Respiratory System Examination Full Notes for Medical Students

THE RESPIRATORY SYSTEM EXAMINATION

Introduction, Wash Hands, Consent
General Inspection:
- Alert/Orientated
- Pain/Distress
- Body Habitus:
  - Obesity (Blue Bloaters)
  - Cachexia (Pink Puffers, Malignancy)
  - Chest Deformities (Pectus Excavatum, Pectus Carinatum, Barrel Chest, Kyphosis, Lordosis)
  - Chest Scars
- Respiratory Distress?
  - Tripoding
  - Pursed-Lip Breathing (Obstructive Lung Disease)
  - Dyspnoea
  - Audible Wheeze/Cough/Stridor (Obstructive Lung Disease)
  - Intercostal Recession & Tracheal Tug (Restrictive Lung Disease)
- Colour:
  - Cyanosis (Blue Bloaters)
  - Plethora (Pink Puffers)
  - Pallor (Anaemia)

Vital Signs:
- Pulse:
  - Tachycardia (Anaemia, Cyanosis, Infection)
- Blood Pressure:
  - Typically Normal
  - Postural Variation (Severe Anaemia)
  - Pulsus Paradoxus (Severe COPD, Asthma, Tamponade, Pneumothorax)
- Respiratory Rate:
  - Tachypnoeic (Anaemia & All Lung Diseases)
- SPO2:
  - May be reduced or preserved (Must be recorded if the reading was on supplemental O2)
- Temperature:
  - Fever (Infection)
Hands:
- Perfusion/CRT
- Clubbing (Chronic Cyanosis)
- Pale Nails (Anaemia)
- Koilonychia (Iron Deficiency Anaemia)
- Palmar Crease Pallor (Anaemia)
- Tar Staining (Smoking)
- Intrinsic Hand Muscle Wasting *(Pancoast Tumour)
- Hand Muscle Weakness *(Pancoast Tumour)
- Asterixis (CO2 Retention)
Arms:
- HPOA (Lung Tumour)
- Pemberton’s Sign *(SVC Obstruction due to Pancoast Tumour)

Face:
- Plethora (Polycythaemia, SVC Obstruction)
- Skin Lesions (SCC/BCCs)
- Conjunctival Pallor (Anaemia); Subconjunctival Haemorrhages (Severe Cough)
- Atrophic Glossitis/Angular Stomatitis (All Types of Anaemia)
- Hydration
- Central/Peripheral Cyanosis (All Lung Pathology)
- Leukoplakia/Erythroplakia (Premalignancy from Smoking)
- Tar-Stained Teeth (Smoking)
- HORNERS Syndrome (Sympathetic Nerve Palsy):
  - Unilateral Ptosis, Anhydrosis, Miosis (Pinpoint Pupil, Enophthalmos, Laryngeal Hoarseness
Neck:
- Virchow’s Node (Supraclavicular) (Malignancy)
- Cervical Lymphadenopathy (Infection, Malignancy)
- ↑JVP (SVC Obstruction – Pancoast Tumour)(or Pulmonary Hypertension)
- Abdojugular Reflux (Negative if SVC Obstruction)
- Tracheal Deviation (Atelectasis, Pneumothorax)
- Tracheal Tug (Restrictive Lung Disease)
Chest – ONCE FROM BEHIND, ONCE FROM THE BACK:
- Inspection:
  - Chest Deformities
  - Scars
  - Visualise Chest Expansion FROM BEHIND
- Palpation:
  - Chest Expansion >5cm = Normal (From Behind)
  - ↑Tactile Fremitis (Consolidation)
  - Hoover’s Sign (Severe COPD, Emphysema, Asthma)
  - Chest Wall Tenderness (Malignancy)
- Percussion:
  - Dullness = Consolidation
  - Stony Dullness = Pleural Effusion
  - Hyperresonant = COPD/Emphysema/Asthma/Pneumothorax
  - Lung Borders for Hyperinflation (6^th rib anteriorly = normal) (COPD, Emphysema, Asthma)
- Auscultation:
  - ↑Vocal Resonance
  - Breath Sounds:
    - Vesicular = Normal
    - Bronchial = Consolidation
    - Pleuritic Rub = Pleuritis/Mesothelioma
    - Muffled = Pleural Effusion
    - Inspiratory Crepitations/Crackles = Pulmonary Oedema/Pneumonia
    - Expiratory Wheezes = Bronchial Disease
- (+ Mention Cardiovascular Examination)
Abdomen:
- Percuss & Palpate for Liver Ptosis (due to Lung Hyperinflation)
Legs:
- Oedema
- Calf Tenderness & Erythema (DVT➔PE)
- Signs of Venous Stasis – Shiny Skin, Hair Loss, Venous Ulcers (DVT➔PE)
Feet:
- Perfusion/CRT
- Clubbing
- Koilonychia (Iron Deficiency Anaemia)
- Pale Nails (Anaemia)

