1. 1
RESPIRATORY SYSTEM – CASE SHEET
– TUESDAY
1. Identification
2. History taking
a. CHIEF COMPLAINTS
o Chest pain
o Cough – sputum and blood
o Breathlessness (dyspnea)
o Cyanosis
o Wheezing
o Sore throat that associated with cough
Chest pain
 SIQORAAASite, intensity, quality, onset, radiation, etc
 Causes
o CVS
o GIT
o Respiratory
o Miscellaneous problem
 CVS Causes
o MI – death to heart muscle due to lack of oxygen
o Angina pectoris – pain caused by lack of oxygen (no necrosis) (stable, unstable,
prinztemal)
o Percarditis – infection of the pericardium and inflammation of the pericardium
o Thromboembolism (PT)
o Dissecting aortic aneurysm
 Aneurysm is an abnormal, permanent dilatation of a blood vessel
 Most common aortic aneurysm is the descending aorta
 Also the aneurysm is commonly found in the arch of the aorta
 Tearing type of chest pain that radiates to the back
 GIT Causes
o Esophagus problem
 Inflammation – esophagitis
 Spasm of esophagus
 GERD – reflux disease
 Gastric contents from stomach refluxing to esophagus
 Esophagus carcinoma
 Peptic ulcer

2. 2
o Stomach
 Gastritis of the upper part of the stomach
 Peptic ulcers
 Respiratory Causes
o Lung parenchyma do not have nerve ending, therefore you can’t feel pain
o Any involvement pathology of pleural would lead to chest pain
o Upper Respiratory Tract
 Mostly talking about the trachea
 Inflammation of the trachea – trachitis but bronchioles usually involved 
upper bronchie, tracheabronchitis
 Site of pain  upper sternum or parasternum
 Intensity  moderate to severe
 Quality
 Character sharp pain, can be burning
 Onset  acute
 Radiation  no radiation
 Aggravating factor coughing (not as much) will cause more pain and
cause breathlessness, smoking
 Alleviating factor  coughing more alleviating factor
 Associated factorbreathlessness, fever, malaise, cough
o Lower Respiratory Tract
 Conditions that lead to chest pain would have pleura involvement
 Causes: every pathology of the lung can lead to pain cause every
pathology involved the pleura
 Pleuritis
 Pleural effusion  accumulation of exudates fluids
 Pneumothorax, hydrothorax
 Empyema
 Hemothorax
 pneumonia
 The lower respiratory does not have any nerve endings, only the pleura
has nerve endings
 Site depends on pathololgy and intensity same depends on pathology
 Pluera are the coverings of the lungs  visceral pleura and parietal pleura
 Quality/Character sharp knife like pain
 Aggravating factor  pain increased during inspiration is an
important signed of pleuritis, take deep breath and if pain is
aggravating pleaura is involved
 Onset  can be acute, subacute or chronic
 Radiation no radiation

3. 3
 Alleviating factors  lying on the same side as the chest pain
 Association factors  coughing, breathlessness
 Miscellaneous Causes
o Trauma
o Musculospasms
o Anxiety
o Malingering – lying about chest pain
o Panic attacks
o Breathlessness
o Musculoskeletal problems
o Teitze’s syndrome – acute costalchondroitis (inflammation of the costal cartilage
of the ribs)- inflammation of the ribs where the sternum attaches to the ribs
o Fractured ribs
o Blunt trauma to ribs
o Exam question- pt. comes in with a cough for three days and feels pain upon
palpation of the chest. What does the pt. most likely not have
 Teitze syndrome
 Fractured ribs
 Pleuritis
 Trachitis *
Breathlessness (dyspnea)
 Non painful, uncomfortable awareness of your own breathing
 Cause
o Cardiovascular
o Respiratory System
o Miscellaneous conditions
 CVS cause
o Basically, only left sided of the heart is involved
o Left heart failure  failure of the heart to properly function; failure of the heart to
have normal cardiac outputfailure of heart to pump the blood and backs up into
the lungs
o Obstruction of the mitral valve is the most important causes
 Mitral stenosis  lumen decreases, narrowing of the lumen
o Mitral regurgitation two leaflets(unidirectional), pathology of leaflets, defect in
the mitral valve, some blood goes back (regurgitates)
o Congestive heart failure  right hearted failure
o Also associated with pulmonary edema/congestion and pulmonary hypertension
o Paraxymal Nocturnal dyspnea (PND)  sign of left heart failure
o Aortic narrowing (stenosis)

