RS EXAM

Introduction:
 Diseases of the respiratory system are a significant cause of mortality globally,
contributing to up to a third of deaths in many countries.
 Respiratory ailments also constitute a major portion of medical consultations and
absenteeism from work or school.
 Effective diagnosis in medicine hinges upon a thorough and meticulously documented
patient history.
 Symptoms, irrespective of their perceived severity, can signify underlying conditions
ranging from minor to life-threatening.

The History:
 Breathlessness, cough, excess sputum, hemoptysis, wheeze, and chest pain are
commonly reported symptoms among patients with respiratory diseases.
 These symptoms serve as key indicators during patient presentations and examinations.
 Understanding the presence and characteristics of these symptoms aids in diagnosing
respiratory conditions accurately.

Breathlessness:
 Dyspnea, or breathlessness, occurs when one experiences difficulty breathing that is not
proportionate to the level of physical activity.
 Its underlying mechanisms are intricate and not fully comprehended, involving factors
beyond just low blood oxygen levels (hypoxia) or high blood carbon dioxide levels
(hypercapnia), though these may contribute significantly.
 Conditions such as cardiac disease, anaemia, thyrotoxicosis, or metabolic acidosis can
also lead to dyspnea, in addition to respiratory issues.
 Assessing dyspnea involves determining whether it is solely related to exertion and
gauging the patient's exercise tolerance, often through discussions about their daily
activities.
 Variability in symptoms, good days versus bad days, and specific times of exacerbation
(e.g., nocturnal worsening in asthma) are crucial details to elicit during evaluation.
 Asthma often worsens at night and in the early morning, while individuals with chronic
obstructive pulmonary disease (COPD) may feel relatively normal at rest but experience
dyspnea with exertion.
Cough:
 Coughs can be dry or productive of sputum.
 Duration of the cough is important to assess; a short-lived cough post-cold is different
from a prolonged one in a middle-aged smoker, which could indicate malignancy.
 Timing of the cough, whether worse at certain times of the day or night, can offer
diagnostic clues; for instance, a nighttime dry cough might indicate early asthma.
 Triggers exacerbating the cough, such as allergens (e.g., dust, animals, pollen) or non-
specific factors like exercise or cold air, can suggest underlying conditions such as
asthma or post-viral reactive airways.
 Severe coughing, regardless of cause, may lead to vomiting as a consequence.

Sputum:
 Is sputum being produced?
 Description of sputum's color and consistency is essential; yellow or green sputum
typically indicates purulence.
 In asthma, sputum may be scant and thick, sometimes forming jelly-like blobs or cast
shapes resembling the airways.
 Eosinophils may accumulate in the sputum in asthma, giving it a purulent appearance
even without infection.
 Quantity of sputum production is noteworthy; in the past, severe lung damage in
childhood often led to bronchiectasis in adults, characterized by significant daily sputum
production. However, bronchiectasis is now rare, with chronic bronchitis causing smaller
amounts of sputum.

Haemoptysis:
 Haemoptysis refers to coughing up blood in the sputum, which warrants careful
evaluation.
 Patients may not always mention haemoptysis due to fear, so specific questioning is
necessary to ascertain its presence, freshness, quantity, onset, and frequency.
 Blood may be coughed up alone or may stain the sputum, making it challenging for
patients to determine its origin, whether from the chest, gums, nose, or stomach.
 Associated conditions such as epistaxis (nosebleeds) or melena (altered blood in stool)
should be queried to rule out upper gastrointestinal bleeding.
 Although sometimes difficult to ascertain, if the origin of blood is likely from the chest,
further investigation is warranted.
Wheezing:
  Always inquire if the patient hears any chest noises.
 Even if wheezing isn't present during examination, it's valuable to know if the patient has
noticed it at times.
 Wheezing may be observed by others, especially partners at night when asthma worsens,
but may go unnoticed by the patient.
 Stridor, a serious finding, may be mistaken for wheezing by both patient and doctor,
indicating narrowing of the larynx, trachea, or main bronchi.