Respiratory Disorders and It’s Clinical Co-relation

Acute Bronchitis:

TYPICAL Symptoms/Presentation:
- Fever
- Productive, Wheezy Cough, +/- Dyspnoea
- + URTI Symptoms (Sore-Throat, Runny Nose, Sneezing, Hoarseness)
- + Non-Specific Viral (Fever, Malaise, Headache, Myalgia)

TYPICAL Clinical Signs:
- Vitals:
  - Fever, Tachycardia, Tachypnoea
- Other:
  - End-Expiratory Wheezes
- Signs of Causes:
  - 2^o to URTI

Bronchial Asthma (Variable Obstructive):

TYPICAL Symptoms/Presentation:
- Asymptomatic unless during an “Attack”:
  - Wheezy Dry Cough,
  - Dyspnoea
  - Anxiety
- If Severe:
  - Exhaustion
  - Inability to Speak in Full Sentences
TYPICAL Clinical Signs:
- Vitals:
  - Tachypnoea, Tachycardia,
- Other:
  - Peripheral Cyanosis, Wheals, Hives, Rhinitis
  - Accessory Muscle Usage
  - Inspiratory Wheezes, Marked Expiratory Wheezes, Prolonged Expiratory Phase,
  - ↑Chest Expansion (+/- Hyperinflated Lung Fields)
  - Reduced Breath Sounds (Silent if Severe)
  - NO signs of Consolidation (Normal ↑Fremitis, ↓Percussion & ↑Vocal Resonance)
  - (+/- Pulsus Paradoxus if Severe)
- Signs of Causes:
  - Signs of Atopia (Wheals, Allergic Rhinitis, Hives)
  - Family History

Bronchiectasis:

(Chronic Bronchial Thickening & Dilation + Mucus Accumulation due to ↓Mucociliary)

TYPICAL Symptoms/Presentation:
- Wheezy Productive Cough
- Copious Purulent Sputum (Green/Yellow)
- (+/- Haemoptysis)
TYPICAL Clinical Signs:
- Vitals:
  - Tachypnoea, Tachycardia, (+/- Fever if Infection)
- Other:
  - Clubbing, Cyanosis, Cachexia,
  - Foul-Smelling Sputum (Sometimes Haemoptysis)
  - Coarse Pan-Inspiratory Crackles, End-Expiratory Wheezes
  - (+/- Cor-Pulmonale if Severe)
- Signs of Causes:
  - **Cystic Fibrosis (Clubbing, Peripheral Cyanosis, Sputum, Salty Frost, Wasting)

Emphysema (Dry):

TYPICAL Symptoms/Presentation:
- Pink Puffers:
  - Wheeze
  - Severe Dyspnoea
  - Weight Loss
  - (+/- Peripheral Oedema & Ascites in Corpulmonale)
TYPICAL Clinical Signs:
- Vitals:
  - Tachypnoea, Tachycardia
- Other:
  - (NB: Does NOT cause Clubbing or Haemoptysis)
  - Thin (No Oedema), Pink (No Cyanosis),
  - Tachypnoea, Accessory Muscle Usage, Intercostal Recession, Tripoding (Stooping), Pursed- Lip Breathing, Barrel Chest,
  - ↓Chest Expansion, Hoover’s Sign Positive, Tracheal Tug
  - Hyperinflated Lungs Fields, Hyperresonant Percussion (Gas Trapping)
  - ↓Breath Sounds, Early Expiratory Crackles (Small Airway Disease), (+/- Wheeze).
  - (+/-↑JVP, Ascites, Oedema if RVF Due to Cor-Pulmonale)
- Signs of Causes:
  - Heavy Smoking (Tar Staining, Smoke Smell, Yellow Teeth, Leuko/Erythroplakia)
  - (If Young Age – Think Congenital a1-Antitrypsin Deficiency.)

