Genera examination related to respiratory system
1. General observations
RR, Body mass, Fever, confusion, mental status, distress and demeanour, jaundice?
Cubbing, peripheral cyanosis, tobacco staining, flapping tremor, fine tremor, yellow nails?
LAP, JVP, Accessory muscle use?
Centra lcyanosis, ptosis or Hornor’s syndrome, bursing lips, nasal flare, anemia?
Chest expansions, deformities, pattern of breathing?
DVT, Bilateral odema?
Regarding General exam …
• You must calculate RR in general examination ..
• You must count RR in all patients with SOB
• Accessory respiratory muscles are SCM, Trapezius and platysma.
Adverse signs of community acquired pneumonia
• Confusion (altered mental status).
• Blood pressure – diastolic <60 mmgH.
• RR > 30 breaths/min.
• Age > 65 years old.
What cause cyanosis?
• Arterial hypoxemia
• Circulatory disorders
• Severe central cyanosis
• In patients with signs of anemia or hypovolemia you may not see cyanosis.
• Patients with polycythemia become cyanosed at higher arterial oxygen
BP and Pulse in respiratory system
• Diastolic BP <60 mmHg is an adverse sign of CAP.
• Hypotension is also seen in pneumothorax.
• Pulsus paradoxicus is exaggerated pulse variation with respiration is
seen in asthma (not indicate the severity)
• Fall in pulse volume or systolic fall >10mmHg in inspiration is
abnormal and indicate cardiac tamponade.
2. Apex beat
3. LNs (axillary, neck)
4. Trachea position and tracheal tag
5. Chest expansion (by tape measure or with hands) : for upper lobes
and lower lobes.
6. Vocal fremitus
• Bilateral reduced chest expansion is seen in severe COPD and diffuse
• Subcutaneous emphysema is a complication of intercostal drainage
and it may complicates (1) severe acute asthma (2) pneumothorax
and (3) rupture of esophageous.
• Hamman’s sign is a cruching systolic sound indicate a mediatineal
• Measuring distance between suprasternal notch and cricoid cartilage
• Normally it is 3-4 fingerbreadths (بالطول)
• Less distance suggests hyperinflation
Position of trachea
• Upper mediastinum shifting = change in tracheal position.
• Lower mediastinum shifting = change in apex beat location.
Sites that needed to be percussed in anterior chest examination
• The percussion on clavicles is directly.
• Ask patient to say 44 (in Arabic)
• Put your palm (base of fingers) in this areas
• Increased vocal fremitus seen in consolidation and fibrosis.
• Decreased (muffled) focal fremitus seen in pleural effusion and
1. determine air entry to lung
• Good air entry, diminished or absent
• Determine breath sound
• Vesicular with prolonged expiratory phase
• Determine add sounds
• fine or coarse,
• inspiratory early mid late or biphasic,
• changing with cough)
• Localized, diffused or scattered
• Inspiratory, expiratory or biphasic
• Changing with cough
• Pleural rung
• Pneumothorax click
• Vocal resonance
Diminished vesicular breathing
• Pleural effusion;
• Marked pleural thickening;
• Hyperinflation (COPD);
• Over area of occluded major bronchus;
Bronchial breath sound
• They are audible In normal people, posteriorly over the right upper chest
where the trachea is contiguous with the right upper bronchus. Other than
this site this type of breath sound is considered abnormal
4. Over pleural effusion
• Bronchial breathing exclude the possibility of lung cancer.
Crackles (rales, crepitations)
• Pleural effusion do not produce crackles ( outside lung ).
• Crackles caused by the opening of collapsed distal airways and alveoli
• Crackles results from collapsed peripheral airways on expiration.
• Mainly heard during expiration
• An inspiratory wheeze implies severe airway narrowing.
• In general, expiratory wheeze is usually due to bronchial asthma, or
• Inspiratory wheeze is usually due to infection, tumour or foreign
• Biphasic wheeze is usually due to infection and COPD
Pleural rub and pneumothorax click
• Best heard at the end of inspiration and at the beginning of
• Did not change with cough to be distinguished from crepitations
• Pericardial rubs persist after patient stop breathing.
• Heard in systole
• Due to pneumothorax overlying heart
Sites that needed to be auscultated in anterior chest examination are
the same that were percussed except the clavicles.
• Ask patient to say 44 (in Arabic) 2 times (high and whisper)
• Put your stethoscope in this areas
• In normal lung, whisper is not heard, and it become heard at area of
• Spoken numbers are audible on area of consolidation and also normal
lung, and become muffled on collapse (pneumothorax) or pleural
• Lung sounds are bestheard with the bell (they are low pitch sounds)
• The patient must be relaxed are breathing deeply from his muth.
• Auscultate each side alternately.
• avoid auscultation for 3 cm from the midline.
IF bronchial breathing,
Then candidate may asked to do
Egophony OR pectoriloquy
• Egophony is said to be present when the spoken word heard through
the lungs is increased in intensity and takes on a nasal or bleating
• The patient is asked to say (eeee) as in 'bee' whiles the candidate
listens to an area in which consolidation is suspected. If egophony is
present, the (eeee) will be heard as (aaaa) as in 'bay'. This (e to a)
change is seen in consolidation of lung tissue. The area of compressed
lung above a pleural effusion often produces egophony.
• Whispered pectoriloquy is the term for the intensification of the
whispered word heard in the presence of consolidation of the lung.
The patient is instructed to whisper (one-two-three) while the
candidate listens to the area suspected of having consolidation.
Normally, little or nothing may be heard when one listens to a normal
• However, if consolidation is present, the transmission of the spoken
words will be increased, and the words will be clearly heard