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Examination of the Respiratory Examination

Introduce yourself. Explain procedure Obtain consent Position patient supine and inclined at 45 degrees Expose the chest to the waist Clubbing: Thoracic Tumours: Bronchial Carcinoma Mesothelioma Pleural Fibroma Atrial Myxoma Thymoma Oesophageal Cancer Sepsis: Bronchiectasis (+CF) Lung Abcess Infective Endocarditis TB Empyema Interstitial: Fibrosing Alveolitis Asbestosis AV Shunt: AV malformations Cyanotic CHD Non-Thoracic: Hepatic Cirrhosis IBD Coeliac Disease

Inspect: General appearance Hands: colour, nails, CO2 Flap Face Tongue Neck - JVP Front of chest: deformity, scars, Chest movement and accessory muscle activity Respiratory rate

Tracheal Deviation: Towards Lesion: Upper lobe/lung collapse Upper lobe Fibrosis Pneumonectomy Away from Lesion: Tension Pneumothorax Massive PE Upper Mediastinal Mass Retrosternal Goitre Lymphoma Lung Cancer

Palpate: Trachea Lymph nodes: neck and axilla Chest tenderness or lumps Depth and symmetry of breathing Tactile vocal fremitus: four sites from top to bottom

Chest Wall Deformities Barrel Chest: COPD Kyphoscoliosis Pectus Carinatum: Severe childhood asthma / osteomalacia Pectus Excavatum

Percussion: Resonant: Normal Lung Hyperresonant: Pneumothorax Dull: Consolidation Lung/lobe collapse Severe Fibrosis Stoney Dull: Pleural Effusion Haemothorax

Percuss: Clavicles Upper zone Mid zone Lower zone Laterally - comparing right and left at each stage Tactile Vocal Fremitus: Trasmission of Vibration from mouth to chest wall Over areas of Dull Percussion: TVF: Consolidation/Fibrosis TVF: Fluid/Collapse

Decreased Chest Expansion: Unilateral: Pleural Effusion Lung/lobe collapse Pneumohthorax Unilateral Fibrosis Bilateral Advanced COPD Diffuse Fibrosis

Auscultate: Upper zone Mid zone Lower zones Laterally -comparing right and left at each stage Check vocal resonance at same sites Sit patient forward and repeat inspection, palpation, percussion and auscultation on the back of the chest. Look for Sacral/Ankle Oedema Breath Sounds: Normal = Vesicular rustling quality Bronchial Breathing: High Pitched Blowing Quality Insp/Exp Similar length and intensity Characteristic Pause

Diminished Vesicular Breathing: Decreased Conduction: Obesity Pleural Effusion Pheumothorax Decreased Airflow Generalised: COPD Localised: collapse

Cause: uniformly conducting tissue Common: Consolidation (pneumonia) Uncommon: Local Fibrosis Top of Pleural Effusion Collapsed lung with major bronchus patent

Crackles Musical Quality Wheeze: (inspiratory): Opening of narrowed Airway Osscilating collapsed small airways Interrupted, non musical sounds Usually Loudest Expiration Early: Inspiratory = Severe Airway disease Mediastinal DDx Small airway disease (bronchiolitis) Shift Middle: rub: grating sound creaking leather Friction Pulmonary Oedema pleural inflammation and thickening. Late: Stridor: on inspiration Pleural Effusion no/away Fine: of the upper airways narrowingPulmonary Fibrosis Medium: Pulmonary Oedema Consolidation No Coarse: Bronchial Secretions (COPD, (pneumonia) Pneumonia) Lobar - Coarse Biphasic: Bronchiectasis Collapse Towards Pneumothorax No (simple) Away (Tension) Pleural No Thickening Asthma/COPD No

Expansion

Percussion

Tactile Vocal Fremitus/ Vocal Resonance

Auscultation

Normal/

Stoney Dull Dull Dull Hyperresonant Dull

Breath Sounds
Occasional Rub Bronchial Breathing + Crackles (coarse) Breath Sounds Breath Sounds

Normal/

Breath Sounds
Polyphonic wheeze COPD: Coarse Crackles