Assessment of a patient with
respiratory disorder review
1

• Session objectives
• General guidelines for thorax and lungs
examination
• Pertinent Subjective Data
• Equipment for Examination
• Physical examination of Thorax and lungs
– Inspection
– Palpation
– Percussion
– Auscultation
2

Session objectives
 At the end of this session you will be able to :
• Take a history of patient with respiratory
problems
• Describe subjective datum of patient with
respiratory problems
• Perform physical assessment of patient with
respiratory problems
3

For thorax and lungs examination
• Physical setup
- Quiet, warm , well-lit and equipped room.
- Full medical instrument (stethoscope must)
• Position :-
- Supine - for examination of anterior chest.
- Sitting- for examination of posterior chest.
• Exposure:- chest above waist ,but in female
patient drape the anterior chest while
examining the posterior. 4

Cont’d...
Sitting - examine posterior thorax and lungs.
– The pt’s arms should be folded across the
chest. So that the scapula moves partly out
of the way and increasing your access to the
lung fields.
Supine- examine anterior thorax & lungs.
– Easier to examine women b/c the breasts
can be gently displaced and wheezes, if
present are more likely to be heard. 5

Equipment for Examination
• Stethoscope
• Ruler – 15cm.
• Tape measure
• Washable marker
• Alcohol swabs
6

History Pertinent Data
• Cough
• Shortness of breath
• Wheezing
• Chest pain with
breathing
• History of respiratory
infections
• Smoking history
• Blood-streaked
sputum (hemoptysis)
• Environmental
exposure
• Self-care behaviors
7

History Pertinent Data……
Cough:
• Forced expulsive action against an initially closed
glottis
• Acute cough –
– lasting < 3 weeks,
– Most common in acute viral URTI
– Self-limiting and benign
– May have 'red flag' symptoms (Haemoptysis ,
Breathlessness (Fever ,Chest pain & Weight loss)
• Chronic cough > 8 weeks. 8

Disease Type of cough
Severe asthma or chronic
COPD-
Prolonged wheezy coughing
Lung cancer Non-explosive 'bovine' cough with hoarseness
Laryngeal inflammation,
infection and tumour
Harsh, barking or painful and associated
with hoarseness and the rasping or croaking
inspiratory sound of stridor.
Bronchial infection and
bronchiectasis
Moist cough
Chronic bronchitis Persistent moist 'smoker's cough‘ in the
morning
Pneumonia Dry, centrally painful and non-productive
cough.
Asthma May have a paroxysmal dry cough after a
viral infection that may last several months
(bronchial hyper-reactivity).
9

Timing and associated features of cough
Nocturnal cough Common in asthma
A chronic cough that lessens during
weekends and holidays
Occupational asthma and exposure to
dusts and fumes
Daytime cough Occult gastro-oesophageal reflux
disease (GERD) and chronic sinus
disease
Dry cough after medication Angiotensin-converting enzyme (ACE)
inhibitors
Coughing during and after swallowing
liquids
Neuromuscular disease of oropharynx
Large purulent sputum to be
coughed up, varying with posture
Bronchiectasis
Sudden large amounts of purulent
sputum on a single occasion
Rupture of a lung abscess or
empyema
Large volumes of watery sputum with
a pink tinge in an acutely breathless
Pulmonary oedema
10

Types of sputum
Type (4) Appearance Cause
Serous Clear, watery Acute pulmonary oedema
Frothy, pink Alveolar cell cancer
Mucoid Clear, grey Chronic bronchitis/COPD
White, viscid Asthma
Purulent Yellow Acute bronchopulmonary
infection
Asthma (eosinophils)
Green Longer-standing infection
Pneumonia
Bronchiectasis
Cystic fibrosis
Lung abscess
Rusty Rusty red Pneumococcal pneumonia
11

White
12

Yellow
13

Green
14

Rusty red
15

Types of sputum…
• Signs, which vary from blood-stained
sputum to a large, sudden hemorrhage
• The most common causes are:
– Pulmonary infection
– Carcinoma of the lung
– Abnormalities of the heart or blood vessels
– Pulmonary artery or vein abnormalities
– Pulmonary embolus and infarction
16

• Looking for general signs of respiratory
diseases
:-
i. inspection
ii. Palpation
iii. Percussion and
iv. Auscultation.
17

A. General Appearance
I. Look for pattern of Breathing:-
 Respiratory rate
 Normal (14-20 x/min).
 Abnormalities;-
 Tachypnea = RR > 20/min,
e.g. lung infection (pneumonia, P.TB…)
 Bradypnea= RR<12/min,
e.g. increased ICP, diabetic coma… 18

Cont’d...
Rhythm:
• Normal - regular & quite
• Abnormalities;-
 Rapid and shallow
 Causes, metabolic acidosis (DKA),
exercise, anxiety…
19

