Respiratory Examination Positioning: Undressed to the waist and sitting over edge of bed or chair.

r. General Appearance CHANDLER (Color, Hydration, Aletness, Nutrition, Disability, Limp symmetry, External support, Respiratory distress). o Dyspnea - normal < 25bpm (bradypnea < 8 sedation, adverse outcome); accessory muscles, constraction abdominal muscles (obstruction), pursed lips. o Cyanosis deox hemoglobin (>5g/100ml and oxsat < 90% with normal Hb, if anaemic cyanosis at greater levels of desaturation. o Character of cough vocal cord paralysis (bovine cough), muffled/wheezy (COPD), loose productive (bronchitis, pneumonia, bronchiectasis), dry irritating (chest infection, asthma, CA, ACEi) o Sputum color, volume, type (purulent, mucoid, mucopurulent), presence/absence blood o Stridor obstruction (foreign body, tumor, infection, inflammation) o Hoarseness voice (recurrent laryngeal nerve palsy left CA lung or laryngeal CA) Hands o Clubbing- with HPOA (primary lung CA, primary mesothelioma NOT chronic bronchitis/pneumonia) o Staining o Wasting and weakness Compression by peripheral lung tumour of lower trunk brachial plexus o Pulse rate tachycardia (Rx asthma -agonists), pulsus paradoxus (severe asthma), Flapping tremor ( severe carbon dioxide late COPD) Face o Eyes (horners syndrome) o Skin changes (scleroderma/connective tissue disease) o Nose (polyps asthma, engorged turbinates-allergy, deviated septum-obstruction) o Tongue (central cyanosis), mouth (infection) o Sinuses (transillumination, translumination eliminated sinusistis), facial plethora (SVCO) Trachea o Displacement (upper lobe disease), tracheal tug (overexpansion due to obstruction), if dyspneic hands in supraclavicular fossa Chest o Inspection shape and symmetry (if AP>lateral = barrel shaped if > 0.9) Pectus carinatum localized prominence outward bowing sternum, repeated strong contractions diaphragm Pectus excavatum localized depression lower sternum, developmental defect. Harrisons sulcus linear depression lower ribs at site of attachment of diaphragm (childhood asthma, rickets) Kyphoscoliosis forward curvature of the spine (80% idiopathic, secondary to poliomyelitis, associated with MArfans), severe may reduce lung capacity and increase work breathing. Lesions of chest wall scars, radiotherapy (tattoo marks), subcutaneous emphysema (diffuse swelling of chest wall and neck, air tracking due to pneumothorax, rupture oesophagus or pneumomediastinum). Prominent veins

Bronchial breath sounds turbulence in airways not filtered by alveoli, hollow/blowing. Audible throughout expiration, gap btw exp and insp (consolidation). Intensity of sounds (normal or reduced intensity (COPD, pleural effusion, pneumothorax, pneumonia, large neoplasm, pulmonary collapse.) Added sounds two types ( continuous (wheezes = significant narrowing, asthma, COPD, fixed obstruction, distinguish from stridor) and interrupted (crackles low pitch = rales and high pitch = crepitations, loss of aiway stability with expiratory collapsesound caused by opening and closing of airways. Timing important, early inspiratory (disease small airways COPD), late / pan inspiratory crackles = alveoli and fine, medium or coarse. Fine pulmonary fibrosis, Medium = left heart failureo, Coarse = pools of retained secretions, gurgling, change in cough). Pleural friction rub indicates pleurisy, may be due to pneumonia or pulmonary infarction. Rare malignant involvement, pleurodynia, or spontaneous pneumothorax. Vocal resonance ausc while patient speaks, aegophany (e becomes a), ask to say 99 and listen, clear over consolidation, muffled over normal lung. Heart o Patient at 45d, measure JVP, examine precordium, listen to P2 (2 ICS on left), not louder than aortic component, if louder than pulmonary HTN (COPD, pulmonary fibrosis, pulmonary thromboembolism, marked obesity, sleep apnoea, severe kyphoscoliosis.) Abdomen o Palpate liver for ptosis (COPD or enlarged secondary deposits in lung CA). Pembertons sign raise arms over head and watch for facial plethora, cyanosis, inspiratory stridor and non-pulsatile elevation of JVP = SVCO. Feet swelling or cyanosis. Respiratory rate on exercise Temperature Forced expiratory time normal is 3s or less, note audible wheeze or cough. If smoking plus FET >9s = COPD (PPV = 9.6) Peak flow meter normal are 600L for men and 400 for women Spirometry FEV1 and FVC, normal is 80% though decreases in old age. Obstructive ventilatory defect (FEV1/FVC reduced), loss of elastic recoil or airway narrowing (asthma or COPD), Restrictive ventilatory defect (FEV1/FVC ratio higher than normal = pulmonary fibrosis, sarcoidosis, pneumonia, chest expansion), Flow volume curve exp and insp flow as fxn of exhailed volume rather than time. Yellow nail sign hypoplasia of lymphatic system, nails thickened and yellow + onycholysis. Associated with effusion and bronchiectasis, usually lymphedema of lower legs.