4. 4
o Stroke- volume of blood for each contraction (70-80ml)
o Normal heart rate 70 heart rates
o Cardiomyopathy (ventrical muscle problemventricle muscle doesn’t contract)
o Hypertrophic obstructive cardiomyopathy increase in size and function of heart
muscle (left side particularly) due to and obstruction of blood flow to muscle from
left side.
o Pulmonary hypertension
 Respiratory cause
o COPD
 Bronchiole asthma (mucus in bronchi, bronchi constriction)
 Can be acute, subacute, chronic
 Breathlessness and it very common during night
 Onset is nocturnal
 Very common during winter season  seasonal variations
 Hypersensitive to allergens (e.g dust, dander, pollen, cold air)
 Most important sign is the present of wheeze, an abnormal
breath sound heard during expiration which is heard by
observer as well as the subject, crepitationscrackle/poping
sound at the rales
 Treatment  bronchiole dilators, corticosteroid
 Chronic Bronchitis
 Chronic inflammation of bronchi
 Three months and two years
 Breathlessness is progressive
 Lot of secretion and severe cough and productive( things coming
out) for at least three months
 Intermittent fever
 More chance of superimposed infection
 Most important factor is chronic smoking and air pollution
 Most important cause/complication of emphysema is chronic
bronchitis
 Can have wheeze but COPD (4) 1) bronchiole asthma, 2)
brochioestasis, 3) emphysema, 4) chronic bronchitis
 Brochioestasis
 Abnormal dilation, perfusion at the level of the alveoli
 Can lead to dysnea
 Empysema
 Loss of elasticity, trypsinhypoxia, elasticity (elastase)
 See blebs

5. 5
o Interstitial lung diseases (chronic)
 Pneumoconiosis
 Asbestosis
 Berrylium
 Coal
 Sarcoidosis-affects motor system of CNS, accumulation of inflammatory
cells (granulomas)
 Most important is pulmonary fibrosis
 Chronic progressive dyspnea
 Can be initiated by allergens air pollutions
 Aggravating factors  exercise
 Associated factors  fatigue or muscle weakness
o Pneumonia
 Acute dyspnea with discharge of 3-5 days with severe cough and high
grade fever
 Sputum coughing
 Know definition of mycoplasmic (dry cough, walking pneumonia, atypical
bacterial) pneunia and pneumococcal pneumonia (causes hemoptysis
caused by strep pneumonia)
 Causes: bacteria, fungal, viral, etc
o Pneumothorax
 Tension pneumothorax
 inspiration bp decreases, can lead to hypoxia and hypotension
 allowing air to enter the pleural space and preventing the air from escaping
naturally
 Spontaneous pneumothorax acute breathlessness and sudden with acute
pleuritis chest pain more air comes in pleural cavity
 Male, young, Tall and thin people have more chance of getting
spontaneous pneumothorax because of narrow chest, so less
expansion of chest wall,
 Spontaneous, no symptoms or signs
 Breathlessness occur in tension and spontaneous
o Pulmonary Thromboembolism
 Acute and severe breathlessness with sudden onset with severe pleuritis
chest pain
 Stasis of bloodpregnancy
 Post surgical patients, hospitalized patients, person who doesn’t move
around
 Sudden and high grade chest pain
 Chronic used of oral contraceptive pills

6. 6
 Exam question. Girl lives with boyfriend. What is the most likely
cause of her to get a pulmonary thromboembolism?
 Lower legs fracture
 Tearing type of pain
 Radiation  starts in anterior part of chest and radiates to retral sterna
radiation (behind sternum)
o Left Heart Failure
 Slowly progressive dyspnea
 Orthopnoea – increase of dyspnea when patients lies down, blood
accumulates in lung tissue
 Almost always seen in left heart failure
 Paroxymal Nocturnal Dyspnea (PND) – another sign of left heart failure,
more blood into pulmonary system when sleeping, awakens a person
 Miscellanous Breathlessness
 Panic attack
 Malingering
 Metabolic acidosisketo acidosis
 Anxiety neurosis
 Hyperthyroidism
 Thyroid toxicosis
 Chronic anemia
 Classification of dyspnea
 Acute – less than 3 days
 Spontaneous pneumothorax – air in thoracic cavity due to trauma
 Pulmonary thromboembolism
 Bronchiole asthma
 Foreign bodies inhalation
o Children would play on playground with chalk, foods,
crayon and put in nose, etc
 Trauma- chest pains, wounds, fractured ribs
 Poisoning
 Anaphylaxis
 Lyrangitis
 Acute bronchitis
 Pharyngitis
 Croupbronchiolitis (barking cough)
 Subacute (5-7days)
 Bronchiole asthma