Chest Pain:
 Chest pain related to lung disease typically stems from pleural involvement, aside from
musculoskeletal discomfort due to prolonged coughing.
 Pleuritic pain is characterized by sharp, stabbing sensations exacerbated by deep
breathing or coughing, commonly caused by pleural inflammation, often secondary to
underlying lung infection.
 Constant pain unrelated to breathing could indicate local invasion of the chest wall by a
lung or pleural tumor.
 Spontaneous pneumothorax presents with pain worsened by breathing, typically
described as aching rather than stabbing, differing from the sharp pain of pleurisy.
 Pulmonary embolism can lead to pleurisy and pleuritic pain due to lung infarction,
though the pain might not always be stabbing. Severe embolism can cause cardiac-type
chest pain due to hemodynamic disturbance.

Other Symptoms:
 In addition to typical respiratory symptoms, certain aspects of the patient's history are
especially pertinent to respiratory conditions.

Upper Airway:
 Inquiries about ear, nose, and throat symptoms are relevant.
 Rhinosinusitis often coexists with asthma or bronchiectasis, potentially exacerbating
respiratory conditions.
 Chronic cough may result from postnasal drip secondary to rhinitis.
 Voice changes could signal left recurrent laryngeal nerve involvement by lung carcinoma.
 Hoarseness or voice weakness in asthma patients using inhaled corticosteroids may
indicate oropharyngeal candidiasis, which typically improves with treatment adjustment.
However, in older patients, hoarseness could signify vocal cord carcinoma, warranting
laryngoscopy if persistent for more than 4 weeks.
Smoking History:
 A comprehensive smoking history should always be obtained, done in a sympathetic and
non-judgmental manner to ensure accuracy.
 Advice on smoking cessation should be provided after completing the assessment, not
initially.
 Simply asking "Do you smoke?" may not suffice, as further inquiry often reveals recent
cessation or intentions to quit.
 Details such as age of starting and stopping (for ex-smokers), and average consumption
for both current and ex-smokers, are essential.
 Identifying an individual as a current or ex-smoker significantly influences the
interpretation of findings from history and examination.
 It's crucial to note that almost all cases of lung cancer and chronic obstructive pulmonary
disease (COPD) occur in individuals with a history of smoking.

Family History:
 Asthma has a strong inherited susceptibility.
 Relatives of individuals with asthma may also have associated atopic conditions like
eczema and hay fever, especially if asthma developed at a young age.

Occupational History:
 Lungs are highly susceptible to the working environment, with numerous substances
identified as causing occupational asthma.
 Certain occupations, such as paint sprayers, electronics workers, rubber/plastics
industry workers, and woodworkers, are commonly associated with occupational
asthma.
 Always inquire about any correlation between symptoms and work.
 Inhalation of asbestos can lead to serious health issues, including malignant
mesothelioma, which may manifest decades later. The incidence of mesothelioma has
increased in industrialized countries and is expected to rise further in the next 20 years.
 In middle-aged individuals presenting with pleural effusion, a potential sign of
mesothelioma, it's crucial to inquire about past asbestos exposure, tracing back to the
time of first employment.
The Examination - General Assessment:
 The examination of the respiratory system should include a simultaneous general
assessment.
 Observe the patient's appearance and behavior from the moment they enter the room,
during history taking, and while undressing and preparing for the examination.
 Note any signs of breathlessness, such as the use of accessory muscles of respiration or
pursed-lip breathing, especially in severe COPD patients.
 Assess for audible wheezing or stridor.
 Evaluate the patient's voice for hoarseness and their ability to produce a normal,
explosive cough.
 Determine the presence and characteristics of wheezing or stridor.
 Take note of items on the bedside table, such as inhalers, peak flow meters, tissues,
sputum pots, or oxygen masks.
 Assess the patient's physique and general nourishment.
 Ensure the patient is comfortably positioned on a bed or couch, supported by pillows at a
45° angle for optimal examination.

