Clinical examination of the Respiratory system

Demographic profile
Name:
Age:
Sex:
Occupation:
History taking
Presenting complaint:
1. Cough (dry or wet): No complaint of cough
2. Sputum : No sputum
3. Haemoptysis : No blood in the sputum
4. Chest pain: No complaint of chest pain
5. Dyspnoea: No difficulty in breathing
6. Wheeze or rhonchi: No complaint of whistling noise during breathing
Past history:
surgery
Family history:
Asthma
Tuberculosis
Habitual history:
Smoking

General examination

The subject is conscious, Oriented to time, place and person, Co-operative.

1. Physique: Well-built and well nourished
2. Voice: No abnormal voice
3. Cervical Lymphadenopathy: No enlargement of lymph nodes
4. Anemia: No pallor
5. Cyanosis: No bluish discolouration
6. Finger Clubbing: No nail bed fluctuation
7. Use of accessory muscles during breathing: No involvement of accessory muscles during breathing
No icterus, No pedal edema, No Hypo/Hyperpigmented skin patches.

Vitals:
Afebrile
Pulse - __ beats /min, regular rhythm, normal volume, normal character, no vessel wall thickening, no radio
radial delay, all other peripheral pulses are felt equally on both sides.
Blood Pressure – __/__ mmHg measured in right arm sitting posture by auscultatory method.

Systematic examination:
Inspection:
1. Position of the trachea: Appears to be in the midline
2. Shape of the chest: Elliptical
3. Symmetry of chest: Bilaterally symmetrical
4. Chest movements: Symmetrical and equal chest movements on both sides
5. Apical impulse: not visible
6. Any scars, Sinuses: No
7. Any chest wall deformity /Spinal deformity: No
8. Any dilated veins over the chest region: No
9. Respiratory movements
a. Rate of Respiration: __/ min.
b. Depth of respiration: Normal (Neither shallow nor deep)
 c. Rhythm of respiration: Regular
d. Type of respiration: Abdominothoracic type / Thoracoabdominal type
e. Abnormal type of respiration: No abnormal type seen

Palpation:
All inspectory findings are confirmed by palpation

1. Position of the trachea: Felt in the midline

2. Any tenderness over the ribs: No
3. Chest expansion: Expands equally on both sides. Both thumb recedes equally
4. Apex beat: Felt at the left 5th intercostal space ½ inch medial to the midclavicular line.
5. Measurement of chest expansion
Inspiration =
Expiration =
Chest expansion = (inspiration)- (expiration)

6. Vocal Fremitus:
S.no Areas Vocal fremitus
1. Supraclavicular Spoken voice is felt with equal intensity on both sides
2. Infraclavicular Spoken voice is felt with equal intensity on both sides
3. Mammary Spoken voice is felt with equal intensity on both sides
4. Inframammary Spoken voice is felt with equal intensity on both sides
5. Axillary Spoken voice is felt with equal intensity on both sides
6. Infraaxillary Spoken voice is felt with equal intensity on both sides
7. Suprascapular Spoken voice is felt with equal intensity on both sides
8. Interscapular Felt with normal intensity
1.upper
2.middle
3.lower
9. infrascapular Spoken voice is felt with equal intensity on both sides

Percussion:
Region Areas Right Left
Anterior chest wall
1. Supraclavicular Resonance Resonance
2. Clavicular Resonance Resonance
3. Infraclavicular Resonance Resonance
4. Mammary Resonance Cardiac dullness
5. Inframammary Liver dullness Cardiac dullness
Lateral chest wall
6. Axillary Resonance Resonance
7. Infra axillary Resonance Resonance
Posterior chest wall
8. Suprascapular Resonance Resonance
9. Interscapular Resonance Resonance
1.upper
2.middle
3.lower
10. Infrascapular Resonance Resonance
Auscultation:
1. Breath sounds:
Bronchial breath sounds: High pitched, blowing sound
Vesicular breath sounds: Low pitched, rustling sound

S.no Areas Breath sounds

1. Trachea Bronchial
2. Interscapular Bronchial

s.no Areas Right Left

1. supraclavicular Vesicular Vesicular
2. infraclavicular Vesicular Vesicular
3. Mammary Vesicular Vesicular
4. Inframammary Vesicular Vesicular
5. Axillary Vesicular Vesicular
6. Infraaxillary Vesicular Vesicular
7. Suprascapular Vesicular Vesicular
8. infrascapular Vesicular Vesicular

2. Vocal resonance:
S.no Areas Vocal resonance (Right & Left)
1. Supraclavicular Spoken voice is heard with equal intensity on both sides
2. Infraclavicular Spoken voice is heard with equal intensity on both sides
3. Mammary Spoken voice is heard with equal intensity on both sides
4. Inframammary Spoken voice is heard with equal intensity on both sides
5. Axillary Spoken voice is heard with equal intensity on both sides
6. Infra axillary Spoken voice is heard with equal intensity on both sides
7. Suprascapular Spoken voice is heard with equal intensity on both sides
8. Interscapular Heard with normal intensity
1.upper
2.middle
3.lower
9. Infrascapular Spoken voice is heard with equal intensity on both sides

3. Adventitious sounds:
No adventitious sounds like plural rub, rhonchi or wheeze, crepitations are heard.

Result:
The clinical examination of the respiratory system in the given subject is found to be normal.