1. Respiratory System Examination
By Dr.Khalil Alsoutary
Asst professor
Balqa Applied university
June 15,2019

2. Surface markings of the lung, pleura and trachea the bifurcation of the trachea at sternal angle

3. Surface anatomy of the
Thorax
Lobes of the lung
Anterior view
And lateral view

4. Common Symptoms Cough Spurum Production Hemoptysis Chest pain
Breathlessness
Wheezing

5. Causes of cough Infection sinuses
Infection ,tumors (benign ,malignant), Aspiration
Gastro-esophageal reflux
Foreign body, irritant Dust
Larynx, trachea
Large airways
Asthma
Post-viral airway reactivity Chronic Bronchitis
Bronchiectasis ,Bronchiolitis
Small airways

6. Characters of cough
A nocturnal cough causing sleep disturbance is a common symptom of asthma. Occult gastro-esophageal reflux is a common cause of daytime cough, as is chronic sinus disease with associated postnasal drip.

7. Character of cough
Angiotensin-converting enzyme inhibitors used to treat left ventricular failure and hypertension may cause a dry cough, particularly in women. This is caused by peptides, e.g. bradykinin and substance P, that would normally be degraded by angiotensin-converting enzyme.

8. cough
Coughing during and after swallowing liquids suggests neuromuscular disease of the oropharynx. Occupational asthma and exposure to dusts and fumes are a recognized cause of chronic cough that typically lessens during weekends and holidays.

9. Sputum production SPUTUM PRODUCTION
Expectorated respiratory secretions are known as sputum or phlegm and need to be specifically asked about. Patients may find it difficult to discuss sputum production because of a natural reluctance, and it may be regularly swallowed.

10. main types of sputum Cause Appearance Type Acute pulm edema
Clear, watery
Serous
Chronic Bronchitis,COPD
Asthma
Clear, gray
White, viscid
Mucoid
Broncho-pulmon
infection
Yellow-green
Purulent
Pneumococcal inf
Golden-yellow
Rusty

11. Common Symptoms
All of these can also occur in the absence of respiratory disease. For example, breathlessness, wheeze and central chest pain may be the presenting feature of an acute myocardial infarction complicated by pulmonary edema. Diabetic ketoacidosis may present with breathlessness and weight loss.

12. Although many respiratory conditions share the same combination of symptoms (e.g. cough, sputum production and breathlessness are features of pneumonia, asthma, COPD, cystic fibrosis and bronchiectasis),
the mode of onset, duration, progression and severity of each symptom characteristically differ.Therefore , each symptom needs careful exploration of mode of onset, duration, progression, aggravating/relieving factors and relationships with other symptoms.

13. Causes of cough Infection sinuses
Infection,tumors (benign,malignant), Aspiration
Gastroesophageal reflux
Foreign body,irritant Dust
Larynx, trachea
Large airways
Asthma
Post-viral airway reactivityChronic Bronchitis
Bronchiectasis,Broncolitis
Small airways

14. Cough-character
A feeble non-explosive 'bovine' cough with hoarseness may occur with respiratory muscle weakness but is more usually associated with lung cancer invading the left recurrent laryngeal nerve with resultant paralysis of the left vocal cord. A rare cause is thoracic aortic aneurysm that also damages the left recurrent laryngeal nerve.

15. cough
Patients with severe airflow obstruction (asthma or COPD) often have prolonged wheezy coughing, and sometimes the sustained increase in intrathoracic pressure is sufficient to impair venous return to the heart, resulting in reduced cardiac output and cough syncope or near-syncope.
The cough of laryngeal inflammation, infection and tumour tends to be harsh, barking or painful and may be associated with hoarseness and stridor.

16. Cough-character
moist cough usually indicates secretions in the upper and larger airways and occurs in bronchial infection and bronchiectasis. A persistent moist 'smoker's' cough first thing in the morning is typical of chronic bronchitis. Smokers often do not mention it because it is so common they assume it is normal. Any change in the pattern of this cough may indicate the development of lung cancer.
A dry centrally painful and non-productive cough is a feature of tracheitis and pneumonia. A paroxysmal dry cough in patients with asthma may follow a viral respiratory infection and last several months.
A chronic dry cough is common in interstitial disease, e.g. cryptogenic fibrosing alveolitis.

17. Sputum production
SPUTUM PRODUCTION : Expectorated respiratory secretions are known as sputum or phlegm and need to be specifically asked about. Patients may find it difficult to discuss sputum production because of a natural reluctance, and it may be regularly swallowed. There are four main types of sputum

18. Sputum production
Amount : Ask how many teaspoons of sputum are coughed up each day. Statements by patients that they cough up small (a teaspoonful) or large (a teacupful) amounts of sputum are usually helpful. Regular coughing up of large volumes of purulent sputum influenced by posture is characteristic of bronchiectasis.

19. Sputum production
The sudden production of large amounts of purulent sputum on a single occasion suggests the rupture of a lung abscess or empyema into the bronchial tree.
Large volumes of watery sputum with a pink tinge in an acutely breathless patient suggests pulmonary oedema, whereas large volumes of watery sputum for weeks (bronchorrhoea) is a symptom of alveolar cell cancer.