Hands Examination:
 Check for clubbing, pallor, or cyanosis.
 Clubbing in the hands can be indicative of respiratory conditions such as bronchogenic
carcinoma, pulmonary fibrosis, bronchiectasis, lung abscess, and pleural empyema.
 A fine tremor in the hands may suggest the use of inhaled β2 agonists like salbutamol.
 Asterixis (flapping tremor) can indicate carbon dioxide retention or hypercapnia, often
seen in drowsy patients with warm hands and a bounding pulse.
 During a significant asthma attack, the pulse rate tends to rise.
 In acute asthma, severe inspiratory efforts can lead to a decrease in systolic blood
pressure, known as pulsus paradoxus, which can serve as a marker of asthma severity.

Respiratory Rate and Rhythm:

 Note the respiratory rate and pattern of respiration during examination.
 The normal respiratory rate in a relaxed adult ranges from about 14 to 16 breaths per
minute.
 Tachypnea refers to an increased respiratory rate observed by the doctor, while dyspnea
is the subjective sensation of breathlessness experienced by the patient.
  Apnea denotes the cessation of respiration.
 Cheyne-Stokes breathing is characterized by cyclical variations in the depth and rate of
respiration, often observed in severely ill patients, particularly those with severe cardiac
failure, narcotic drug poisoning, or neurological disorders. It can also occur during sleep
in elderly individuals without serious underlying diseases.
 Some patients experience apneic episodes during sleep, either due to complete cessation
of respiratory effort (central apnea) or despite continued respiratory effort (obstructive
sleep apnea), which is more common and often related to upper airway obstruction,
particularly in obese patients.

Respiratory Rate and Rhythm:

 Note the respiratory rate and pattern of respiration during examination.
 The normal respiratory rate in a relaxed adult ranges from about 14 to 16 breaths per
minute.
 Tachypnea refers to an increased respiratory rate observed by the doctor, while dyspnea
is the subjective sensation of breathlessness experienced by the patient.
 Apnea denotes the cessation of respiration.
 Cheyne-Stokes breathing is characterized by cyclical variations in the depth and rate of
respiration, often observed in severely ill patients, particularly those with severe cardiac
failure, narcotic drug poisoning, or neurological disorders. It can also occur during sleep
in elderly individuals without serious underlying diseases.
 Some patients experience apneic episodes during sleep, either due to complete cessation
of respiratory effort (central apnea) or despite continued respiratory effort (obstructive
sleep apnea), which is more common and often related to upper airway obstruction,
particularly in obese patients.

Venous Pulses:
 Inspect the venous pulses in the neck.
 A raised jugular venous pressure (JVP) may indicate cor pulmonale, which is right heart
failure resulting from chronic pulmonary hypertension in severe lung disease, often seen
in COPD. Pitting edema of the ankles and sacrum may accompany this condition.
 Engorged neck veins may also be caused by superior vena cava obstruction (SVCO),
typically due to malignancy in the upper mediastinum. SVCO can present with facial
swelling and redness (plethora).
Head Examination:
 Examination of the eyes may reveal signs of anemia or, rarely, Horner’s syndrome, which
can be secondary to a Pancoast tumor invading the cervical sympathetic chain.
 The lips and tongue should be inspected for central cyanosis, indicating poor
oxygenation of the blood by the lungs, while peripheral cyanosis alone typically suggests
poor peripheral perfusion.
 Oral candidiasis may indicate the use of inhaled steroids or may be a sign of debilitation
or underlying immune suppression in the patient.

