Respiratory system examination

 

I. History Taking

A meticulous history provides invaluable clues to underlying respiratory pathologies.

A. Presenting Complaints

1. Breathlessness (Dyspnea)

   • Onset:
     • Acute: Pneumothorax, Pulmonary Embolism (PE), Acute Asthma Exacerbation, Pneumonia.
     • Subacute: Tuberculosis (TB), Pleural Effusion, Subacute Hypersensitivity Pneumonitis.
     • Chronic: Chronic Obstructive Pulmonary Disease (COPD), Interstitial Lung Disease (ILD), Congestive Heart Failure (CHF), Pulmonary Hypertension.
   • Character:
     • Exertional: COPD, ILD, CHF.
     • Orthopnea: Left Ventricular Failure (LVF), Severe Asthma.
     • Paroxysmal Nocturnal Dyspnea (PND): CHF.
     • Platypnea: Hepatopulmonary Syndrome.
     • Trepopnea: Unilateral Lung Disease.
   • Severity: Utilize scales such as the New York Heart Association (NYHA) classification or the Medical Research Council (MRC) Dyspnea Scale.
   • Progression: Rapid worsening may indicate PE or Acute Respiratory Distress Syndrome (ARDS); gradual progression suggests ILD or COPD.

2. Cough

   • Onset:
     • Sudden: Aspiration, PE.
     • Gradual: Bronchiectasis, TB.
   • Character:
     • Dry: ILD, Viral Infections, Medication-induced (e.g., ACE Inhibitors).
     • Productive: Bronchiectasis, COPD, TB.
     • Paroxysmal: Pertussis, Asthma.
     • Nocturnal: Asthma, Gastroesophageal Reflux Disease (GERD).
   • Sputum Characteristics:
     • Mucoid: COPD, Asthma.
     • Purulent: Bacterial Infections.
     • Rusty: Pneumococcal Pneumonia.
     • Foul-smelling: Anaerobic Infections.
     • Blood-streaked: TB, Malignancy.

3. Chest Pain

   • Site:
     • Pleuritic: Lateral Chest (e.g., Pleurisy).
     • Retrosternal: Non-pleuritic (e.g., Myocardial Ischemia).
   • Character:
     • Sharp: Pleuritic Pain.
     • Dull/Aching: Malignancy.
   • Severity: Severe pain may indicate PE or Pneumothorax; mild pain is common in Pleuritis.

4. Hemoptysis

   • Quantity:
     • Streaky: Acute Bronchitis.
     • Massive (>200 mL/24 hrs): TB, Malignancy, Bronchiectasis.
   • Frequency: Single episode versus recurrent episodes.

5. Wheezing/Stridor

   • Inspiratory Stridor: Suggests Upper Airway Obstruction (e.g., Laryngeal Tumor).
   • Expiratory Wheeze: Common in Asthma, COPD.
   • Biphasic Stridor: Indicates Fixed Airway Obstruction (e.g., Tracheal Stenosis).

6. Systemic Symptoms

   • Fever, weight loss, and night sweats are indicative of conditions like TB or malignancy.
   • Anorexia and fatigue may accompany chronic hypoxic states.

B. Past Medical History

• Previous respiratory illnesses: Childhood Asthma, TB, Pneumonia, ICU admissions.
• History of ventilatory support.
• Systemic diseases: Connective Tissue Disorders (CTD), Vasculitis.

C. Personal & Occupational History

• Smoking history quantified in pack-years.
• Substance use: Cannabis, Cocaine.
• Occupational exposures: Asbestos, Silica, Organic Dusts.
• Environmental exposures: Biomass fuels, Bird exposure.

D. Medication History

• Drugs with pulmonary toxicity: Methotrexate, Amiodarone, Nitrofurantoin, Chemotherapy agents.

E. Family History

• Genetic predispositions: Asthma, Atopy, ILD, Cystic Fibrosis.

F. Associated Comorbidities

• Cardiovascular diseases, GERD, Diabetes Mellitus, CTD.

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Certainly! Continuing from Physical Examination of the Respiratory System in an advanced, structured, post-PhD style with all possible clinical interpretations and variations:

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II. Physical Examination (Continued)

A. General Inspection

• Patient Position & Posture:

  • Tripod position: Suggestive of severe airway obstruction (e.g., COPD exacerbation, severe asthma).
  • Orthopnea position: Implies left heart failure, large pleural effusion.
  • Unable to lie supine (Trepopnea): May occur in unilateral lung pathology.

• Respiratory Rate & Pattern:

  • Tachypnea: Reflective of hypoxia, metabolic acidosis, fever, pain.
  • Bradypnea: Possible CNS depression, severe respiratory muscle fatigue.
  • Kussmaul Breathing: Deep, labored, rapid breathing — Diabetic ketoacidosis.
  • Cheyne-Stokes Respiration: Seen in CHF, CNS lesions.
  • Biot’s Breathing: Brainstem injury, opioid overdose.

