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Tracheal Deviation:Towards Lesion:

Upper lobe/lung collapseUpper lobe FibrosisPneumonectomy

Away from Lesion:Tension PneumothoraxMassive PE

Upper Mediastinal MassRetrosternal Goitre

LymphomaLung Cancer

Chest Wall Deformities

Barrel Chest: COPDKyphoscoliosisPectus Carinatum: Severechildhood asthma / osteomalaciaPectus Excavatum

Clubbing:Thoracic Tumours:

Bronchial CarcinomaMesothelioma

Pleural FibromaAtrial MyxomaThymomaOesophageal Cancer

Sepsis:Bronchiectasis (+CF)Lung AbcessInfective EndocarditisTBEmpyema

Interstitial:Fibrosing Alveolitis

Asbestosis

AV Shunt:AV malformationsCyanotic CHD

Non-Thoracic:Hepatic CirrhosisIBDCoeliac Disease

Decreased Chest Expansion:Unilateral:

Pleural EffusionLung/lobe collapsePneumohthoraxUnilateral Fibrosis

BilateralAdvanced COPDDiffuse Fibrosis

Percussion:Resonant:

Normal LungHyperresonant:

PneumothoraxDull:

ConsolidationLung/lobe collapseSevere Fibrosis

Stoney Dull:Pleural EffusionHaemothorax

Examination of the Respiratory Examination

Introduce yourself.

Explain procedure

Obtain consent

Position patient supine and inclined at

45 degrees Expose the chest to the waist

Inspect:

General appearance

Hands: colour, nails, CO2 Flap

Face

Tongue

Neck - JVP

Front of chest: deformity, scars,

Chest movement and accessorymuscle activity

Respiratory rate

Palpate:

Trachea

Lymph nodes: neck and axilla

Chest tenderness or lumps

Depth and symmetry of breathing

Tactile vocal fremitus: four sites from top tobottom

Percuss:

Clavicles

Upper zone

Mid zone

Lower zone

Laterally - comparing right and left at each stage

Tactile Vocal Fremitus:Trasmission of Vibration frommouth to chest wallOver areas of Dull Percussion:

TVF: Consolidation/FibrosisTVF: Fluid/Collapse

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Breath Sounds:Normal= Vesicular rustling qualityBronchial Breathing:

High Pitched

Blowing QualityInsp/Exp Similar length and intensityCharacteristic Pause

Cause: uniformly conducting tissueCommon:

Consolidation (pneumonia)

Uncommon:Local FibrosisTop of Pleural EffusionCollapsed lung with majorbronchus patent

Diminished Vesicular Breathing:Decreased Conduction:

ObesityPleural Effusion

PheumothoraxDecreased Airflow

Generalised: COPDLocalised: collapse

Auscultate:

Upper zone

Mid zone

Lower zones

Laterally -comparing right and left at eachstage

Check vocal resonance at same sites

Sit patient forward and repeat inspection,palpation, percussion and auscultation onthe back of the chest.

Look for Sacral/Ankle Oedema

DDx MediastinalShift

Expansion Percussion Tactile VocalFremitus/VocalResonance

Auscultation

Pleural Effusion no/away Stoney Dull Breath SoundsOccasional Rub

Consolidation(pneumonia)

No Normal/ Dull Bronchial Breathing +Crackles (coarse)

Lobar Collapse Towards Dull Breath SoundsPneumothorax No (simple)

Away (Tension)Normal/ Hyper-

resonant Breath Sounds

PleuralThickening

No Dull Breath Sounds

Asthma/COPD No Polyphonic wheezeCOPD: Coarse Crackles

ackles (inspiratory):ening of collapsed small airwayserrupted, non musical soundsrly:

Small airway disease (bronchiolitis)ddle:

Pulmonary Oedemae:Fine: Pulmonary FibrosisMedium: Pulmonary OedemaCoarse: Bronchial Secretions (COPD,Pneumonia)

hasic: Bronchiectasis - Coarse

eeze: Musical Qualityscilating narrowed Airwayually Loudest Expirationpiratory = Severe Airway disease

ction rub: grating sound creaking leatherural inflammation and thickening.idor: on inspirationrowing of the upper airways