Physical Examination in Respiratory System
Physical Examination in Respiratory System
Physical Examination in Respiratory System
Respiratory System
Physical examination is a
fundamental examining method, it
is proceeded by the sense organs
such as eyes, ears, nose and
hands or simple tools –
stethoscope.
The basic methods of
physical examination
1 inspection
2 palpation
3 percussion
4 auscultation
Physical Exam Steps
§ General examination
§ Mediastinal position
§ Chest expansion
§ Lung resonance
§ Breath sounds
§ Adventitious sounds
§ Voice transmission
General Examination
§ Respiratory rate
§ Pattern of breathing
§ Cyanosis
§ Clubbing
§ Weight
§ Cough
§ Hospital setting
§ Effort of ventilation
§ Shape of thorax
Inspection
1. General
Ø barrel, pigeon, rib recession, clubbing.
2. Respiratory movement
Ø Abdominal breathing: male adult and child
Ø Thoracic breathing: female adult
Ø paroxysmal breathing,etc.
3. Respiratory rate: 16-18 f/min
Ø Tachypnea: >20 f/min
Ø Bradypnea: <12 f/min
Ø Shallow and fast
¡ respiratory muscular paralysis, elevated
intraabdominal pressure, pneumonia, pleurisy
Ø Deep and fast
¡ Agitation, intension
Ø Deep and slow
¡ Severe metabolic acidosis (Kussmaul’s breathing)
Inspection
4. Respiratory rhythm
§ Cheyne-Stokes’ breathing
§ Biot’s breathing
Decreased excitability of respiratory center
§ Inhibited breathing
Ø Sudden cessation of breathing due to chest pain
¡ Pleurisy, thoracic trauma
§ Sighing breathing
Ø Depression, intension
Clubbing
§ In clubbing, there is widening of the lateral
diameter of terminal portion of fingers and toes
giving the appearance of clubbing.
§ The angle between the nail and skin is greater
than 180.
Shifting
range
kronig isthmus
Percussion of the anterior lungs
§ If the patient is in the supine position, the
patient’s arms should be slight abducted
region. work
downward to the flatness Traube
region of hepatic semilunar
space
dullness on the right
and the traube Percussion of the anterior lungs
semilunar space on the
left
Percussion of the anterior lungs
§ The entire anterior region should be resonant,
except for the area of cardiac dullness
Dullness in anterior region enlarge:
cardiac dilatation
pericardial effusion
aortic aneurysm
pulmonary hilar lymph node enlarged
Dullness in anterior region narrow:
pulmonary emphysema
Percussion of the posterior lung
§ The patient is in the sitting or standing
position. the patient’s arms are folded in
front and requested to pull his shoulders
forward (hump the shoulders), with the
spine slightly anteflexed
Percussion of the posterior lung
§ Percussion of each hemithorax is begun at
the top, working downward to compare
symmetrical regions sequentially. the zone
of resonance ends inferiorly at about the
9th to 10th rib.
(10th)
Percussion of the posterior lung bases
s marking
Percussing bottom of lung,
Shifting range of
bottom of lung
Asking the pat. to inspire deeply and hold
6-8 cm
Percussing bottom of lung, marking
§ Anterior border
Ø absolute cardiac dullness area
§ Lower border
Ø 6th, 8th, 10th intercostal space in midclavicular
line, midaxillary line, scapular line,
respectively
Abnormal percussion notes
Abnormal distribution
§ Dullness replacing resonance in the upper
lung
Neoplasm
Atelectasis
Consolidation of the lung
Abnormal distribution
§ Dullness replacing resonance in the lower
lung
Neoplasm
Atelectasis
Consolidation of the lung
pleural effusion
pleural thickening
elevation of the diaphragm
Abnormal distribution
§ Flatness replacing resonance or dullness
large pneumothorax
Auscultation
Auscultation
§ Requires a stethoscope
Ø Used to assess body sounds produced by the
movement of various fluids or gases in the
patient's organs or tissues
§ Note characteristics of:
Ø Intensity
Ø Pitch
Ø Duration
Ø Quality
Auscultation
position:
sequence :
(1) start from apices of lung,then work
downward
(2) anterior lateral posterior
(3) compare symmetrical points sequentially
Stethoscope
Figure 13-3
Auscultation
§ 12 anterior locations
§ 14 posterior locations
§ Auscultate symmetrically
§ Should listen to at least 6 locations
anteriorly and posteriorly
Order of auscultation
Sound of auscultation
1) Decreased or disappeared
¡ ?Movement of thoracic wall
¡ Respiratory muscle weakness
¡ Obstruction of airway
¡ Hydrothorax or pneumothorax
¡ Abdominal diseases: ascites(腹水), large tumor
2) Increased
¡ Movement of respiration
Abnormal vesicular breath sound
3) Prolonged expiration
¡ Bronchitis
¡ Asthma
¡ emphysema
4) Cogwheel breath sound
¡ TB
¡ Pneumonia
5) Coarse breath sound
¡ Early stage of bronchitis or pneumonia
Abnormal bronchial breath sound
(tubular breath sound)
§ wheeze
§ Rhonchi (dryrale)
§ bruit
Adventitious Breath Sounds
§ Crackles (Rales)
Ø Discontinuous, intermittent, nonmusical, brief sounds
Ø Heard more commonly with inspiration
Ø Classified as fine, medium, coarse rales or crepitus
Ø Normal at anterior lung bases
¡ Maximal expiration
¡ Prolonged recumbency
Ø Crackles caused by air moving through secretions and
collapsed alveoli
Ø Associated conditions
¡ pulmonary edema, early CHF, Pneumonia
Mech. of Moist Rales
mediu
m
fine
crepi
ti
Adventitious Breath Sounds
§ Wheeze
Ø Continuous, high pitched, musical sound,
longer than crackles
Ø Hissing quality, heard with expiration,
however, can be heard on inspiration
Ø Produced when air flows through narrowed
airways
Ø Associated conditions
¡ asthma, COPD
Adventitious Breath Sounds
§ Rhonchi
Ø Similar to wheezes
Ø Low pitched, snoring quality, continuous,
musical sounds
Ø Implies obstruction of larger airways by
secretions
Ø Associated condition
¡ acute bronchitis
Mech. of Rhonchi
sonorou
s
sibilant
Adventitious Breath Sounds
§ Stridor
Ø Inspiratory musical wheeze
Ø Loudest over trachea
Ø Suggests obstructed trachea or larynx
Ø Medical emergency requiring immediate
attention
Ø Associated condition
¡ inhaled foreign body
Adventitious Breath Sounds
§ Pleural Rub
Ø Discontinuous or continuous brushing sounds
Ø Heard during both inspiratory and expiratory
phases
Ø Occurs when pleural surfaces are inflamed and
rub against each other
Ø Associated conditions
¡ pleural effusion, pneumothorax
Auscultation of voice sound
Voice sound (vocal resonance)
§ METHOD: Ask the patient to say “Ninety-
nine”, should normally be muffled, In the
normal lungs, sounds are faint and their
syllables are not distinct, except over the
main bronchi
Voice sound
§ Clinical significance:
Increases in loudness and distinctness
consolidation
atelectasis
fibrosis
Decreases in loudness or absent
pleural effusion
pulmonary emphysema
Thank you
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