EXAMINATION OF A EXAMINATION OF A PATIENT WITH PATIENT WITH

COUGHCOUGH

GENERAL EXAMINATIONGENERAL EXAMINATION

Attitude: Sit in a propped up position if Attitude: Sit in a propped up position if dyspnoea presentdyspnoea present

Mental state:Mental confusion,stupor and Mental state:Mental confusion,stupor and flapping tremors…Respiratory failureflapping tremors…Respiratory failure

Recent loss of weight: Recent loss of weight: Pulmonary Pulmonary tuberculosis & Bronchogenic carcinomatuberculosis & Bronchogenic carcinoma

Fever: Tuberculosis & PneumoniaFever: Tuberculosis & Pneumonia

PallorPallor

1.1. Severe haemoptysisSevere haemoptysis

2.2. Tuberculosis:Malnutrition & anaemiaTuberculosis:Malnutrition & anaemia

CyanosisCyanosis

Central: Respiratory failure & CHFCentral: Respiratory failure & CHF

ClubbingClubbing

Tumours Tumours

1.1. Bronchogenic carcinomaBronchogenic carcinoma

2.2. MesotheliomaMesothelioma

Interstitial lung diseaseInterstitial lung disease Chronic pulmonary tuberculosisChronic pulmonary tuberculosis

SepsisSepsis

1.1. BronchiectasisBronchiectasis

2.2. Lung abcessLung abcess

3.3. EmpyemaEmpyema

Pulmonary osteoarthropathyPulmonary osteoarthropathy

Painful clubbing+thickening of Painful clubbing+thickening of periosteum of distal parts of periosteum of distal parts of radius,ulna,tibia,fibula+ painful radius,ulna,tibia,fibula+ painful enlargement of ankles & wristsenlargement of ankles & wrists

Bronchogenic carcinoma Bronchogenic carcinoma

LymphadenopathyLymphadenopathy

Pulmonary tuberculosisPulmonary tuberculosisCarcinomaCarcinomaSarcoidosisSarcoidosis

Scalene nodesScalene nodes

EdemaEdema

RHF secondary to pulmonay diseases is RHF secondary to pulmonay diseases is termed termed COR PULMONALE.COR PULMONALE.

1.1. EmphysemaEmphysema

2.2. Pulmonary fibrosisPulmonary fibrosis

Head to foot examinationHead to foot examination

Subcutaneous nodules raised, firm tender: Subcutaneous nodules raised, firm tender: Metastatic lung cancerMetastatic lung cancer

Erythema nodosum over the shin:Acute Erythema nodosum over the shin:Acute sarcoidosissarcoidosis

VITALS!!!!VITALS!!!!

BPBP

1.1. High BP:COPD , Pulmonary embolismHigh BP:COPD , Pulmonary embolism

2.2. Low BP:Pulmonary edema, ACEI, Low BP:Pulmonary edema, ACEI, Community acquired pneumoniaCommunity acquired pneumonia

(CRB-65)(CRB-65) JVPJVP Raised in cor pulmonaleRaised in cor pulmonale

Examination of oropharynxExamination of oropharynx

Evidence of postnasal dripEvidence of postnasal dripOropharyngeal mucosa erythema or Oropharyngeal mucosa erythema or

cobble stone appearancecobble stone appearance

Movement of accessory muscles of Movement of accessory muscles of respirationrespiration

Examination of neck:Posture,Movement of Examination of neck:Posture,Movement of accessory muscles,Jugular veinsaccessory muscles,Jugular veins

RESPIRATORY SYSTEMRESPIRATORY SYSTEM

INSPECTIONINSPECTIONShape of the chestShape of the chest

Barrel shaped chestBarrel shaped chest

EmphysemaEmphysema

Drooping of the shouldersDrooping of the shoulders

RespirationRespiration

RateRate >15/min+increase ventilatory drive>15/min+increase ventilatory drive

1.1. Acute asthmaAcute asthma

2.2. Exacerbation of COPDExacerbation of COPD

>15/min+decrease ventilatory drive>15/min+decrease ventilatory drive

1.1. PneumoniaPneumonia

>30/min:Community acquired pneumonia>30/min:Community acquired pneumonia

Decrease rate: Respiratory failureDecrease rate: Respiratory failure

Use of accessory muscles of respirationUse of accessory muscles of respiration

Movements of the chestMovements of the chest

Intercostal recession:Indrawing of Intercostal recession:Indrawing of intercostal spaces with respiration… intercostal spaces with respiration… Severe airway obstruction..laryngeal ds or Severe airway obstruction..laryngeal ds or tumours of tracheatumours of trachea

