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1 Physical Examination in Respiratory System Zhao Li, M.D.

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1 Physical Examination Physical Examination in Respiratory System in Respiratory System Zhao Li, M.D. Zhao Li, M.D.
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Page 1: 1 Physical Examination in Respiratory System Zhao Li, M.D.

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Physical Examination Physical Examination in Respiratory Systemin Respiratory System

Zhao Li, M.D.Zhao Li, M.D.

Page 2: 1 Physical Examination in Respiratory System Zhao Li, M.D.

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Skeletal landmarksSkeletal landmarks

Sternal angle

subscapular angle

Intercostal space

Spinous process

xiphoid

Costalspinal angle

Page 3: 1 Physical Examination in Respiratory System Zhao Li, M.D.

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Anterior imaginary lines and Anterior imaginary lines and landmarkslandmarks

epigastric angle

Infraclavicular fossa

Anterior midline

Suprasternal fossa Supraclavicular fossa

Sternal line

Parasternal line

Midclavicular line

Sternal angle

Page 4: 1 Physical Examination in Respiratory System Zhao Li, M.D.

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Lateral imaginary lines Lateral imaginary lines

Anterior axillary line

Midaxillary line

Posterior axillary line

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Posterior imaginary lines and Posterior imaginary lines and landmarkslandmarks

Scapular line

Posterior midline

Infrascapular region

Interscapular region

Suprascapular region

Scapular region

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Anterior view of lobesAnterior view of lobes

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Posterior view of lobesPosterior view of lobes

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Right lateral view of lobesRight lateral view of lobes

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Left lateral view of lobesLeft lateral view of lobes

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Thoracic deformity Thoracic deformity

Pectus excavatumBarrel chest

Kyphosis

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Inspection(1) Inspection(1)

1. Respiratory movement

Abdominal breathing: male adult

and child

Thoracic breathing: female adult

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Inspection(2)Inspection(2)

2. Respiratory rate: 16-18 f/min

Tachypnea: >20 f/min

Bradypnea: <12 f/min

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Inspection(2)Inspection(2)

Shallow and fast

respiratory muscular paralysis, elevated intr

aabdominal pressure, pneumonia, pleurisy

Deep and fast

Agitation, intension

Deep and slow

Severe metabolic acidosis (Kussmaul’s breat

hing)

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Inspection (3)Inspection (3)

3. Respiratory rhythm Cheyne-Stokes’ breathing Biot’s breathing

_____Decreased excitability of respiratory center Inhibited breathing

Sudden cessation of breathing due to chest pain Pleurisy, thoracic trauma

Sighing breathing Depression, intension

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Palpation Palpation

Thoracic expansion

Massive hydrothorax, pneumonia, pleural

thickening, atelectasis

Vocal fremitus (tactil fremitus)

Pleural friction fremitus

Cellulose exudation in pleura due to pleur

isy

Holding breathing disappeared

Tuberculous pleurisy, uremia, pulmo emb

olism

Page 16: 1 Physical Examination in Respiratory System Zhao Li, M.D.

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PercussionPercussion

Page 17: 1 Physical Examination in Respiratory System Zhao Li, M.D.

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1. Method1. Method

Mediate Pleximeter: distal inter-phalangeal j

oint of left middle finger Plexor: right middle finger tip

Immediate Order

Up to down, anterior to posterior

Page 18: 1 Physical Examination in Respiratory System Zhao Li, M.D.

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2. Affected factors2. Affected factors

Thickness of thoracic wall

Calcification of costal cartilage

Hydrothorax

Containing gas in alveoli

Alveolar tension

Alveolar elasticity

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3. Classification3. Classification

Resonance Normal

Hyperresonance Emphysema

Tympany Cavity , pneumothorax

Dullness Hydrothorax, atelectasis

Flatness Massive Hydrothorax, massive atelectasis

Page 20: 1 Physical Examination in Respiratory System Zhao Li, M.D.

