breathing & Bronchial Breathing.
*as Mentioned Before.

3- Added Sound:
Rhonchi & Crackles.
*as Mentioned Before.

4- Vocal Resonance:
Similar to Tactile Vocal Fremitus But By Using Stethoscope, Put it in Same Areas of Intercostal
Space in Order According to Numbers in The Picture ,, and Ask Patient to Say (44) in Each Area.

*Finally: Cover the Patient and Thank The Patient and Say  .. ‫ سامحني وان شاء هللا الباس عليك‬, ‫شكرا يا حاج‬

14 DR. MOHCEN AL. HAJ