Examination of the Chest - Relevant Anatomy:

 The bifurcation of the trachea corresponds anteriorly to the sternal angle, which is the
transverse bony ridge at the junction of the body of the sternum and the manubrium
sterni. Posteriorly, it is located at the disc between the fourth and fifth thoracic
vertebrae.
 Ribs are most easily counted downwards from the second costal cartilage, which
articulates with the sternum at the extremity of the sternal angle.
 The upper border of the lower lobe (oblique or major interlobar fissure) corresponds to a
line from the second thoracic spine to the sixth rib, aligned with the nipple.
 On the right side, a horizontal line from the sternum at the level of the fourth costal
cartilage, meeting the line of the major interlobar fissure, delineates the boundary
between the upper and middle lobes (the horizontal or minor interlobar fissure).
 Most of each lung, as seen from behind, comprises the lower lobe, with only the apex
belonging to the upper lobe.
 The middle and upper lobes on the right side and the upper lobe on the left occupy the
majority of the area in front.
 The stethoscope, although iconic in medicine, should not overshadow the importance of
visual inspection and palpation before auscultation during chest examinations.

Inspection of the Chest - Looking:

 Examine the appearance of the chest, checking for any obvious scars from previous
surgeries such as thoracotomy (lobectomy or pneumonectomy), pleural procedures, or
tracheostomy.
 Look for any visible lumps beneath the skin or lesions on the skin itself.
 Assess the shape of the chest, which should be bilaterally symmetrical and elliptical in
cross-section, with the narrower diameter being anteroposterior.
 Note any distortion of the chest caused by rib or spinal vertebrae diseases, as well as
underlying lung disease.
  Kyphosis (forward bending) or scoliosis (lateral bending) of the vertebral column can
lead to chest asymmetry and may restrict lung movement if severe.
 Severe airways obstruction, particularly in conditions like COPD, can result in
overinflated lungs and a "barrel-shaped" chest, characterized by an increased
anteroposterior diameter, making the chest cross-section more circular. On X-ray, the
hemidiaphragms may appear lower than usual and flattened.

Chest Movement:
 Observe whether chest movements are symmetrical.
 Diminished movement on one side suggests an abnormality on that side.
 Intercostal recession, a drawing-in of the intercostal spaces with inspiration, may
indicate severe upper airways obstruction, such as in laryngeal disease or tracheal
tumors.
 In COPD, lower ribs may paradoxically move inwards on inspiration instead of the
normal outward movement.

Palpation of the Chest - Lymph Nodes:

 Palpate the lymph nodes in the supraclavicular fossae, cervical regions, and axillary
regions.
 Enlarged lymph nodes in these areas may indicate the spread of malignant disease from
the chest, which can influence treatment decisions.
 To examine lymph nodes in the neck, it is best to sit the patient up and examine from
behind.

Palpation of the Chest - Swellings and Tenderness:

 Palpate any area of the chest with obvious swelling or where the patient complains of
pain.
 Apply gentle pressure during palpation, as increased pressure may exacerbate the pain.
 Identifying sites of tenderness, especially in cases of musculoskeletal pain, can be crucial
for diagnosis and management.

Palpation of the Chest - Trachea and Heart:

 Determine the positions of the cardiac impulse and trachea during examination.
  Locate the trachea by placing the second and fourth fingers of the examining hand on
each edge of the sternal notch and using the third finger to assess whether the trachea is
central or deviated to one side.
 Use gentle pressure during tracheal palpation to avoid discomfort for the patient.
 Note that a slight deviation of the trachea to the right may be found in healthy
individuals.
 Displacement of the cardiac impulse without displacement of the trachea may be due to
scoliosis, congenital sternum deformities, or left ventricle enlargement.
 Significant displacement of the cardiac impulse, trachea, or both together suggests
alteration of the mediastinum position due to lung or pleural disease.
 Pleural effusion or pneumothorax can push the mediastinum away from the affected side
(contralateral deviation), while lung fibrosis or collapse can pull the mediastinum
towards the affected side (ipsilateral deviation).