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4. Normal sound4. Normal sound

Lung’s sound in percussion

Resonance

Slight dullness in some areas (upper, right,

back) due to thickness of muscles and

skeletons

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4. Normal sound4. Normal sound

Border of lungs in percussion Apex of lungs

Kronig’s isthmus: 5cm in width Narrow: TB, fibrosis wider: emphysema

Anterior border absolute cardiac dullness area

Lower border 6th, 8th, 10th intercostal space in midclavicular line, midaxillary

line, scapular line, respectively Downward: emphysema Upward: atelectasis, intraabdominal pressure increased

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4. Normal sound4. Normal sound

Shifting range of bottom of lung

Decreased: emphysema, atelactasis, fibrosis, pulmo. edema, pneumonia

Detected impossibly: pleura adhesion, massive hydrothorax, pneumothorax, diaphragmatic paralysis

Shifting range of

bottom of lung

6-8 cm

Along the scapular line

To percuss bottom of lung, marking

To ask the pat. to inspire deeply and hold

To percuss bottom of lung, marking

To ask the pat. to expire deeply and hold

To percuss bottom of lung, marking

To measure the dist. between upper and lower lines

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5. Abnormal sound5. Abnormal sound

Dullness, flatness, hyperresonance or tympa

ny appear in the area of supposed resonanc

e.

Unchanged sound (resonance) The depth of the lesion > 5 cm

The diameter of the lesion 3 cm

Mild hydrothorax

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5. Abnormal sound5. Abnormal sound

Dullness or flatness

Decreased containing gases in alveoli Pneumonia Atelectasis? TB Pulmo. embolism Pulmo. edema Pulmo. fibrosis

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5. Abnormal sound5. Abnormal sound

Dullness or flatness No gases in alveoli

Tumor Pulmo. Hydatid (肺包虫 ) Pneumocystis (肺囊虫 ) Non-liquefied lung abscess

Others Hydrothorax Pleural thickness

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5. Abnormal sound5. Abnormal sound

Hyperresonance Emphysema

Tympany Pneumothorax Large cavity (TB, lung abscess, lung cyst)

Amphorophony (空瓮音 ) Large and shallow cavity with smooth wall Tension pneumothorax

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5. Abnormal sound5. Abnormal sound

Tympanitic dullness (浊鼓音 ) Decreased tension and gases in alveoli

AtelectasisCongestive or resolution stage of pneumonia

Pulmo. edema

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5. Abnormal sound5. Abnormal sound

Special areas on percussion in moderate hydrothorax Damoiseau’s curve

Garland’s triangle area

(tympanitic dullness)

Grocco’s triangle area

(dullness)

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AuscultationAuscultation

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Order of auscultation Order of auscultation

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Sound of auscultationSound of auscultation

1. Normal breath sound

2. Abnormal breath sound

3. Adventitious sound

4. Vocal resonance (语音共振 )

5. Pleural friction rub

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1. Normal breath sound1. Normal breath sound

Tracheal breath sound Bronchial breath sound

Larynx, suprasternal fossa, around 6th, 7th cervical vertebra, 1st, 2nd thoracic vertebra

Bronchovesicular breath sound 1st, 2nd intercostal space be

side of sternum, the level of 3rd, 4th thoracic vertebra in interscaplar area, apex of lung

Vesicular breath sound Most area of lungs

Bronchovesicular

Bronchial

Bronchial

Bronchovesicular

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2. Abnormal breath sound2. Abnormal breath sound

Abnormal vesicular breath sound

Abnormal bronchial breath sound

Abnormal bronchovesicular breath sound

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Abnormal vesicular breath Abnormal vesicular breath soundsound(1)(1)

1) Decreased or disappeared Limited movement of thoracic wall Respiratory muscle weakness Obstruction of airway Compressed atelectasis

