Respiratory System Dr. Muhammad Atif Qureshi Associate Professor Department of Medicine

A 45 years old male presented with one year history of: Recurrent chest infections Fever Cough and expectoration

17 year old female presented with 3 months history of: Weight loss Cough with expectoration Fever Night sweats

60 years old male Chronic chain smoker Weight loss Cough Hemoptysis

Chest Pain 1.Onset 2.Severity 3.Site 4.Character 5.Nature 6.Aggravating factors 7.Relieving factor 8.Radiation 9.Referred pain 10.Associated complaints

Cough 1.Onset 2.Severity 3.Character 4.Aggravating factors 5.Relieving factor 6.Associated complaints 7.Hemoptysis

Other presenting symptoms – Apnea – Hoarseness – Stridor – Snoring – Fever – Night sweating – Weight loss

General physical examination Related to Respiratory system

Vital signs General appearance Hands – Tremers – Nicotine stains – Clubbing – Koilonychia – Pallor – Cyanosis – Palmar erythema Use of accessory muscles of respiration Lymph nodes

Hands examination Central Cyanosis – COPD, Asthma – Pulmonary fibrosis – Pneumonia, PE – A/V malformation – Cardiac Rt to Lt shunts Peripheral cyanosis – Cold weather – Low COP

Clubbing – Bronchiectasis – Ca lung – Lung abscess – Pulmonary fibrosis – Asbestosis – Cystic fibrosis

Hypertrophic pulmonary osteoarthropathy – Carcinoma lung

Tremors – FineB2 agonist – FlappingCO2 retention

Inspection: 1.Shape: AP diameter compared to transverse (barrel-chest), pectus excavatum, pectus carinatum, kyphoscoliosis,…. others 2.Symmetry: assessment of upper & lower lobes should be done posteriorly looking for ↓ or delayed chest movement during moderate respirat’n. 3.Scars: from previous operat’n or chest drains or cautery marks or radiotherapy markings. 4.Prominent veins: in case of SVC obstruct’n

1.Trachea: normally central, slight Rt displacement could be N. Check for gross displacement. Tracheal tug means the N distance bet sternal notch & cricoid cartilage is < 3-4 finger breadths & occurs in chest overexpansion as copd. 2.Apex beat : Check for displacement. 3.Chest expansion : N expansion ≥ 5cm 4.Tactile vocal fremitus (TVF): can be done with the palm of one hand.

Should be done symmetrically (Lt compared with the Rt), posteriorly (the back), anteriorly (the front) & laterally (the sides). Supraclavicular area, then clavicles should be percussed directly to evaluate the upper lobes. Liver dullness: of the upper edge starting at the 5 th rib MCL, resonant note below this area indicates hyper- inflation (copd, severe asthma) Cardiac dullness: may be ↓ in hyperinfated chest.

Using the diaphragm of a stethoscope & comment on the following: 1.Breath sounds (BS): Intensity: N or ↓ as in (consolidation, collapse, pl effusion, pneumothorax, lung fibrosis) Quality: Vesicular or bronchial in consolidation Differentiation between vesicular & bronchial BS: Vesicular: louder &longer on inspiration than expiratory phase & has no gap between the 2 phases Bronchial: louder &longer on exp phase & has a gap between the 2 phases

Type: Wheezes or Crackles or friction rub Timing: inspiratory or expiratory WHEEZES: are continuous musical polyphonic sound, heard louder on expiration & can be heard on inspiration which may imply severe AW narrowing. High pitched- wheezes are found in BA due to acute/chronic airflow limitation & low pitched in COPD. Localized monophonic wheeze due to fixed AW obstruct’n in CA bronchus. CRACKLES: interrupted non-musical inspiratory sound coarse medium fine Crackles may be early, late or pan-inspiratory & fine, medium or coarse. Ex: late/pan-insp coarse crackles in bronchiectasis, late/pan-insp medium crackles in pul edema, late/pan-insp fine crackles in pul fibrosis

It’s due to thickened or roughened pleural surfaces rub together as lungs expand & contract & give off a continuous or intermittent grating sound. It indicates pleurisy & may be heard in pneumonia or pulmonary infarction. VOCAL RESONANCE: It’s the ability to transmit sounds. Ask patients to say 123 (Urdu) or 99 (English) & listen for the transmitted sound which may be ↓ or ↑ or N (low pitched component of speech heard with booming & high pitched become attenuated).

Thank You