II. Watch for sign of respiratory distress
 use of respiratory accessory muscles (
sternoclediomastoid & trapizus –during
inspiration ,and abdominal muscles – during
expiration).
• Signs of respiratory distress:-
- contraction of SCM
- IC & SC, retraction
- Sub costal retraction
20

III. Listen for
• Stridor:- audible harsh sound during
inspiration.
– Upper air way obstruction.
- Wheeze:- audible harsh sound during
expiration. Audible both to the patient and
to others.
• Wheezing - partial airway obstruction from
secretions, tissue inflammation, or a foreign
body.
– Bronchial asthma
– Viral pneumonia
21

IV) Assess the patient’s colour for
cyanosis:-
• Is subtle bluish discoloration of mucous
membranes of mouth, lips and nail beds.
• Cyanosis signals:-
i. Hypoxia.
ii. Clubbing of the nails in COPD or
iii. Congenital heart disease
22

Two types.
1) Central cyanosis:- inadequate gas exchange
in the lungs resulting in a significant
reduction in arterial oxygenation.
• It occurs if oxygen saturation < 80%, or 2 to
3 g of unsaturated Hgb/100 ml of blood.
• It results from primary pulmonary problems
,or other conditions
23
E.g. Pulmonary edema
,asthma, COPDS, very
sever pneumonia,
pulmonary fibrosis
 Inspecting- Lips and

2) peripheral cyanosis: results from an
excessive extraction of oxygen at the
periphery.
- Is due to increased oxygen extraction in
states of low cardiac output . e.g. Shock,
exposure to cold…
-Is seen in nail beds ,toes and nose
24

V) Finger clubbing:-
• Curving, roundness & ,thickening of finger
nails.
• Resulted from deposition of soft tissue in
nail beds due to hyper plastic response for
hypoxemia.
e.g Lung abscess, bronchiectasis,
empyma…..
25

26

 Examination is done by inspecting finger
nails ,and it includes grading of the
clubbing.
Grade – 1:- fluctuation of nail bed.
Grade – 1I:- obliteration of angle of nail
bed.
Grade – III:-Increased curvature of nail
Grade – 1V:- drum stick appearance
27

Jugular venous pressure (JVP)
28
Distended neck veins Dilated superficial veins over chest
Superior vena caval obstruction

Inspect the neck:-
• During inspiration,
– Contraction of the sternomastoid or other
accessory muscles, or supraclavicular retraction
– Trachea midline- lateral deviation in
pneumothorax, pleural effusion, or atelectasis
• shape of the chest
Anteroposterior (AP) increase - aging
&COPD.
29

Lymph node groupings in the neck
30

Asterixis. Hand and arm position for
observing the 'flapping tremor' of CO2
retention
31

32
Abnormal shapes:
 . Pectus carnitum (pigeon chest) –
protrusion of sternum and costal cartilages
anteriorly.
– Increasing the AP diameter.
– Costal cartilage adjacent to the sternum
is depressed.
Causes:- Congenital, or ricket

II. Pectus excavatum (Funnel chest):
• Depression in the lower portion of the
sternum.
• So the heart & great b/vs are compressed
causing murmurs.
• Cause can be rickets /congenital.
33

III . Barrel chest : - a chest with increased A-P
Diameter.
• Normal shape during infancy.
• Cause: COPDs
34

IV). Thoracic kyposcoliosis
• Abnormal spinal curvatures & vertebral rotation
deforming the chest.
• Elevated scapulae, s-shaped spine.
• Interrupts lung function.
• Causes can be :-osteoporosis, skeletal disorders
V) Flail chest
• Is an unstable chest resulting when multiple ribs
are fractured.
• So that it interferes with respiration.
35

B. Chest movement;- (symmetrical/
asymmetrical)
- Normally: Symmetrical
- Abnormal (asymmetric);
-Causes:- Unilateral lagging – due to
pneumonic consolidation, pleural effusion,
pneumothorax, atelectasis
(Collapse),pulmonary fibrosis.
36

II. Palpation
A. Position of trachea.
• Placing the index & third finger at
sternoclavicular joint on clavicle and feeling for
its position with the middle finger.
• Normally - central to slightly shifted to the Rt
37

Displacement of trachea & causes
Towards side of lesion
• Lung fibrosis
• Collapse (atelectasis)
Away from side of
lesion
• Pleural effusion
• Pneumothorax
• Hemothorax
• Lung mass
38

B. Pain & tenderness.
Causes of tenderness:
- Over inflamed pleura (Pleuritis)
- Over fractured rib
39

C. Chest expansion (symmetrical/ asymmetrical)
- Placing the hands at costal margins with making
skin fold at the center with thumbs,
- Asking the patient to inhale and exhale & looking
for symmetry of separation of thumbs.
• Normally – symmetrically
• Abnormalities
– Unilateral reduction of chest expansion.
– causes: pleural effusion, pneumothorax, collapse,
consolidation and fibrosis. 40

41
Posterior chest
-Place both hands Posteriorly at
the level of T9 or T10.
-Slide hands medially to pinch a
small amount of skin between your
thumbs.
-Observe for symmetry as the
patient exhales fully following a
deep inspiration.
Anterior chest
-Placing the hands at costal margins
with making skin fold
Asking to inhale and exhale &
looking for symmetry of separation
of thumbs.