Chronic Bronchitis (Wet): (+/- Emphysema)

TYPICAL Symptoms/Presentation:
- Blue Bloaters:
  - Wet, Wheezy Productive Cough
  - Chronic Sputum Production (>3mths/year for >2years)
  - Severe Dyspnoea
  - Oedema
TYPICAL Clinical Signs:
- Vitals:
  - Tachypnoea, Tachycardia
- Other:
  - (NB: Does NOT cause Clubbing or Haemoptysis)
  - Obese Patient, Gross Cyanosis (Central & Peripheral),
  - Cor-Pulmonale (Ascites, Oedema, Cyanosis, ↑JVP)
  - Tachypnoea, Accessory Muscle Usage, Intercostal Recession, Tripoding (Stooping), Pursed- Lip Breathing, Barrel Chest
  - ↓Chest Expansion, Positive Hoover’s Sign, Tracheal Tug
  - Hyperinflated Lung Fields, Hyperresonant Percussion
  - ↓Breath Sounds, End-Expiratory Wheezes (Bronchial Disease)
- Signs of Causes:
  - Heavy Smoking (Tar Staining, Smoke Smell, Yellow Teeth, Leuko/Erythroplakia)

Pneumonia (Consolidation):

TYPICAL Symptoms/Presentation:
- Acute High Fever + Chills + Rigors
- Productive Cough (+/- Haemoptysis)
- Pleuritic Chest Pain
TYPICAL Clinical Signs:
- Vitals:
  - Fever, Tachycardia, Tachypnoea
- Other:
  - Appears Ill: P/C-Cyanosis, Exhaustion, Dyspnoeic, Respiratory Distress,
  - Consolidation: Area of ↓Expansion, ↑Tactile Fremitis, Dull Percussion, Bronchial Breathing, ↑ Vocal Resonance.
  - Bronchial Breath Sounds, Pleural Friction Rub, Pan-Inspiratory Crackles
- Signs of Causes:
  - - Broncho Pneumonia ➔ Diffuse, Patchy Consolidation
    - Lobar Pneumonia ➔ Localised Consolidation

Melioidosis: (Burkholderia Pseudomallei)

TYPICAL Symptoms/Presentation:
- Presents Similar to TB but with Pneumonia:
  - PUO (Fever, Night Sweats, Chills, Rigors)
  - Skin Lesions (Abscesses/Ulcers)
  - Pneumonia (Dyspnoea, Cough, Sputum, Pleuritic Chest Pain)
- (May ➔ Sepsis)
TYPICAL Clinical Signs:
- Vitals:
  - Fever, Tachycardia, Tachypnoea
- Other:
  - Cyanosis, Dyspnoea, Skin Lesions (Melioid Abscesses/Ulcers), Lymphadenopathy,
  - Consolidation: Area of ↓Expansion, ↑Tactile Fremitis, Dull Percussion, Bronchial Breathing, ↑ Vocal Resonance.
  - Bronchial Breath Sounds, Pleural Friction Rub, Pan-Inspiratory Crackles
- Signs of Causes:
  - - Living in Tropical NQ

Pulmonary Tuberculosis:

TYPICAL Symptoms/Presentation:
- Fever, Night Sweats,
- Chronic Productive Cough (+/- Haemoptysis)
- Weight Loss
- +/- Pleuritic Chest Pain

TYPICAL Clinical Signs:
- Vitals:
  - Fever, Tachycardia, Tachypnoea
- Other:
  - Cachexia, Dyspnoea, Lymphadenopathy, Hepatomegaly, Splenomegaly,
  - (NB: Cavitation Can ➔ Pleural Effusion (Stony Dullnes), Haemoptysis, Atelectasis)
- Signs of Causes:
  - Immunocompromise (HIV), Immigrant, Overseas Travel,