Physical Signs + Disease 1. Consolidation A. Signs a. Expansion reduced on affected side b. VF increased, affected c. Percussion dull d. Breath sounds bronchial e. Additional med/late/pan inspiratory crackles f. Vocal resonance increased g. Pleural rub present B. Causes a. Lobar pneumococcal (90%), H. influenza, staph b. Broncho H. influenza, pneumococcus, influenza v, adenov c. Primary atypical M. pneumonia, C. psittaci, Legionella, C. burnetti 2. Pleural effusion A. Signs a. Trachea/apex displaced b. Expansion reduced affected c. Percussion stony dull d. Breath sounds reduced absent e. Vocal reasonance reduced B. Causes a. Transudate - <30g protein/L, cardiac failure, hypoalbuminemia, hypothyroidism, Meigs syndrome (ovarian fibroma) b. Exudate - >30g protein/L, pneumonia, neoplasm-bronchial CA, metastatic CA, mesothelioma, TB, pulmonary infarction, subphrenic abscess, acute pancreatitis, conn tissue disease, drugs (methysergide), rad, trauma c. Haemothorax, Chylothorax, Empyema

(SVCO).
Movement chest wall - asymmetry chest wall movement (one side = localized pulmonary fibrosis, consolidation, collapse, pleural effusion, pneumothorax, bilateral = COPD or diffuse pulmonary fibrosis, paradoxical movement = diaphragmatic paralysis). Palpation Chest expansion (thumbs off) normal = 5cm, reduced = ipsilateral lesion. Lower lobe at back, middle upper at front. Apex beat (45d, displacement to side of lesion in ipsilateral lobe collapse or localized fibrosis, away by pleural effusion or tension pneumothorax, impalpable in COPD. Vocal fremitus palpate front of chest with palm (99) Ribs compress, looking for pain (trauma, tumor deposition, bone disease or severe coughing) Percussion posterior cross arms; liver dullness (normal is fifth rib in right MCL, cardiac dullness (may be dec in COPD) Ausculation Breath sounds Normal Breath Sounds breath through mouth, louder longer on inspiration and no gap between insp and exp sounds. Transmission of sounds in airways through normal lung.

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3. Pneumothorax A. Signs a. Expansion reduced affected b. Percussion hyperresonance if large c. Breath sounds greatly reduced/absent d. + Subcutaneous emphysema e. No signs if pneumothorax is small (<30%) B. Causes a. Spontaneous subpleural bullae rupture (tall thin), emphysema bulla rupture, rare asthma, lung abscess, bronchial CA, eosinophilic granuloma, firbosis, marfans, insertion CVC. b. Traumatic rib fracture, penetrating chest wall injury 4. Tension Pneumothorax A. Signs patient is tachypnoeic and cyanosed, hypotensive a. Trachea and apex beat displaces b. Expansion reduced/absent c. Percussion hyperresonant d. Breath sounds absent e. Vocal resonance absent B. Causes a. Trauma, mechanical ventilation high pressure, spontaneous 5. Bronchiectasis A. Signs a. Systemic fever, cachexia, sinusitis (70%) b. Clubbing and cyanosis c. Sputum voluminous, purulent, foul smelling d. Coarse pan inspiratory or late inspiratory crackels e. Signs of severe bronchiectasis copious sputum, haemoptysis, clubbing, widespread crackles, signs airway obstruction, sings of respiratory failure, cor pulmonale, signs of secondary amyloidosis B. Causes a. Congenital primary ciliary dyskinesia (immotile cilia syndrome, cystic fibrosis, congenital hypogammaglobinaemia C. Acquired infections in childhood, whooping cough, pneumonia, or measles, localized disease such as a foreign body, CA, TB, allergic bronchopulmonary aspergillosis 6. Broncial Asthma A. Signs a. Wheezing b. Tachypnoea c. Dry or productive cough d. Tachycardia e. Prolonged expiration f. Prolonged FET g. Use accessory muscles h. Hyperinflated chest (inc AP diameter) i. Inspirtory and expiratory wheeze 11.

j.

Signs of severe asthma (exhaustion, fear, inability to speak, drowy, cyanosis, tachycardia, pulsus paradoxus, reduced breath sounds (silent chest).