7. 7
 Pleural effusion
 Pneumonia
 Chronic
 Chronic asthma
 COPD
o Bronchiole asthma
o Bronchiectasis
o Chronic bronchitis
o Emphysema
 Carcinoma
 Pneumoconiosis
 Chronic anemia
 Congestive heart failure
 Left heart failure
WEDNESDAY
Cough
 History taking
o SIQORAAA
o Duration – ask for how long
o See if the cough is productive (wet) or non productive (dry)
 what comes out
 If sputum is it watery, purulent, mucoid, blood
 How much sputum is coming out, fever, breathlessness
 Infections and inflammation of upper and lower respiratory tract
 Medications, chest pain, etc
 Cause of productive cough
o Pharyngitis
o Brachial bronchitis
o Laryngitis
o Pneumonia
o Pleural effusion
o COPD
o Lung abscess
o Left heart failure
o Most bacterial infection there is productive cough
o Chronic-Tuberculosis
o Character
o Smoking history

8. 8
o Medication history
o Immune deficiency
o Occupation
o Associated factors  breathlessness, chest pain, fever
 Cough
o Dry (non productive)
 Early state of viral infections
 Allergic conditions
 Atypical pneumonia  Mycoplasma/PCP lead to dry cough
 ACE inhibitors
 COPD
o Wet
o Exam question: pt has a cough. Upon history taking, you find out that he is taking
antihypertensive meds. What is your next move
 Switch to beta blocker
 Switch to ace inhibitory
 Switch to lostartin
 Switch to cough drops and an antibacterial
 Type of sputum for productive cough
o Watery sputum
 Allergies
 Infections
o Purulent Sputum
 Bacterial infections such as TB, pneumonia
 Lung abscess
 Volume of sputum for purulent sputum
 Cup full of sputum per day of sputum  lot
o TB
o Bronchiestasis
o Lung abscess
o Cystic Fibrosis chromosome 7
 Spoon per day of sputum little
 If there is blood
o Associated factors
 Cough with chest pain, Fever  pneumonia
 Breathlessness  can be infections or something else
 Cough associated with hoarseness of voice  laryngitis
 Cough association with hawking (barking)  important sign of croup,
laryngobranchitis
 Cough associated with cachexia  carcinoma and auto immune disease

9. 9
 Cough associated with fatigue and muscle weakeness  Pneumoconiosis
 and autoimmune disease
o Drug history that lead to cough
 ACE inhibitors
 AT-1 inhibitors
 Use Lorsatan to replace these drugs
Hemoptysis
 Exam question: what does hemoptysis (coughing bloodbright red) have that
hematemesis GIT (vomiting bloodbrown blood) doesn’t have?
o Bright red frothy blood?
o Dark brown blood ?
o Acidic pH?
o More than one of the above?
 Coughing up blood
 Bright red color (color of blood)
 Presence of air bubbles
 Alkaline pH
 Cause
o Respiratory
 Infections
 Severe pneumonia
o Fungal pneumonia have more chance leading to hemoptysis
o Especially if immunocompromised
 parasitic
 Lung abscess
 TB
 Pneumococcal pneumonia
 Trauma
 Foreign bodies
 Blunt trauma
 Any types of wound
 Fracture ribs
 Neoplasm
o Primary
o Secondary
o All neoplasm can lead to hemoptysis
 Vascular conditions
 Vasculitis – inflammation of blood vessels

10. 10
o Good pasture syndrome-automimmune (ab target the
good pasture antigen) involves lung tissue, pulmonary
capillarieshemmorrage of lungs
o Disorder of clotting system
o Kawasaki disease-Mucocutaneous lymph node syndrome,
autoimmune necrosis of medium sized vessels vasculitis
attacked by
o Wegener’s Granulomatosisformation of granuloma,
vasculitis of lungs and kidneys, autoimmune attack by an
abnormal type of circulating antibody termed ANCAs
(antineutrophil cytoplasmic antibodies) against small and
medium-size blood vessels
o SLE
o Takawas arthritis
 Drugs
 Heparin
 Anticogulants
 Thrombolytics
 Interstitial lung diease
 Pneumoconiosis
 Sarcodoisis
 Cystic fibrosis
 Bronchiectasis
o Cardiovascular
 Mitral Stenosis
 Left heart failure
 Aortic stenosis
 Mitral regurgitation
 Dissecting aortic aneurysm
 AV fistula
Hematemesis
 Vomiting blood
 Brown colored blood
 Absence of air bubbles
 Acid pH
 Blood contains food particles