• Use of Accessory Muscles: SCM, scalene activation → severe airway obstruction, respiratory distress.

• Intercostal/Supraclavicular Retractions: Suggest increased negative intrathoracic pressure → airway obstruction.

• Cyanosis:

  • Central cyanosis: Hypoxemia (PaO2 < 60 mmHg) — COPD, ILD, R-L shunt.
  • Peripheral cyanosis: Peripheral vasoconstriction — cold exposure, shock.

• Clubbing:

  • Bilateral: Bronchogenic carcinoma, bronchiectasis, ILD, cyanotic heart disease.
  • Unilateral: Aneurysm, hemiplegia-related vascular changes.

• Pallor, Pedal Edema: CHF, Cor Pulmonale.

• Chest Wall Abnormalities:

  • Barrel chest → Emphysema.
  • Pectus excavatum/carinatum → May impair respiratory mechanics.
  • Kyphoscoliosis → Restrictive lung disease.

B. Palpation

• Tracheal Position:

  • Shifted towards lesion: Lung collapse, fibrosis.
  • Shifted away: Massive pleural effusion, tension pneumothorax, large mass.
  • Midline: Normal or bilateral disease.

• Chest Expansion:

  • Unilateral reduction: Pneumothorax, consolidation, effusion.
  • Bilateral reduction: COPD, ILD, NM disease.

• Tactile Vocal Fremitus:

  • Increased: Consolidation, cavity with patent bronchus.
  • Decreased: Pleural effusion, pneumothorax, bronchial obstruction.
  • Absent: Thick pleura, large effusion, pneumothorax.

• Position of Apex Beat:

  • Displaced: Large effusion, lung collapse, cardiomegaly.

C. Percussion

• Percussion Note Variations:

  • Resonant: Normal lung.
  • Hyperresonant: Pneumothorax, emphysema.
  • Dull: Consolidation, collapse, mass.
  • Stony dull: Pleural effusion.
  • Impaired resonance: Thickened pleura, small effusion.

• Upper Border of Liver Dullness & Traube’s Space: Elevated in pleural effusion, diaphragmatic paralysis.

D. Auscultation

• Breath Sounds:

  • Vesicular: Normal.
  • Bronchial: Consolidation, cavity.
  • Absent: Pneumothorax, effusion, bronchial obstruction.
  • Reduced: Emphysema, thickened pleura.

• Adventitious Sounds:

  • Crackles:
    • Fine end-inspiratory → ILD.
    • Coarse, biphasic → Bronchiectasis.
    • Basal → CHF.
  • Wheezing:
    • Diffuse, expiratory → Asthma, COPD.
    • Localized → Bronchial obstruction.
  • Stridor: Upper airway obstruction.
  • Pleural rub: Pleurisy, pulmonary infarction.

• Vocal Resonance:

  • Increased (Bronchophony, Egophony, Whispering Pectoriloquy): Consolidation, cavity.
  • Decreased/Absent: Effusion, pneumothorax, collapse.

E. Additional Advanced Tests (Bedside)

• 6-minute Walk Test: Exercise-induced desaturation.
• Peak Expiratory Flow Rate: Asthma severity assessment.
• Assessment of Respiratory Muscle Power: In suspected NM disorders.
• Measurement of Jugular Venous Pressure (JVP): Cor pulmonale, CHF.
• Oxygen Saturation Monitoring & Arterial Blood Gas Analysis: Detect hypoxia, hypercapnia.

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III. Advanced Clinical Interpretation & Differential Possibilities

1. Tracheal Shift:

   • Towards: Fibrosis, lobar collapse.
   • Away: Effusion, tension pneumothorax, large mass.
   • Bilateral elevation: Mediastinal mass, bilateral fibrosis.

2. Dull Percussion:

   • Localized: Consolidation, collapse.
   • Massive, stony dull: Pleural effusion.
   • Diffuse: ILD.

3. Breath Sound Changes:

   • Bronchial with crackles: Consolidation.
   • Absent with dullness: Effusion.
   • Absent with hyperresonance: Pneumothorax.

4. Fremitus & Resonance:

   • Increased fremitus + bronchial breathing + dull percussion → Consolidation.
   • Decreased fremitus + stony dull percussion + absent breath sounds → Effusion.
   • Hyperresonance + absent fremitus + absent breath sounds → Pneumothorax.

5. Bilateral Basal Crackles:

   • CHF, ILD.

6. Clubbing + Coarse Crackles + Copious Sputum:

   • Bronchiectasis.

7. Wheezing + Prolonged Expiration + Accessory Muscle Use:

   • COPD, Asthma.

8. Pleural Rub + Sharp Localized Pain:

   • Pleurisy, PE.

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