Chest Expansion Assessment:

 Besides visual inspection, possible asymmetrical chest expansion can be further explored
by palpation.
 Stand facing the patient and place the fingertips of both hands on either side of the lower
ribcage, with the tips of the thumbs meeting in the midline in front of the chest, but not
touching it.
 Ask the patient to take a deep breath; increased distance between the thumbs indicates
the degree of chest expansion.
 If one thumb remains closer to the midline, it suggests diminished expansion on that
side.
 This technique essentially uses the hands as calipers to measure expansion in the lateral
bases of the lungs where maximum expansion occurs.
 Tactile vocal fremitus can be detected by palpation, although it's not commonly used as a
routine examination technique and is discussed further under auscultation.

Percussion of the Chest:

 Percussion technique originated as a method to ascertain fluid levels in barrels of wine or
other liquids.
 Auenbrugger developed percussion after learning this method in his father’s wine cellar.
 Effective percussion requires consistent practice; practice on oneself or willing
colleagues, as it can be uncomfortable for patients if performed repeatedly and
inexpertly.
  The middle finger of the left hand is placed flatly and firmly on the part to be percussed,
with slight hyperextension of the distal interphalangeal joint.
 Strike the back of the percussing finger with the tip of the middle finger of the right hand
(vice versa for left-handed individuals), using a tapping movement at the wrist rather
than the elbow.
 The character of the sound produced varies both qualitatively and quantitatively, and the
sensation felt by the percussing finger on the chest wall is also important.
 Resonance over a healthy lung has a characteristic sound and feel that must be learned
by practice.
 Compare the percussion note on both sides of the chest systematically, moving back and
forth rather than solely down one side and then the other.
 Reduction of resonance (dullness) occurs when the underlying lung is more solid than
usual, as in consolidation or collapse, or when there is fluid in the pleural cavity, such as
in pleural effusion.
 Pleural effusion causes a sensation similar to percussing a solid wall, known as "stony
dullness."
 Increased resonance, or hyperresonance, is more difficult to detect and may indicate the
presence of air in the pleural cavity, as in pneumothorax.
 Further examination and chest X-ray are often necessary to confirm findings when
assessing percussion.

Auscultation of the Chest:

 Use the diaphragm, not the bell, of the stethoscope, as chest sounds are relatively high
pitched and the diaphragm is more sensitive.
 Instruct the patient to take deep breaths in and out through the mouth. Demonstrate the
desired breathing pattern to the patient and visually confirm that they are following your
instructions.
 If the patient tends to cough, instruct them to breathe more deeply than usual, but not
excessively to avoid inducing coughing with each breath.
 Similar to percussion, auscultate comparable positions on each side alternately,
switching back and forth to compare.
 This systematic approach ensures comprehensive assessment of lung sounds and
facilitates detection of any abnormalities.
Breath Sounds:
1. Intensity and Quality:
 Intensity may be normal, reduced, or increased.
 Quality of normal breath sounds is described as vesicular.
2. Normal Intensity:
 Indicates normal lung inflation.
 Reduced intensity may result from localized airway narrowing, extensive lung
damage (e.g., emphysema), or pleural thickening/fluid.
 Increased intensity may occur in very thin subjects.
3. Origin and Transmission:
 Breath sounds likely originate from turbulent airflow in larger airways.
 Lung tissue filters out higher frequencies, resulting in vesicular breath sounds.
 No distinct pause between inspiration and expiration.
4. Abnormalities:
 Airless areas, such as consolidation, transmit sounds more efficiently, resulting in
louder sounds with less filtering of high frequencies.
 This produces bronchial breathing, resembling tracheal sounds but less intense.
 Bronchial breath sounds have a harsh quality, with clearer higher frequencies
and a more sibilant expiratory phase.
5. Variability:
 Intensity and quality of breath sounds vary widely among individuals and
situations.
 Recognition of normal variations and abnormalities requires repeated
auscultation of many patients' chests.

