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!!