7. COPD A. Diagnosis on three findings a. History of heavy smoking (>70 packet years) b. Previous Dx COPD c. Reduced breath sounds *If 2-3 present positive LR is 25.7 8. Emphysema A, Signs pink puffers a. Barrel shaped chest b. Pursed lip breathing c. Accessory muscles d. Palpation reduced expansion, hyperinflation e. Percussion hyperresonant with dec liver dull f. Breath sounds decreased, EIC g. Wheeze often absent h. Signs of RHF B. Causes a. Smoking b. Alpha1 antitrypsin deficiency 9. Chronic Bronchitis A. Signs bronchial hypersecretion and airways obstr a. Loose cough and sputum b. Cyanosis blue bloaters c. Palpation hyperinflated w/ reduced expansion d. Percussion increased resonance e. Breath sounds red with end exp high or low crackles f. Signs RHF B. Causes a. Smoking b. Recurrent infection 10. Pulmonary fibrosis A. Signs a. General dyspnea, cyanosis, clubbing b. Palpation expansion slightly red c. Auscultation fine (velco) late insp/pan d. Signs of assoc connective tissue disease: RA, SLE< Scleroderma, Sjorgens, polymyositis, dermatomyositis B. Causes a. Upper lobes = SCHART silicosis, sarcoidosis, coal workers, histiocytosis, ankylosing spondylitis, allergic bronchopulmonary aspergillosis, radiation, TB b. Lower lobe RASCO RA, asbestosis, scleroderma, cryptogenic firbosis alveolitis, other (drugs = busulphan, bleomycin, nitrofurantoin, hydralazine, methotrexate, amiodarone.

12. Mediastinal Compression A. Superior vena caval obstruction a. Facial plethora, exopthalmos, conjunctival injection, venous dilatation in fundi, pulsatile JVP, enlarged thyroid, suprasclavicular LA, + pembertons b. Trachial compression stridor, resp distress c. Recurrent laryngeal nerve involvement hoarseness of voice d. Horners syndrome e. Paralysis of phrenyc nerve dullness to percussion at affected base, absent breathsounds 13. Carcinoma of lung A. Respiratory signs a. Haemoptysis b. Clubbing (HPOA) c. Lobar collapse d. Pneumonia e. Pleural effusion f. Fixed inspiratory wheeze g. Tender ribs h. MEdiastinal compression, signs i. Supraclavicular or axillary LA B. Non=metastatic extrapulmonary manifestations a. Anorexia, weight loss, cachexia, fever b. Endocrine changes: i. Hypercalcemia (PTLH) ii. Hyponatremia ADH iii. Ectopic ACTH syndrome iv. Carcinoid syndrome v. Gynaecomastia vi. Hypoglycaemia c. Neurological manigestations i. Eaton-Lambert syndrome (prog muscle weak) ii. Retinal blindness (small cell) iii. Peeripheral neuropathy iv. Subacute cerebellar degeneration v. Polymyositis, Cortical degeneration d. Haematological features i. Migrating venous thrombophlebitis ii. DIC iii. Anaemia e. Skin i. Acanthosis nigricans, dermatomyositis f. Renal i. Nephrotic syndrome due to membranous GN 14. Sarcoidosis A. Pulmonary signs a. Lungs no signs usually, although 80% have lung 16. involvement B. Extrapulmonary signs a. Skin lupus pernio (violaceous patches on face) b. Eyes ciliary injection, anterior uveitis c. Lymph nodes generalized LA d. Liver and Spleen enlarged

e. f. g. h. i. 15. A. B. C.

Parotids gland enlargement CNS cranial nerve lesions, peripheral neuropathy Musculoskeletal arthralgia, swollen fingers Heart heart block, presenting as syncope Signs of hypercalcemia

Pulmonary embolism General signs tachycardia, tachypnoea, fever Lungs pleural friction rub Massive embolism elevated JVP, right ventricular gallop, right ventricular heave, tricuspid regurgitation, increased pulmonary component of second heart s. D. Signs of deep venous thrombosis fewer than 50% have clinical evidence of source. Chest X ray checklist A airway (midline, no deformities, no paratracheal masses B Bones and soft tissue (fractures, subcut emphysema C cardiac size, silhouette, retrocardiac density normal D diaphragms (R>L 1-3cm, costophrenic angles sharp E Equal volume (count ribs, look for med shift F Fine detail pleura and lung parenchyma G Gastric bubble, above should not be > 0.5cm H Hilum (left above right by 3cm (thumb) Classification Systems British Thoracic Society Comm Acq Pneumonia 1. Confusion 2. Urea - >7mmol/L 3. Respiratory rate: >30/min 4. BP: Diastolic < 30mmHg, systolic <90mmHg GOLD Criteria COPD Severity 0 At Risk Chronic Cough Sputum Production Normal Sp I Mild W/wo cough/sputum FEV1/FVC<0.7, FEV1>80 II Moderate FEV1 < 80% III Severe FEV1 < 50% IV Very severe FEV 1 < 30% or < 50% w/ RHF Wells Diagnostic Scoring System for PE, if <4 LR = 8% 3p Clinical signs and Sx DVT 3p Alternative Dx is less likely than PE 1.5p Heart rate > 100b/min 1.5p Immobile/Surgery last 4w 1.5p Previous PE/DVT 1p Hemoptysis 1p Malignancy