Pulmonary Embolism:

TYPICAL Symptoms/Presentation:
- Sudden, Severe Dyspnoea
- Pleuritic Chest Pain
- (+/- Haemoptysis)
- (+/- Syncope)
TYPICAL Clinical Signs:
- Vitals:
  - Fever, Tachycardia, Tachypnoea, Hypotension (LVF)
- Other:
  - RVF ➔ Cool Peripheries, ↑CRT, Peripheral Cyanosis, ↑JVP, RV-Heave, Tricuspid Regurg Murmur
  - ↓Resp.Function ➔ Central Cyanosis
  - Pleural Friction Rub,
- Signs of Causes:
  - DVT – Calf Pain, Calf Tenderness, Calf Swelling/Erythema, Pedal Oedema.
  - (B/G of Pregnancy, Air Travel, Recent Surgery, Clotting Disorders)

Pulmonary Hypertension & Corpulmonale: (LVF, COPD)

TYPICAL Symptoms/Presentation:
- RVF Secondary to Pulmonary Hypertension:
  - COPD: Dyspnoea, Cough, Wheeze
  - Pul HTN: Cough/Dyspnoea/PND/Orthopnea
  - RVF: Swelling (Legs, Abdo), Chest Pain
TYPICAL Clinical Signs:
- Vitals:
  - Tachycardia (if LVF), Tachypnoea (if COPD/LVF), Hypotension (If LVF), Afebrile
- Other:
  - If LVF: Cool Peripheries, ↑CRT, Peripheral & Central Cyanosis, Low Volume Pulse
  - If COPD: Clubbing, Tar Staining, Peripheral & Central Cyanosis
  - RVF: ↑JVP + a-Wave, RV-Heave, Medium Pan-Inspiratory Crackles in Lung Bases, Loud S2 (closure of Pul.Valve) Abdojugular Reflux Positive, Portal Hypertension (Tender Hepatomegaly), Ascites, Sacral/Pedal Oedema,
- Signs of Causes:
  - LVF, Smoking, COPD, IPF

Pneumothorax (Including Tension Px):

(Air in Pleural Space)

TYPICAL Symptoms/Presentation:
- Similar Presentation to Pulmonary Embolism:
  - Sudden, Severe Dyspnoea
  - Pleuritic Chest Pain
  - (+/- Syncope)
TYPICAL Clinical Signs:
- Vitals:
  - Tachycardia, Tachypnoea, Hypotension (Mediastinal Compression),
- Other:
  - Cyanosis, Dyspnoea, Anxiety, Respiratory Distress,
  - Peripheral Shutdown (↑CRT, Cool Pale Peripheries, Peripheral Cyanosis, Low-Vol Tachycardia)
  - Tracheal Deviation AWAY from Affected Side (If Tension Ptx),
  - @Site of Pneumothorax: ↓Chest Expansion, ↓Tactile Fremitis, Hyperresonant Percussion, Absent Breath Sounds, Absent Vocal Resonance.
  - (IF KINKING OF GREAT VESSELS ➔ Syncope, Negative Abdojugular Reflux)
- Signs of Causes:
  - Signs of Trauma, Signs of Smoking (Emphysema), Mechanical Ventilation,

Atelectasis: (Collapsed Lung):

(Due to Airway Obstruction by Foreign Object or Cancer)

TYPICAL Symptoms/Presentation:
- Dyspnoea
- Chest Pain
- (May Quickly ➔ Pneumonia)
TYPICAL Clinical Signs:
- Vitals:
  - Tachypnoea
- Other:
  - Dyspnoea,
  - Tracheal Deviation TOWARDS the Affected Side.
  - @Site of Atelectasis: ↓Chest Expansion, ↑Tactile Fremitis, Dull Percussion, Bronchial Breath Sounds, ↑Vocal Resonance
- Signs of Causes:
  - Mucous (Asthma, Cystic Fibrosis), Foreign Body Aspiration, Bronchial Ca (Cachexia)

Pleural Effusion:

TYPICAL Symptoms/Presentation:
- Sudden Severe Pleuritic Chest Pain (Worse on Inspiration)
- Dyspnoea
- Dry Cough
TYPICAL Clinical Signs:
- Vitals:
  - Fever, Tachypnoea, Tachycardia,
- Other:
  - Tracheal Deviation AWAY from Effusion
  - Displaced Apex Beat AWAY from Effusion
  - @ Site of Effusion: ↓Chest Expansion, ↓Tactile Fremitis, STONY DULLNESS, ↓Breath Sounds, ↓Vocal Resonance
- Signs of Causes:
  - NB: ALWAYS Suspect Mesothelioma
  - Portal Hypertension, Hypoalbuminaemia (CLD, Nephrotic Synd), Congestive L-Heart Failure, Lung Injury, Lung Infection.

Interstitial Lung Diseases: (“Pneumoconioses”)

(Inhaled Dusts: Anthracosis, Asbestosis, Silicosis)

TYPICAL Symptoms/Presentation:
- (On a Background of Occupational Exposure)
  - Chronic Cough (+/- Productive)
  - Dyspnoea (+/- Cyanosis)
- (Asbestosis is most severe and can ➔Mesothelioma ➔ Pleural Effusions, Metastases)
TYPICAL Clinical Signs:
- Vitals:
  - Tachypnoea
- Other:
  - Clubbing, Dyspnoea, Cyanosis, Cachexia, Accessory Muscle Usage, Intercostal Recession, Tracheal Tug.
  - Cough
  - ↓Chest Expansion,
  - Fine Pan-Inspiratory Crackles
  - + Restrictive Pulmonary Function Tests.
- Signs of Causes:
  - - Signs of Connective Tissue Diseases (Rheumatoid Arthritis, SLE, Scleroderma, Sjogren’s)

Idiopathic Pulmonary Fibrosis:

TYPICAL Symptoms/Presentation:
- Gradual Onset of Symptoms
  - Progressive Dyspnoea
  - Dry Cough
- (Very Poor Prognosis – 3yrs – No Treatment)
TYPICAL Clinical Signs:
- Vitals:
  - Tachypnoea
- Other:
  - Hypoxia/Cyanosis ➔ Clubbing
  - Dry, Velcro-like inspiratory crackles
- Signs of Causes:
  - Restrictive Pattern on Pulmonary Function Tests (↓VC, ↓TLC)

Sarcoidosis: (Idiopathic Immune ➔ Non-Caseating Granulomas)

TYPICAL Symptoms/Presentation:
- Systemic Disease – (Lungs, Eyes, Skin, LNs, Liver & Spleen)
  - General: Fatigue, Weight Loss,
  - Lungs: Dyspnoea, Dry Hacking Cough
  - Eyes: Uveitis
  - Skin: Erythema Nodosum (Nodules on Shins), Lupus Pernio (Red plaques), Hypertrophic Scars
  - LNs: Lymphadenopathy
  - Liver/Spleen: Organomegaly
  - MSK: Arthralgia, Finger Swelling
  - Heart: Heart Block, Syncope, Corpulmonale
TYPICAL Clinical Signs:
- Vitals:
  - Tachypnoea
- Other:
  - Dyspnoea, Cyanosis, Cachexia, Accessory Muscle Usage, Intercostal Recession, Tracheal Tug.
  - Cough
  - ↓Chest Expansion,
  - Fine Pan-Inspiratory Crackles
  - + Restrictive Pulmonary Function Tests.

Wegener’s Granulomatosis: (Autoimmune)

TYPICAL Symptoms/Presentation:
- Many Non-Specific Symptoms (Arthralgia, Myalgia, Night Sweats, Weight Loss, Red Eyes, URTI, Chronic Ear Infections, Fever)
- BUT Relevant as it can ➔ Pneumonia:
  - Dyspnoea
  - Cough (+/- Haemoptysis)
TYPICAL Clinical Signs:
- Vitals:
  - Fever, Tachycardia, Tachypnoea,
- Other:
  - Cachexia, Epistaxis, Nasal Sores, Various Skin Lesions, Haematuria, Conjunctivitis, Chest Pain, Cough (+/- Haemoptysis), Dyspnoea, Weakness, Wheezing.