D. Feeling Tactile Fremitus (palpable vibrations)
• Speech creates vibrations &When one palpates the
chest wall these vibrations can be felt and are
termed tactile fremitus
• provides useful information about the density of
the underlying lung tissue and chest cavity.
• Asking the patient to say “99” ,or in “amharic”
“arba-arat (44)”
• Feel the vibration with the ball (bony part) of palm
of the hand.
42

43

Palpation sequence for tactile fremitus:
posterior thorax (left) and anterior thorax
(right).
44

45
Sites

Causes of asymmetry in tactile
fremitus
Increased
• Conditions that increase
the density of the lung
and make it more solid
• E.g. Pneumonia
(consolidation)
,atelectasis , lung masses
Decreased
• States that decrease
the transmission of
these sound waves
• E.g. Pleural effusion,
pneumothorax
,obesity , thick chest
wall
46

III. Percussion:
• Tapping on the chest wall and determining
the nature of underlying structure.
– Air filled, fluid –filled or solid
To identify level of diagrammatic dullness.
To estimate diaphragmatic excursion.
47

Percussion Cont’d...
-
48

• Percussion of the
posterior thorax
• In sitting
position, --
symmetric areas
• Percussed at 5-
cm intervals.
• Progression starts
at the apex of
each lung and
• concludes with
percussion of
each lateral
chest wall.
49

Percussion Cont’d...
• Hyper extended the middle finger of your left
hand.
• Press the hyper extended finger distal
interphalangeal joint on the surface to be
percussed avoid surface contact by any other
part of the hand as it dumps the vibrations.
• Position your right forearm close to the
surface in the hand cocked upward.
50

Percussion Cont’d...
• With a quick, sharp, but relaxed wrist motion
strike the hyper extended finger with the tip of
the partially right middle finger.
• You should use always lightest percussion
that produces a clear note a thick chest wall
requires heavier percussion than a thin one.
• Constantly compare two sides.
51

52
Sites
• Causes of abnormal percussion note
- Stony dull percussion note , due to pleural
effusion, lung mass….
-Relative dullness, due to pneumonia, collapse,
fibrosis…..
- Hyperresonance, can be due to, pneumothorax,
emphysema…..

Percussion findings notes
Percussion notes Normal Abnormal
Flat Thigh Massive pleural
effusion, tumor
Dull Liver Lobar pneumonia,
pleural effusion,
hemothorax
Resonance Normal lung
tissue
Chronic bronchitis
Hyper-resonance Emphysema.
Bronchial asthma.
Pneumothorax.
Tympani Puffed out
checks,
abdomen
Large pnemothorax
53

Diaphragmatic excursion(descent of the
diaphragms).
• Normal resonance of the lung stops at the
diaphragm.
• Position of the diaphragm is different during
inspiration and expiration.
• Determining the distance between the level
of dullness on full expiration and the level of
dullness on full inspiration.
54

Techniques :
• Holding the pleximeter finger above & parallel to
the expected level of dullness
• Instructs to take a deep breath & hold it while
the maximal descent of diaphragm is percussed.
• Percuss downward in progressive steps until
dullness clearly replaces resonance.
• Point at w/c percussion note at the midscapular
line changes from resonance to dullness is
marked with a pen.
• Then, instructed to exhale fully and hold it while
again percusses downward to the dullness of the
diaphragm and mark this point.
55

Techniques ….
• Distance between the two markings indicates the range of
motion of the diaphragm.
• Max. Excursion 8 - 10 cm ( healthy, tall men )
• For most people 5 -7 cm .
• Normally, about 2 cm higher on the right
• Decreased diaphragmatic excursion
• Pleural effusion and emphysema.
• Increase in intra-abdominal pressure, as in
• Pregnancy,
• Obesity, or
• Ascites,
56

• Technique of determining diaphragmatic
excursion.
57

• To identify lung sounds.
• Objectives of chest auscultation is to asses air entry in to
lungs.
– Normally – good air entry bilaterally.
– Abnormalities
• Unilateral decreased air entry,
– Pleural effusion, lung collapse, pneumonia,
pneumothorax ,foreign body/mass in air way…
• Bilateral decrement of air entry
– Emphyema, thick chest wall
58

There are four types of normal breath
sounds
• Tracheal
• Bronchial
• Bronchovesicular
• Vesicular
59