20. Different colours of sputum. (A) White. (B) Yellow. (C) Green
Different colours of sputum. (A) White. (B) Yellow. (C) Green. (D) Rusty red

21. General Examination Respiratory Rate
Count the number of respiration per minute, tachypnea is resprate>15 caused by fever,asthma and COPD,reduced ventilatory capacity as in B.Asthma and pneumonia,pulmonary edema and interstitial lung disease

22. HEMOPTYSIS
Hemoptysis induce anxiety in many patients, bwcause of lung cancer
It is important to determine if the blood has been coughed up,or vomited from the upper resp tract or suddenly appear in the mouth without coughing

23. hemoptysis
Amount and appearance—streaking of clear sputum with blood, or the presence of blood clots in sputum for 1wk or more suggest lung cancer
Duration and frequency—coughing up of large amounts of blood is rare, life threatening condition that occur in bronchiectasis ,TB, lung cancer,
pulmonary infarction, lung abscess, mycetoma(rare)

24. Causes of Hemoptysis Lung cancer Tumor Endobronchial metastasis
Bronchial carcinoid
Bronciectasis
Infection
Pulmonary TB
Lung abscess, Mycetoma
Pulmonary Infarction
vascular
Wegner Granulomatosis
Goodpasteur`s syndrome
Vasculitis

25. Causes of hemoptysis/2 Inhaled foreign body Trauma Chest trauma
Iatrogenic; Bronchoscopic biopsy
Transthoracic lung biopsy
Mitral valve disease
cardiac
Acute left ventricular failure
Blood dyscrasia
hematological
Anticoagulation

26. Non central causes of chest pain
Infection
Malignancy
Pneumothorax
Pulmonary Infarction
Connective tissue disease Rheumatoid arthritis, SLE)
PLEURAL
Pesistant cough, breathlessness
Muscle sprain /tears
Bronholm`s disease
Rib fracture
Intercostal nerve compression
Chest wall

27. Chest pain
Chest pain can originate from the pleura, the chest wall and mediastinal structures
History should include- site, radiation,mode of onset, duration,severity, aggravating and releiving factors including relation to breathing

28. Central causes of chest pain
Infections
Irritant Dust
Tracheal
Massive pulmonary embolism
Acute M. infarction/ischemia
cardiac
Oesophagitis
Rupture
Esophageal
Aortic Dissection
Great vessels
Lung cancer, Thymoma, lymphadenopathy, metastasis, mediastininitis
Mediastinal

29. Pleural pain
Typicall sharp, stabbing and always increased by inspiration and coughing
Irritation of the parietal pleura of upper 6 ribs is perceived as a localized pain
Irritation of the parietal pleura overlying the central diaphragm is referred yo the neck or shoulder tip
The lower 6 intercoatal nerves innervate the parital pleura and outer diaphragm,pain may be referred to the upper abdomen

30. Chest wall pain
Chest wall pain Pain originating from the chest wall may indicate respiratory or musculoskeletal disease. Or develop a generalized feeling of chest tightness or diffuse pain.
Patients with asthma or COPD often mention this form of pain if asked but it is rarely a presenting complaint.
The sudden onset of localized pain after vigorous coughing or direct trauma is characteristic of rib fractures or intercostal muscle injury.

31. Chest wall pain
Prevesicular herpes zoster and intercostal nerve root compression can cause chest pain in a thoracic dermatomal distribution.
Malignant chest wall pain due to lung cancer, mesothelioma or rib metastases is typically dull, aching, or gnawing in nature, unrelated to respiration, progressively worsening and eventually disrupting sleep.
The pain of Pancoast's tumour of the lung apex is due to erosion of the first rib and is often referred down the medial aspect of the arm because of invasion of the lower roots of the brachial plexus

32. Breathlessness
Breathlessness (dyspnoea) is an undue awareness of breathing. It is a natural consequence of strenuous physical exercise. Patients may use terms such as 'shortness of breath', 'difficulty getting enough air in', 'feeling puffed', or 'tiredness'. These terms indicate that the patient is getting breathless but are usually unhelpful in elucidating possible causes (Table 4.5).

33. Breathlessness A careful history of breathlessness covers
Mode of onset,
duration,
progression,
variation,
aggravating/relieving factors
severity and associated symptoms.

34. Causes of breathlessness
Anemia , Obesity
Noncardio-respiratory
Metabolic acidosis
psychogenic
Neurogenic
Left ventricular failure
cardiac
Mitral valve disease
cardiomyopathy
Constrictive pericarditis
Pericardial effusion

35. Respiratory Laryngeal tumors Airways Foreign body Asthma COPD
Bronchiectasis
Lung cancer
Bronchiolitis
Cystic fibrosis
Pulmonary fibrosis,alveolitis
Parynchima
Tuberculosis, pneumonia, diffuse infection
sarcoidosis

36. Causes of breathlessness/2
Pulmonary Embolism
Pulmonary circulation
Pulmonary vasculitis
Primary pulmonary HTN
Pneumothorax
pleura
effusion
Diffuse pleural fibrosis
kyphosis
chest wall
Ankylosing spondylitis
Myasthenia gravies,Muscle dystrophies
Neuromuscular

37. Breathlessness, mode of onset,duration and progression
Pulmonary thromboembolism
Minutes
Pneumothorax
Acute left ventricular failure
Asthma, inhaled foreign body
pneumonia
Hours to days
Asthma
COPD exacerbation

38. Breathlessnes,mode of action, duration, and progression
Weeks to months
Anemia
Pleural effusion
Respiratory N-Muscular disease
Months-Years
COPD
Pulmobnary fibrosis
Pulmonary tuberculosis

39. Severity of Breathlessness
Grade 1 breathless when hurrying on level
Grade 2 Breathless when walking with people of own age on level ground
Grade 3 has to stop because of breathlessness when walking on ground level at own pace

40. wheeze
A high-pitched whistling sound produced by air passing through small vessel
Typically wheeze is limited to and louder during expiration
Wheeze on exercise is a common symptom of asthma and COPD
A common mistake is failure to distinguish a wheeze from inspiratory stridor caused by partial occlusion of a large airway by a tumour or foreign body