Mediastinal Compression: (Lung Ca, Lymphoma, Retrosternal Goitre, Aortic Aneurysm)

TYPICAL Symptoms/Presentation:
- Facial Plethora
- Supraclavicular Lymphadenopathy
- Hoarseness
- Horner’s Syndrome
- Dyspnoea
TYPICAL Clinical Signs:
- Other:
  - SVC Obstruction: Facial Cyanosis, Facial Plethora, Positive Pemberton’s, Periorbital Oedema, ↑Non-Pulsatile JVP
  - Mechanical Compression: Stridor (Tracheal Compression), Tracheal Deviation, Hoarseness
  - Nerve Compression:
  - Horner’s Syndrome (Unilateral Ptosis, Anhydrosis, Miosis, Enophthalmos, Laryngeal Hoarseness)
  - Unilateral Phrenic Nerve Paralysis ➔ Unilateral Diaphragm Paralysis ➔ Asymmetrical Chest Expansion.
- Signs of Causes:
  - ↑Thyroid Gland (Retrosternal Goitre)
  - Virchow’s Node (R-Supraclavicular Lymphadenopathy) for Lung Cancer.

Lung Cancers:

TYPICAL Symptoms/Presentation:
- Often Asymptomatic..But may ➔ :
  - Fever, Night Sweats, Weight Loss, Fatigue
  - Dyspnoea
  - Cough (+/- Haemoptysis) (+/- Wheeze if Bronchial involvement)
- (Don’t Forget +/- Paraneoplastic Syndrome)
  - Hypercalcaemia (↑PTH)
  - Hyponatraemia (↑ADH)
  - Cushing’s (↑ACTH)
  - Carcinoid Syndrome (↑Serotonin)
  - Gynaecomastia (↑Gonadotrophins)
TYPICAL Clinical Signs:
- Vitals:
  - Fever, Tachypnoea (late stages)
- Other:
  - General Signs:
    - Anorexia, Clubbing, HPOA (Wrist Tenderness), Intrinsic Hand Muscle Wasting, Virchow’s Node (R-Supraclavicular Lymphadenopathy), Axillary Lymphadenopathy, Liver & Bony Tenderness (Metastases)
  - If Apical (Pancoaste) Tumour ➔
    - SVC obstruction ➔ Pemberton’s Sign (Facial Plethora)
    - Sympathetic Nerve Compression ➔ Deficiency ➔ Horner’s Syndrome (Unilateral Ptosis, Anhydrosis, Miosis, Enophthalmos, Laryngeal Hoarseness)
    - C8/T1 Nerve Lesion ➔ Intrinsic Hand Muscle Weakness & Wasting
  - If Mesothelioma ➔
    - Pleuritic Chest Pain
    - Pleural Effusion
    - Tender Ribs
  - If Bronchocarcinoma ➔
    - Wheezing (Partial Bronchial Involvement)
    - Atelectasis (Complete Bronchial Obstruction)
    - Haemoptysis
- Signs of Causes:
  - Smoker, Miner, Sand-Blaster, Builder,

URTI:

TYPICAL Symptoms/Presentation:
- Fever
- Sore-Throat
- Runny Nose, Sneezing, Hoarseness, Cough
- Sinus Headache
- +/- Non-Specific Viral (Fever, Malaise, Headache, Myalgia)

TYPICAL Clinical Signs:
- Typical URTI Symptoms:
  - Fever, Malaise, Headache, Cough
  - + Specific Symptoms:
  - Adolescent + Sore Throat + Lymphadeopathy = EBV (Glandular Fever)
  - Toddler + Drooling Saliva = Epiglottitis (Haemophylis Influenza)
  - Photophobia + Neck Stiffness = Meningitis (Eg. Nesseria Meningiditis)
  - Arthritis + New Cardiac Murmur after 2wks = GAB-Strep Pharyngitis ➔ Rh-Fever/Rh-Heart Disease
  - Hx of Recurrent Pneumonia + SOB = Cystic Fibrosis/Immunocompromised/Smoker
  - SOB + Weight Loss = Tuberculosis (Mycobacterium Tuberculosis)
  - Community Outbreak + Travel History = SARS (SARS-Associated Coronavirus

Thank You so Much. Happy Learning!!

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