11. 11
WHEEZE
 Abnormal breath sounds that do not need to hear with a stethoscope
 Only sound that can be heard by the subject and observer
 Expiration breath sound, not heard during inspiration
 Cause
o Bronchiole asthma
o Bronchioestasis
o Emphysema
o Chronic bronchitis
o Left heart failure
 Wheeze heard in left heart failure is cardiac asthma
o Othoponeapostural breathing increase in breathlessness (SOB) when
laying down increase fluid (blood) in lung tissue
o Paroxysyml Nocturnal Dyspnea (PND) sudden, severe shortness of breath
at night that awakens a person from sleepmore fluid (blood) in pulmonary
circulation (causes cough (blood) with wheezeing)
History of past illness
 Past episodes in the past-episodes of previous history (breathlessness before)
 History of present illness
 Medical history (ask and document)
o Bronchiole asthma
o Tuberculosis
o Hypertension
o Ischemic heart disease
o Epilepsy
o CHF
o Ischemia
 Surgical history
o Post surgical
o Type of surgery that was done
o When it was done and why it was done
 If female patient take Gynecology and Obstetric history
o Clots-thromboembolism
o Oral contraceptive pillsthromboembolism
o 32/3 days
o Obstetric (pregnancy)
 GPLAD
 Child hood history

12. 12
o Measles
o Chicken pox
o Small pox
o Mump
 Immunization history
Family history
 Auto immune disease
o SLE
o Sarcoidosis
 Epilepsy
 Hypertension
 Carcinoma
 Breast, prostate
 Cyanotic congenital heart disease
 Cystic fibrosis
 TBcontagious
 Hemophilia
Drug history
 Which drugs, dosage and duration
 Route of administration
 Any changes in dosage of drug
 Bronchiole asthma  patient on HTN beta blockers C/I causes
bronchoconstriction/spasm so does/ corticosteroids (causes breathlessness)
 HTN – ace inhibitors
o C/I cough, nephrotoxicity (duration is a week, taken ace inhibitor for HTN switch
to losartan (ARP) no cough as C/I
 HTN: losartan
o Angiotensin II antagonists
 Oral contraceptives
 Anaphylaxis
Allergy history
 Allergic to dust, pollen, dander, shellfish
 Drug allergies
 Food allergies
Social history

13. 13
 Occupation
o Pneumoconiosis  miners
o Carcinoma
o Mesothelioma
 Smoking
o Pak years: how many packs per day
 Alcohol
o How much
o Laryngeal carcinoma is more prominent in alcohol and smoking
 Recreation Drugs
o Marijuana, cocaine
o Route of administration- more chances of thrombus embolism, Hepatitis B
o Barbiturates lead to respiratory depression
o Oral contraceptives  thrombo embolism
 Sexual history
o Are you sexually active
o Sexual preference
o How many partners
o Safety measures used during sex
General Examination
 Build of the patient
 Nutritional status
 Mental status of patient
o Loot at the response the patient gives you, if the patient is alert then should
answer your questions correctly and quickly
 Access level of consciousness of patient
 Anemia – look at the conjunctiva, nail beds, lab  check blood normal red blood cell
count = 4-7 millions per cubic meter, white blood cells = 7-11 thousands
 Cyanosis = bluish discoloration of the skin and mucous membranes
o Important sign of cyanosis is increased in pCO2 level. Normal pCO2 is 40 mmHg
(35-45mmHg). Normal pO2 is 100 mm Hg (76-96 mmHg)
o Two types
 Peripheral – pO2 level are either normal, if there is a little decrease in
pO2 then it is okay, increase in pCO2
 Look for finger nail, ear, nose
 Causes
o Cold temperature, frost bites
o Hypovolemia

14. 14
o Vasculitis – peripheral circulation
 Central – pO2 level are decrease, increase in pCO2
 Look at the tip of the tongue (mucous membrane)
 Cause –(lung and heart system)
o Respiratory
 Severe COPD
 Severe pneumonia
o Cardiovascular
 Cyanotic congential heart disease (Left to right
shunt)
 Teratology of fallot
 Truncus arteriosus
 Transposition of great vessels
 How can you differentiate cardiovascular from respiratory causes
o If a patient have CVS give them oxygen  no improve in
conditions
o If a patient have respiratory cause, give them oxygen  big
improvement (bluish discoloration goes away)
 Exam question- pt. had cyanosis. You have them oxygen and the blue
discoloration started to go away. What was most likely the cause
 Teratology of fallot
 Truncus arteriosis
 More than one of the above
 Severe COPD
 In both the CO2 level are increased.
 Clubbing = exaggeration of the angle between nail and nail bed, put two nails
together and if there is a space that is normal and if not then there is clubbing
o Loss of angle between nail and nail bed
o Make the patient put thumb together and look for space between the thumbs. If
the is space normal
o What lead to clubbing
 Chronic hypoxemia
 Loss of angle is due to chronic hypoxia
o Causes
 CVS
 Cyanotic congenital heart diease
 Infective endocarditis
 Respiratory
 Bronchiogenic carcinoma**
 COPD