Added Sounds:
1. Wheezes:
 Musical sounds associated with airway narrowing.
 Polyphonic wheezes are widespread, characteristic of diffuse airflow obstruction
like asthma and COPD.
 Monophonic wheezes may indicate localized bronchial narrowing due to tumors
or foreign bodies.
 Different intensities and positions may affect wheeze characteristics.
  Differentiate from stridor, indicative of serious conditions related to laryngeal or
tracheal narrowing.
2. Crackles:
 Short, explosive sounds described as bubbling or clicking.
 Not typically due to lung moisture but sudden opening of small airways.
 Common in chronic obstructive pulmonary disease (COPD) and bronchiectasis.
 Fine crackles may indicate diffuse interstitial fibrosis, characterized by late
inspiratory timing.
 Coarse crackles may suggest bronchiectasis or pulmonary edema.
3. Pleural Rub:
 Characteristic of pleural inflammation, often associated with pleuritic pain.
 Creaking or rubbing character, akin to foot crunching through fresh snow.
 May be felt with palpation and heard with the stethoscope.
4. Excluding False Sounds:
 Ensure sounds are not artifacts from stethoscope movement or clothing.
 Muscle movement or shivering of a cold patient can mimic added sounds.
 Stethoscope rubbing over hairy skin may resemble fine crackles.

Vocal Resonance:
 Definition: Vocal resonance refers to the transmission of vibrations from the patient's
vocal cords to the chest wall, detected during auscultation by asking the patient to repeat
a phrase, typically "ninety-nine".
 Comparison: Similar to assessing breath sounds, vocal resonance should be compared
bilaterally at each auscultation point.
 Effect of Conditions:
 Consolidated lung: Conducts sound better, leading to increased vocal resonance
and louder, clearer sounds. Whispering pectoriloquy may also be observed, where
whispered phrases are heard clearly.
 Pleural effusion or above consolidated areas: Voice may sound nasal or bleating,
a phenomenon known as aegophony. However, this is an uncommon finding.
 Interpretation: Changes in vocal resonance can provide insights into underlying lung
conditions, with increased resonance often indicating consolidation and decreased
resonance suggesting air-containing lung spaces.
Vocal Fremitus:
 Detection: Vocal fremitus is detected by placing the hand on the patient's chest wall
while the patient repeats a phrase, such as "ninety-nine". Vibrations from the patient's
vocal cords are felt by the examiner's hand.
 Technique: The flat of the hand, including the fingertips, is used for detection, as it is
more sensitive than the ulnar border.
 Sequence: Although it's a form of palpation, vocal fremitus is typically performed after
auscultation.
 Purpose: Like vocal resonance and breath sounds, vocal fremitus assesses how
vibrations from the larynx or large airways are transmitted to the examining instrument
or fingers.
 Correlation with Pathology: In pathological conditions like consolidation, where
breath sounds are better transmitted, vocal resonance and fremitus are increased.
Conversely, in conditions like pleural effusion, where breath sounds are reduced or
absent, vocal resonance and fremitus are decreased or absent.
 Utility: While one sign alone may be challenging to interpret, assessing all three (breath
sounds, vocal resonance, and fremitus) provides a more comprehensive understanding
of the patient's condition.

nterpreting the signs elicited during the chest examination is crucial for developing an
appropriate differential diagnosis. Here are some key points to keep in mind:
1. Diminished Movements: If movements are diminished on one side, there is likely to
be an abnormality on that side, such as lung collapse or consolidation.
2. Percussion Note: A dull percussion note suggests either a pleural effusion or an area
of consolidation. The duller the note, the more likely it is to be a pleural effusion.
3. Breath Sounds, Vocal Resonance, and Tactile Vocal Fremitus: These are
quieter or less obvious over a pleural effusion but louder or more obvious over an area of
consolidation.
4. Pneumothorax: Over a pneumothorax, the percussion note is more resonant than
normal, but the breath sounds, vocal resonance, and tactile vocal fremitus are quieter or
reduced. Pneumothorax can be easily missed and requires careful consideration.