Normal breath sounds….
Vesicular breath
sounds
• Soft, low-pitched
• Heard over most of the
lung fields
• Longer inspiratory >
expiratory
• No pause b/n expiration
and inspiration
• Heard through
inspiration and 1/3rd of
expiration.
Bronchial breath
sounds
• Loud and high
pitched like air
rushing through a
tube.
• Louder expiratory
component
• Over maniuburium
of sternum
• Over lung field is a
sign of pneumonic
consolidation. 60

Normal breath sounds….
Bronchovesicular breath
sounds
• Mixture of bronchial and
vesicular sounds
• Equal inspiratory and
expiratory components
length.
• Silent gap b/n
inspiration & expiration
• Heard in the 1st & 2nd
interspaces anteriorly &
b/n scapulas Posteriorly
Tracheal breath
sounds
• Very loud, harsh
sounds
• Over the trachea
in the neck.
61

Added(adventitious) sounds:-
• Abnormal sounds heard during auscultation
and sign of respiratory pathologies
• There are four types of adventitious sounds:-
- Crackles (Crepitations /rales)
- Wheezes
- Rhonchi
- Pleural rubs
62

I. Crackles (crepitations /rales):-
• Short, discontinuous, nonmusical sounds
heard mostly during inspiration.
- Can be coarse ,or fine in quality.
 Coarse crackles (crepitations): are bubbling
sound produced by bubbling of air through
secretions.
- Causes- pneumonia, bronchiectasis, pulmonary
cavities
Fine crackles: produced by explosive reopening
of narrowed peripheral air ways during inspiration.
- Cause, pulmonary edema ,CHF….
63

II. Wheezes
• Are continuous, musical, high-pitched
sounds heard Mostly during expiration.
• Airflow through narrowed bronchi.
• This narrowing may be due to swelling,
secretions, spasm, tumor, or foreign body.
• Wheezes are commonly associated with the
bronchospasm of asthma.
64

iii. Rhonchi
• Are lower-pitched, more sonorous lung
sounds.
• They are believed to be more common with
transient mucus plugging and poor
movement of airway secretions.
iv) Stridor
• Is a wheeze that is entirely or
predominately inspiratory.
• Indicate partial obstruction of the larynx or
trachea.
• Is a medical emergency.
65

v. pleural rub
• Is a grating sound produced by motion of the
pleura, which is impeded by frictional resistance.
• It is best heard at the end of inspiration and at
the beginning of expiration.
• Pleural rubs are heard when pleural surfaces
are roughened or thickened by inflammatory or
neoplastic cells or by fibrin deposits.
66

Transmitted voice sounds
• As sound vibrations produced in the larynx are
transmitted to the chest wall as they pass through the
bronchi & alveolar tissue,
– The sounds are diminished in intensity & altered so
that syllables are not distinguishable.
• If you hear abnormally located broncho-vesicular
breath sounds or bronchial breath sounds,
– Continue on to assess transmitted voice sounds
done in the following ways:-
67

a. Bronchophony
Ask to say “99, or 44” or “
– Normally the sounds transmitted through
the chest wall are muffled & indistinct/not
distinguishable.
– Louder, clear voice sounds heard through
the stethoscope / bronchophony/ suggests
that air filled lung has become airless.
68

b. Egophony
Ask the pt to say’’ ee’’.
– Normally a muffled long “E” sound heard.
– When “ee” is heard as ‘’ay’’-----
Egophony.
– Suggests that the lung has been changed to
airless.
69

c. Whispered pectoriloquy
Ask the pt to whisper “ninety –nine or “one, two,
three”.
– Normal faintly & indistinct whispered voice heard.
– Louder clear whispered sounds / whispered
pectoriloquy/ suggest airless lung.
N.B:- Increased transmission of voice sounds
suggest that air filled lung has become airless.
Ex. Pneumonia
70

Diagnostic assessments
 Pulmonary Function Tests
 Arterial Blood Gas Studies
 Pulse Oximetry
 Cultures
 Sputum Studies
 Imaging Studies
 Chest X-Ray
 Computed Tomography
 Magnetic Resonance Imaging
 Fluoroscopic Studies
 Pulmonary Angiography
 Biopsy
 Endoscopic
Procedures
– bronchoscopy,
– thoracoscopy,
– thoracentesis.
71

Clinical signs of common respiratory
conditions
72

73

74

Normal posteroanterior chest X-ray
75
A/B: the
cardiothor
acic ratio
(CTR)
should be
<50%

Examples of chest X-ray abnormalities
76
Tuberculosis
:
consolidatio
n and
cavitation in
both upper
zones

77
Right
upper lobe
pneumoni
a
containing
air
bronchogr
ams

78
Right
pneumothorax

79
Left pleural
effusion.

80
Pulse oximeter with probe on finger