PALPATIONPALPATION

Position of tracheaPosition of trachea

1.1. Deviation to same side:FibrosisDeviation to same side:Fibrosis

2.2. Deviation to opp side:Pneumothorax, Deviation to opp side:Pneumothorax, Pleural effusionPleural effusion

Apex beatApex beat Palpation of the chest for any tendernessPalpation of the chest for any tenderness Expansion of the chestExpansion of the chest

Decrease expansion in Decrease expansion in consolidation,emphysemaconsolidation,emphysema

Vocal fremitusVocal fremitusDecrease in bronchial obstrn,emphysemaDecrease in bronchial obstrn,emphysema Increase in pneumonic consolidation & Increase in pneumonic consolidation &

neoplasmsneoplasms

Rhonchial fremitusRhonchial fremitus Palpable rhonchiPalpable rhonchi

PERCUSSIONPERCUSSION

Hyperresonant in emphysemaHyperresonant in emphysemaTympanic in a superficial cavity of lungTympanic in a superficial cavity of lungDullness in consolidationDullness in consolidation

Cracked pot sound:Cracked pot sound:percussion note over percussion note over cavities which communicate with bronchuscavities which communicate with bronchus

Cardiac dullness obliterated in Cardiac dullness obliterated in emphysemaemphysema

AUSCULTATIONAUSCULTATION

Breath soundsBreath sounds

Decreased intensityDecreased intensity

1.1. Collapse & FibrosisCollapse & Fibrosis

2.2. Bronchial obstructionBronchial obstruction

Bronchial breathingBronchial breathing Pneumonic consolidationPneumonic consolidation

Added soundsAdded sounds

Wheezes are musical sounds assoc. with Wheezes are musical sounds assoc. with airway narrowing.airway narrowing.

1.1. Polyphonic wheezesPolyphonic wheezes heard in expiration: heard in expiration: asthma & COPDasthma & COPD

2.2. Monophonic wheezesMonophonic wheezes in localised in localised narrowing of bronchus & tumour or narrowing of bronchus & tumour or foreign bodyforeign body

Stridor is a harsh croaking inspiratory Stridor is a harsh croaking inspiratory noise aagravated by coughnoise aagravated by cough

Should be investigated always.Should be investigated always.

1.1. Foreign bodyForeign body

2.2. Tumour occluding larynx,trachea or a Tumour occluding larynx,trachea or a bronchusbronchus

Crackles are short,explosive sounds Crackles are short,explosive sounds often described as bubbling or clickingoften described as bubbling or clicking

1.1. U/L early inspiratory:bronchial infn or U/L early inspiratory:bronchial infn or pneumoniapneumonia

2.2. B/L basal:pulmonary edemaB/L basal:pulmonary edema

Bronchiectasis:Bronchiectasis: coarse crackles coarse crackles

Diffuse interstitial fibrosis:fine crackles but Diffuse interstitial fibrosis:fine crackles but late inspiratorylate inspiratory

COPD:crackles at the beginning of COPD:crackles at the beginning of respirationrespiration

Vocal resonanceVocal resonance

Increased in pneumonic consolidationIncreased in pneumonic consolidation Whispering pectoriloquy presentWhispering pectoriloquy present

Decreased in emphysemaDecreased in emphysema

Position Position of tracheaof trachea

VFVF PercussioPercussionn

VRVR

PneumoniPneumonic c consolidatconsolidationion

No shiftNo shift increseincrese dulldull increaseincrease

EmphyseEmphysemama

No shiftNo shift decreasedecrease hyperresohyperresonantnant

decreasedecrease

Also examine…Also examine…

CVSCVSCor pulmonaleCor pulmonalePulmonary edemaPulmonary edema