15. 15
 ***Bronchiestasis*
 Cystic fibrosis****
 Chronic lung abscess
 Mesothelioma
 Empysemea***
 Bronchiole asthma*****
 GIT
 Ulcerative colitis
 Cirrhosisdestruction of liver architecture (tria (hepatic artery,
portal vein, bile duct)
 Crohn’s disease
 Sclerosis
 Inflammatory bowel disease
 Clubbing and cyanosis are sign of respiratory distress
 Exam question – which one is a cause of clubbing.
Taking Vital Data
 Blood pressure
 Temperature
 Pulse rate
 Respiratory rate
Before the Systemic Examination – look for sign of respiratory distress
 Exam question
o Which is not a sign of respiratory distress
 Cyanosis
 Clubbing
 Trachea position
 Wheeze
 ***Anemia
 1st
look for Respiratory rate (normal 14-22)
o Hyperventilation – increase in respiratory rates
 2nd
is Cyanosis (see above)
o Increase in pCO2 levels
o pO2100, pCO2 40 normal
o Peripheral –bluish coloration of extremeties, slight decrease in PO2 levels
o Central-mucous membranes (tip of the tongue), reduction in PO2 levels
 3rd
Clubbing

16. 16
 5th
Sign of the neck – look at sternocleidomastoid (abnormal (prominence) contraction of
the sternocleidomastoid)
o Starts from the sternum and goes to the mastoid
o Accessory respiratory muscles
o If stenocleidomastoid is prominent even when not working hard  sign of
respiratory distress
 6th
Position of trachea
o Normal position is in midline
o Trachea deviate to one side pathology that would lead to respiratory distress
(deviation to either sides)
o Mediastinum shifts with the trachea
 4th
sign is the Presence of audible stridor or wheeze
o Wheeze is an expiratory sound
 Abnormal breath sound that has a musical note
 Only sound that can be heard by the subject and observer
o Stridor is an inspiratory sound (abnormal breath sound heard when inspiring)
 Air passing through a partial obstructed tube (narrowing of upper air
ways)
 Causes
 Upper respiratory
 Anaphylaxis
 Epiglottis
Systemic Examination
 Inspection
 Palpation
 Percussion
 Ausculation
Monday 9-17-12
EXAMINATION OF POSTERIOR CHEST WALL
 Best position is the sitting position with his hands in front of his chest and hands over his
opposite shoulder (crossed arms over chest on opposite shoulders) – scapula depressed
laterally, more surface area, increase the lung field
 Tell patient to take in a breath
Inspection

17. 17
1. Shape of chest wall
 Use your eyes to look for the shape of the chest. Normal shape of the chest is
elliptical. It’s have two diameter
o Transverse diameter – if transverse is more than anterior posterior diameter =
normal chest wall (one lateral side to the other lateral side)
o Anterior posterior diameter (from anterior to posterior)
 Abnormality of the chest wall
o Barrel chest wall
 Anterior posterior and transverse diameter is approximately the same.
Increase anterior posterior because of increase in compliance
 Causes (COPD) (expiration problem air (pockets) stays in chest wall),
increase in lung compliance (volume/pressure)
 Chronic bronchial asthma
 Chronic emphysema
 Bronchiolestasis –irreversible dilation of bronchial tree
 Chronic bronchitis
o Pigeon chest = pectus carinatum
 Chest with shape of a pigeon = sternum is protruding. Abnormal
protruding of the cartilage sternum
 Abnormal increase in anterior posterior diameter so therefore anterior
posterior and transverse diameter are approximately the same
 Causes
 COPD
 Usually in pre pubertal boy (10-14 yrs)
 Post surgical after heart surgery
 Children (normal 0-2.5yrs)
 Bone congenital abnormalities
o Marfans Syndrome
o Trisomy 21 (Downs)
o Osterogenic imperfect (Type 1 collagen)-AD but
sporadic
 Can be associated with trisonomy-18 (Edwards) and tri-21,
osteomalacia
 More chance of mitral valve prolapsed
o Funnel Chest = pectus excavatum
 Posterior displaced lower part of the sternum
 Broad upper chest wall with a thin lower chest wall. Lower part of the
sternum is depressed. Once depression of lower part of sternum, the
rib cage get narrow
 Causes

