Respiratory History and Examination Dr. Robert Lee Dr. Gwen Hollaar & Dr. Lanice Jones Faculty of Medical Sciences Lao 2006

History Taking Associated Symptoms in HPI cough sputum production dyspnea hemoptysis chest pain  wheezing

Family History Asthma COPD Lung Cancer

Social History Employment Exposure to dust, agriculture, carpentry Exposure to toxins Smoking – number of years x packs of cigarettes per day Marijuana History suggestive of HIV risk – IV drug abuse, prostitutes, homosexual Risk of exposure to lung flukes, parasites

Physical Examination Inspection Palpation Percussion Auscultation

Inspection Nail cyanosis Clubbing Accessory Muscle Use, thin, leaning on hands Thick wide chest of emphysema

Palpation – Lung Exam chest wall movement tactile fremitus Patient repeats “99” while feeling with medial side of hand Consolidation increases transmission of vibrations Pleural effusion decreases fremitus

Tactile Fremitus Consolidation acts as a solid, transmits vibration better Effusion creates an air/water interface, decreases vibration

Trachea Inspection for masses, obvious deviation Best examined by palpation

Percussion Ask the patient to cross their arms in front – pulls scapula from midline Percuss by tapping on distal third of middle finger Keep rest of fingers off the chest – increases resonance Work between ribs if possible

Review of Lung Anatomy Anterior Anterior – Focus on Upper Lobes

Posterior Lung Anatomy

Right Lateral Chest Anatomy - RML

Lung Anatomy Left Lateral

Auscultation Listen for posterior lobes in the back 4 areas in the posterior chest is enough for normal examinations Listen in more areas if abnormalities Lateral chest for lingula and RML Anterior chest for anterior lobes

Ausculation – normal sounds Vesicular breath sounds on inspiration Little or no sound on expiration

Auscultation – abnormal sounds Rales or crackles Rhonchi or wheezes – whistling sound, mostly on expiration Stridor – wheeze on inspiration –suggests obstuction at tracheal level Bronchial breathing Decreased breath sounds Pleural rub

Tactile Fremitus Consolidation acts as a solid, transmits vibration better Effusion creates an air/water interface, decreases vibration

Some examples

Pleural effusion Reduced chest expansion Dullness to percussion over lower chest Diminished or absent breath sounds Decreased tactile and vocal fremitus

Consolidation – eg lobar pneumonia Reduced chest expansion Dullness on percussion Bronchial breathing Rales or crepitations Increased tactile and vocal fremitus

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