Hydrothorax or pneumothorax Abdominal diseases: ascites, large tumor

2) Increased Increased movement of respiration

Exercise, fever, anemia, metabolic acidosis, compensation (single lung)

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Abnormal vesicular breath sound Abnormal vesicular breath sound (2)(2)

3) Prolonged expiration

___ uncompleted obstruction and / or

decreased alveolar elasticity

Bronchitis

Asthma

emphysema

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Abnormal vesicular breath sound Abnormal vesicular breath sound (3)(3)

4) Cogwheel breath sound TB Pneumonia

5) Coarse breath sound

____ not smooth in airway due to swollen or exudation bronchitis Early stage of pneumonia

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Abnormal bronchial breath soundAbnormal bronchial breath sound (tubular breath sound)(tubular breath sound)

Bronchial breath sound appears in the area where vesicular breath sound is supposed to appear because of increased sound transmission or resonance.

Consolidation: lobar pneumonia (consolidati

on stage)

Large cavity: TB, lung abscess

Compressed atelectasis: hydrothorax, pneu

mothorax

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Abnormal bronchovesicular breatAbnormal bronchovesicular breath soundh sound Bronchovesicular breath sound appears in t

he area where vesicular breath sound is supposed to appear. The lesion is relatively smaller, deeper or

mixed with normal lung tissue.bronchopneumonia TBEarly stage of lobar pneumoniaUpper area of hydrothorax

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3. Adventitious sound3. Adventitious sound

moist Crackles

Rhonchi (wheezes)

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Moist crackles Moist crackles

Mechanism

During inspiration, air flow passes thin secre

tion in the airway to rupture the bubbles, or t

o open the collapse of bronchioli due to adh

esion by secretion.

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Characteristics of cracklesCharacteristics of crackles

1. Adventitious sound

2. Intermittent

3. Appeared in phase of inspiration or early expiration

4. Constant in site

5. Unchanged in character

6. Medium and fine crackles exist meantime

7. Less or disappeared after cough sometimes

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Classification of moist crackles(1)Classification of moist crackles(1)

According to intensity of the sound

1. Loud moist crackles

2. Slight moist crackles

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Classification of moist crackles(2)Classification of moist crackles(2)

According to diameter of the airway crackles

appeared

1. Coarse: trachea, main bronchi, or cavity

Bronchiectasis, pulmo. edema, TB, lung

abscess,

coma (wheezy phlegm, 痰鸣 )

2. Medium: bronchi

bronchitis, bronchopneumonia

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Classification of moist crackles(3)Classification of moist crackles(3)

3. Fine: bronchioli Bronchiolitis, Pneumonia, pulmo. congestion,

pulmo. embolism

4. Velcro: Interstitial lung disease

5. Crepitus: Bronchiolitis, alveolitis, early pneumonia (co

ngestion),

elder subject, pat. lying in bed for long time

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Site of cracklesSite of crackles

1. Local: local lesion Pneumonia TB Bronchiectasis

2. Both bases Pulmo. congestion Bronchopneumonia,

3. Full fields Acute pulmo. Edema Severe bronchopneumonia

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Rhonchi (wheezes)Rhonchi (wheezes)

Mechanism

The turbulent flow is formed in trachea, bronchi or bronchioli due to airway narrow or incomplete obstruction.

Causes Congestion Secretion Spasma Tumor Foreign subject Compression (lymph node, mediastinal tumor)

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Characteristics of rhonchi Characteristics of rhonchi

1. Adventitious sound

2. High pitch

3. Dominance in phase of expiration

4. Variable intensity, character, site or spread

5. Wheezing (appeared in main bronchi)

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Classification of rhonchiClassification of rhonchi

1. Sibilant (哨笛音,高调 )

Bonchioli, smaller bronchi

2. Sonorous (鼾音,低调 )

Trachea, main bronchi

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Site of rhonchi Site of rhonchi

1. Both fields Asthma Chronic bronchitis Acute left heart failure (cardiac asthma)

2. Local site Tumor Endobronchial TB

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Vocal resonanceVocal resonance

Increased sound transmission due to changed density of lung tissue

Bronchophony (支气管语音) Consolidation

Pectoriloqny (胸语音 ) Massive consolidation

Egophony (羊语音 ) Upper area of hydrothorax

Whispered (耳语音 ) Consolidation Increased density

of lung tissue:

Consolidation vs Atelectasis

Page 51: 1 Physical Examination in Respiratory System Zhao Li, M.D.