18. 18
 Congenital problem (lower part of the sternum is displaced
posteriorly)
 Ricketts
 Can be associated with mitral valve prolapsed and Turner’s syndrome
o Flail Chest
 Seen in severe trauma to chest wall (ex. Multiple Fractured rib)
 Deflation during inspiration
 Inflation during expiration
 These are known as paradoxical movements = due to change in
internal pressure.
 Complication of flail chest = pneumothorax
 2. Look for deformities in the chest wall that leads to assymetry
Swelling # of breast, # of nipples lesions of chest wall, spine
Abnormal spine---rib pump-scoliosis
Ant post curvatture-thyphosis
largosis-lumbar motor
Sinus crack-bathing from interior to exterior-causes include severe Bacteria infection
viral infection eg TB-Actinomycetes (bact)
o Kyphosis – anterior displacement of the spine
o Scoliosis – lateral displacement of the spine
o Swelling or outgrowth on one side of the chest wall
o Lordosis-inward curvature of vertebral column
 3. Look for abnormal retraction of interscapular muscles = sign of respiratory
distress (pt is probably using accessory muscles if contracting, ex. using
sternocleidomastoid)
o If someone have respiratory distress they would use the interscapular muscles
a lot. Therefore look for abnormal retraction of interscapular muscle
 4. Look for chest expansion
o Bilateral respiratory movements
o Compare chest expansion with right and left
o During inspiration = expansion of chest wall
o During expiration = deflation of chest wall
o See of the expansion of the chest is symmetrical with both sides
o Abnormality = asymmetrical (decrease expansion in one side)
 Cause
 Any pathology that would lead to decrease in lung capacity
(volume) = lung obstruction. Example, lung effusion
 Pleura effusion
 atelectasis = lung abscess

19. 19
 exam – know which side is affected if there is right sided
decreased expansion, or left sided expansion.
 right sided pleural effusion leads to left sided expansion
 Asymmetrical chest expansion is abnormal. The abnormal side
expands less and lags behind the normal side. Any form of
unilateral lung or pleural disease can cause asymmetry of
chest expansion
 Let us say that the patient has decreased chest expansion on
right side. Now that we know the abnormal side is right, with
the mediastinum shifted to left, then it would mean a pushing
lesion from right. The pushing lesions are pneumothorax,
pleural effusion and large mass. The next step will help us
narrow down those possibilities.
5. Look at position of trachea
Palpation
 Aim of palpation is to confirmed inspection findings
 Use your hands = palms, fingers
Abnormalities
 1st Shape of the chest: 2nd chest deformities
 Swelling of chest wall (but can be used for any type of swelling, not only for chest wall)
o 2nd
Size of swelling, have an approximate idea of how big it is, ex 2 cm
o 1st
Location of swelling (use anatomical landmarks); be precise as possible
 Ex. Right anterior chest – can be clavicle, sternum, ribs,
o 3rd
Shape of the swelling
 Round
 Square
 Irregular
o 4th
Consistency of swelling
 How does it feel when you feel the swelling
 Ex. Soft = fat cells  lipoma
 Firm  dermoid cyst
 Hard Calcification and sclerosis
o 5th
Look for punctum = look like a mole (mole discoloration)

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 Punctum on swelling = sebaceous cyst
o 7th
Inflammatory signs
 Tenderness, pain, warmness, swelling,
o Does the swelling have any discharge
 Purely = abscess
o 6th
Mobility of swelling
 Use two fingers, thumb and index and try to move in all directions
 If its benign = no fixation
 if its fixed (attachment to underlying surface) = tumors/carcinoma
o 8th
Sinus tracts on chest wall
 Opening from interior to the exterior
 Two important causes relate to chest wall
 Complication of tuberculosis (opening on chest wall)
 Chlamydia infections (actinomycetes)
 Look for any discharge coming out of it, if there is discharge, take a swab
and send it to laboratory
 3rd Tenderness on chest wall
o No pain and when one touches chest wall u get pain
=tendernessinflammation
o If you palpate a rib and you get tenderness = fracture ribs
o Palpate and get pain and tenderness between ribs (intercostals space) = pleuritis
o Tietze’s syndrome = costal condritis (close to sternum)
o Muscle spasm
o
 4th Chest expansion Respiratory movements or chest expansion
 Always compare right and left – both should be expand symmetrically
 If there is a decrease expansion in one side
 Any respiratory pathology that reduce chest expansion on one side
(that side that is reduced has the problem) (ex. Pleural effusion,
lung abscess, hydrothorax)
 Lung collapse
 Absence of lung expansion of the side that is collapsed
 Atelectasis – decreased or absent air in the entire or part of a lung.
o If atelectasis (lung collapse) you probably won’t feel
anything = absence of vibration/respiratory expansion
absence
5th Tactile or vocal fremitus
 Make patient speak (say 99 or 123)
 Your epiglottis works, vocal words

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 Speech apparatus
 Sound waves that start from larynx go to nasopharynx  through
respiratory tree trachea  bronchioles  chest wall
 By telling the patient to say something, you can feel the vibration =
If there is no obstruction
o If obstruction there will be decreased vibration, ex
pneumonia, pleaural effusion (due to obstruction)
o If atelectasis (lung collapse) you probably won’t feel
anything = absence of vibration/respiratory expansion
absence
 Compare the right and left using ulna surface of palm (pinky), tell
patient to say numbers and feel
– TUESDAY 9-18-12
Percussion-if ur percussion is solid liquid or gas
Use both middle fingers (interphalangeal joint), movement should be at the wrist
Two steps
1. Percussion the whole lung field and hear the percussion notes as normal breathing
a. 4 types of percussion notes
i. Resonance – where there is air as a medium  normal lung field
1. If no obstruction and contains airresonance
ii. Dull note – where there is solid or liquid
1. Examples = pleural effusion, hydrothorax, lung abscess,
pneumonia, tumor
iii. Hyperresonance – more than normal amount of air in the lungs; too much
gas
iv. Examples = Pneumothorax, emphysema
v. Tympani – when percussed on airway with a lot of pressure/volume
1. Example = Tuberculosis, some pneumothorax. Only seen in some
case of tuberculosis
2. Best place is abdomen in stomach, air bubble under extreme
pressure
3. Drumlike sound
b. Exam question
i. Upon palpation, you find an 8 cm mass what note is heard
1. Mass is too deep to hear the note
2. Dull
3. Resonance

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4. Tympany
5. hyperresonance
c. Each percussion notes have three characters
i. Duration
ii. Pitch-
iii. Intensity-
Intensity Pitch Duration
Dull MEDIUM MEDIUM MEDIUM
Resonance LOUD LOW HIGH-LONG
Hyperresonance LOUDER LOWER HIGH-LONGER
Typani HIGH (LOUD) HIGH DEPEND on the
tube(short
airway-short)
If intensity is lower on one side there is still pathology, even if there is resonance on both sides.
2. Second step in percussion = diaphragmatic excursion (diaghram goes down on
inspiration)
a. Tell patient to take a deep breath and then exhale and keep it in expiration mode
b. Start on the middle of the scapula and go down to the diaphragm – goes from
resonance to dull
c. Start from resonance and go till you get a dull notes = level of diaphragm during
expiration
d. Do the same for inspiration mode
e. Marked the distance = 2 cm is normal
f. Greater than 2 cm = diaphragm is not contracting fully or completely. The
pathology where the lung capacity is low
i. Example = pleural effusion, pneumonia
g. Compare the level of diaphragm on both sides. The level of diaphragm of both
side should be the same = pathology of higher diaphram
i. If the level of diaphragm is high on one side
1. Atelectasis, pleural effusion, something wrong with the
diaphragm., something taking up space in lung cavity
2. Intervation-phrenic nerve
3. Congenital diaghram
h. Dullness should be the same on the same (both) side
i. Low diaghram is normal
Organ and percussion surface should be less than 6cm

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Auscultation (breath sounds, adventitious, transmitted)
i. Breath sounds
ii. Vesicular breath sounds (low pitch)
1. Inspiration is longer than expiration (less pressure) without gap.
Heard all over the back and lung fields
2. If u hear bronchial breath sounds, some path that obstructs air way,
and narrows air way, pneumonia
iii. Bronchial (high pitch)
1. Heard where you have bronchi, over the upper sternum
2. Heard on the bronchi only (narrower)
3. Expiration is longer than inspiration and gap is present
iv. Bronchovesicular (intermediate) sternal angle
1. Inspiration and expiration is the same without a gap
2. Expiration may be longer but there shouldn’t be a gap
3. Seen at the 1st and 2nd intercostal space and the anterior chest
v. Tracheal (high pitch)
1. Inspiration and expiration are equal but there should be a big gap
2. Place stethoscope on trachea
3. Inspiration could be longer
vi. Auscultate with diaphragm and compare one side with the opposite side