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Pleural friction rubPleural friction rub

1. Cellulose exudation in pleurisy (rough pleura)2. Area of auscultation

inferolateral thoracic wall (maximal shifting area of lung)

3. Friction rub disappeared if holding breath4. Friction rub appeared both breath and heart beat: mediastinal pleurisy5. Causes

Tuberculous pleurisy Pulmo. embolism Uremia Pleural mesothelioma

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Main symptoms and signs in Main symptoms and signs in common respiratory diseasescommon respiratory diseases

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Labor pneumoniaLabor pneumonia

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Symptoms Symptoms

Chill Continued fever: 39-40ºC Chest pain Tachypnea Cough Rusty sputum

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Signs (1)Signs (1)

General signs Acute facial features, blushing (颜面潮红 )

Nares flaring (dyspnea)

Cyanosis

Tachycardia

Simple herpes around lips

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Signs (2)Signs (2)

Congestion stage Decreased movement of respiration in affected

area

Increased vocal fremitus

Dullness

Crepitus

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Signs (3)Signs (3)

Consolidation stage Obviously increased vocal fremitus (resonanc

e) Dullness or flatness Abnormal bronchial breath sound (tubular breat

h sound) Pleural friction rub

Resolution Moist crackles

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Chronic bronchitis with Chronic bronchitis with emphysemaemphysema

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Symptoms Symptoms

Chronic productive cough White mucous sputum or pus sputum (infect

ion) Usually exacerbation in winter Morning cough To last more than 3 months Exertional dyspnea Breathlessness (dyspnea) Chest depress

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Signs Signs

Barrel chest Movement of respiration Vocal fremitus Hyperresonance The lower border of lungs downward Shifting range of bottom of lung Cardiac dullness area Decreased vesicular breath sound Prolonged expiration Moist crackles and/or rhonchi (acute episode)

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Bronchial asthmaBronchial asthma

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Symptom Symptom

Expiratory dyspnea with wheezing

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Signs Signs

Expiratory dyspnea with wheezing Orthopnea Cyanosis Severe sweat Decreased movement of respiration Decreased vocal fremitus Hyperresonance Rhonchi in full fields of lungs

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HydrothoraxHydrothorax(pleural effusion)(pleural effusion)

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Symptoms Symptoms

Dry cough Chest pain

Disappeared with growing of pleural effusion Reappeared with the fluid decreasing

Affected side lying Dyspnea, orthopnea, palpitation The symptoms of underlying disease

300ml: no obvious symptoms

>500ml: breathlessness, chest depress

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Signs Signs (Moderate to massive effusion)(Moderate to massive effusion)

Tachypnea Limited movement of affected side Costal interspaces of affected side are wider Trachea shifts to opposite side Decreased vocal fremitus Dullness or flatness Decreased or disappeared vesicular breath sound Decreased or disappeared vocal resonance Pleural friction rub Abnormal bronchial breath sound in upper area of t

he fluid

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Pneumothorax Pneumothorax

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Symptoms Symptoms

Sudden chest pain Dyspnea Forced sitting position Unaffected side lying Dry cough

Tension pneumothorax Progressive dyspnea Severe sweat Tyckycardia Tension, agitated Cyanosis Respiratory failure

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Signs Signs

Costal interspaces in affected side are wider Limited movement of affected side Decreased or disappeared vocal fremitus Trachea and heart shift to opposite side Tympany Vesicular breath sound decreased or disapp

eared


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