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vii. Look for the type of breath sound and the intesnsity of the breath sound
viii. If intensity is decreased on one side, there is a pathology on that side. Ex-
pleural effusion, lung abscess
ix. Adventious breath sounds
1. Crackles/Rales
a. Discontinuous breath sounds (heard without sounds)
b. Duration = 3-5milliseconds or 15-30 milliseconds
i. Bronchiectasis – post…
ii. Deflated airways that tries to open
c. Pitch
d. Creaking cracking, popping quality
i. FINE (soft in nature) high pitch 5-10 milliseconds
1. Parenchyma of lungs, pulmonary fibrosis,
pneumonia
ii. Coarse (loud) low pitch 30-40 milliseconds
1. Bronchiectasis post…
iii. Heard in inspiratory
1. Early inspiratory crackle
a. Bronchial asthma
b. Chronic bronchitis
2. Middle one third mid inspiratory crackle
3. Late inspiratory crackle (lower lobes)
a. Lung Fibrosis
b. Left heart failure
4. PAN inspiratory crackle-heard throughout
inspiratory
iv. Heard in expiratory (bronchiectasis)
1. Early expiratory crackle
2. Middle expiratory crackle
3. Late expiratory crackle
4. PAN expiratory

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2. Wheeze – high pitched! Continuous breath sound, character is
musical
a. Abnormal breath sound, heard during late inspiration or
early expiratory (sound during expiratory mostly)
i. Asthma
ii. Emphysema
iii. Bronchciestatisis
iv. all 4 COPD’s – chronic bronchitis, you’ll hear more
crackles than wheeze
v. Left heart failurecardiac asthma
3. Rhonchi – low pitched! Continuous but low pitch. where there are
large airway secretions. Charactersnoring quality.
4. Stridor, heard during inspirations, where there are obstruction of
upper air ways.
a. Pharyngitis
b. Anaphylaxis-edema in larynx
c. Crouplarynx tracheobronchitis
d. Laryngitis
5. Pleural rub = friction rub, sound heard on surface rub
a. Parietal and visceral pleura rub togetherfriction
b. Pleural effusion
c. Something between the pleura or fluid accumulation
i. Pleuritis best example
Transmitted-
 Make patient speak and listen to sound transmission of sound waves from
respiratory system to surface area.
 Normal lung tissue filters high pitch sounds
o Only low pitch sounds come to surface
1. Bronchophony- (+) get loud and clear 99
a. Ask pt to say 99 or 123 and listen to sounds

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b. Should only hear low pitch sounds, (muffled 99) is normal
c. If abnormal, you get high pitch clear 99
d. Consolidation phase in Lobar pneumonia, bronchial pneumonia
2. Egophony-
a. Ask patient to say eeeeeeeeee
b. If normal muffled eeeeeeeee
c. Pathology is involved eeee becomes loud aaayy
d. Consolidation phase in Lobar pneumonia
3. Whispering pectoriloquoy
a. Tell pt to whisper 123 or 99
b.
c. Normal u don’t hear nothing
d. If whispers 99 u can hear 99 that’s abnormal
e. Consolidation phase in Lobar pneumonia
4. Anterior chest
a. From above the 2nd intercostal space and below 5th intercostals can hear the same on
both sides
b. You can chest both sides
c. Anterior chest
i. During inspection, when pt. inspires, add the position of the trachea
ii. Trachea should be at the midline
iii. Confirm during palpation. = traits method. = use three fingers. 2 on
sternoclaviculare, feel tracheal rings. Anterior most part are most prominent.
Come down feeling the rings. Check the two distances from the midpoint
iv. Tracheal deviation = mediastinal shift.
v. Trachea towards the rights = pathology of right or left lung. Right lung =
atelectasis= deviation of trachea of the same sided lesion, everything else is
towards the opposite side
vi. Trailes procedure

27. 27
1. Use middle three fingers, sit up straight, place two out of three on
sternoclavicule prominence and then make sure the there is same
amount of space between the two fingers
-site of more negative pressure trachea deviates towards that side
-pleural effusion on right side, which side will trachea deviate
towards the left, increase pressure on the right side and lower on the
left side
Pleuaral effusion, hydrothorax, if increase pressure on one side
trachea deviates toward the other
Atelectacissame side