EXAMINATION OF

RESPIRATORY SYSTEM

DR. G.P. Singh

Associate Professor
 Clinical Methods
1- History Taking

2- General Examination

3- System Examination
Respiratory System
 History
1-Personal details (Identification)
2- Chief Complaint
3-History of present illness
4-Past Medical/surgical history
5-family History
6-Personal
7-Social History
8-Treatment History.
9- Misc.
 Respiratory Examination
Chief Complaints(Symptoms)&
History of present Illness:-
Complaint--------------------------------Duration
1-Cough
2-Expectoration
3-Breathlessness
4-Chest Pain
5-Hemoptysis
6-Fever
7-Wheeze
8-Stridor
Respiratory Examination-Symptoms

1-Cough:-
A:- Duration
B:-Diurnal Variation
C:-Aggravating/Relieving factor
D- Character
Respiratory Examination-symptom

--Duration:- A few days---May be due to

common cold
-Several weeks:- Some serious illness
-- Timing/Diurnal variation:-
-Dry cough in night(2-4am)-May be
early symptom of Asthma

-Bouts of cough lasting for several minutes---- ?

Asthma
--Aggravating factor:- Dust, Pollen, Cold air, Viral
infection etc
--Character:- Bovine cough---- Vocal cord palsy
Respiratory Examination- Symptoms

2-Expectoration(Sputum)-
A-Duration
B- Amount
C-Character
D-Smell
Normally about 100ml mucous is produced in the
respiratory tract and is swallowed.
Amount:- Copious (more than 1 cup daily)
-Bronchiactasis
-Lung Abscess
- Scanty- Other conditions
Respiratory Examination- Symptoms

Character of sputum:-
Mucoid (clear & white):-Bronchitis, Asthma,
COPD
- Black particles in sputum---These are black
inhaled soot.
-Purulent or mucopurulent (Yellow, green or
brown)- Indicates bacterial infection. Some times
eosinophillia may give a purulent appearance to
the sputum without any infection
-Rusty- Pneumococcal pneumonia.
Smell:- Foul smell- Bronchiactasis, Lung abscess.
Respiratory exam- symptoms

3-Breathlessness
A-Duration
B-Severity
C-Mode of onset, Progression
D-Aggravating, Relieving Factor
E-Associated features
Respiratory Examination- Symptoms

Dyspnoea:- Uncomfortable awareness of

breathing.
Pathological Dyspnoea:- Uncomfortable
awareness of breathing which is
disproportionate to the degree of exertion.

Severity:-
 Respiratory Examination-Symptoms

Grading of Dyspnoea:-The MRC Dyspnoea scale

Grade Impact (related activity)

Grade-1 Not troubled by breathlessness except on strenuous

exercise
Grade-2 Short of breath when hurrying on the level or
walking up a slight hill.
Grade-3 Walks slower than most people on the level. Stops
after a mile or so, or stops after 15 minute walking
at own pace
Grade-4 Stops for breath after walking about 100 yards or
after a few minutes on leveled ground
Grade-5 Too breathless to leave the house, or breathless
while undressing.
 Respiratory Examination- Symptoms

mMRC (Modified Medical Research Council) Dyspnoea scale

Grade Complaint
Grade-0 ‘I only get breathless with strenuous exercise’
Grade-1 “I get short of breath when hurrying on the level or
walking up a slight hill”
Grade-2 “I walk slower than the people of the same age on the
level because of breathlessness or have to stop for
breath when walking at my own pace on the level

Grade-3 “I stop for breath after walking about 100 yards or after
a few minutes on the level”
Grade-4 “ I am too breathless to leave the home” or “ I am
breathless when dressing”
Respiratory Examination- Symptoms

Dyspnoea- Onset, Progression

Minutes to Hours Hours to days Months to year

•-Pneumothorax •-Pneumonia •-COPD

•-Acute Asthma •-Pl.Effusion •-Pul. Tuberculosis
•-Pulm. Embolism •-Anemea •-Br. Carcinoma
•-Pulmonary edema •-I.L.D.
•-Foreign Body
Respiratory Examination-Symptoms

Dyspnoea- Variability, Aggrevating/ Relieving factors:-

-Good days & Bad days:- Improves on weekend
and holidays- Occupational Asthma
-Time of aggravation:-At night or early morning----
Asthma
- Awakens the patient from sleep:- Asthma,
Pulmonary edema, Severe COPD
- Brought by lying down position (Orthopnoea) –
Heart failure, Severe COPD
-Precipitated by- Exercise, exposure to dust, smoke,
pollen etc:- Asthma
Respiratory Examination-Symptoms

Dyspnoea:- Associated problem:-

A-With Chest Pain
Central(Retrosternal) & Non Central with
non pleuritic pain Pleuritic pain
•Myocardial Infarction •Trauma
•Massive Pulmonary •Pleurisy
embolism •Pneumo thorax
•Pneumonia
•Pulmonary Infarction
Respiratory Examination- Symptoms

B- without chest pain

With cough & wheeze Without cough &

wheeze
•Asthma •Tension
•Pulmonary edema Pneumothorax
•Pneumo Thorax •Pulmonary embolism
•Hypovolumic shock
•Metabolic acidosis
Respiratory Examination-Symptoms

4-Chest Pain:-
A-Duration/severity
B-Site
C-Character/ Aggravating & relieving factors
C-Radiation
Respiratory Examination-symptoms

B-Site:-
Central (Retrosternal):-
- Cardiac pain (Angina pectoris Or MI)
- Aortic dissection
- GERD (gastro esophageal reflux disease)
-Pericardiris
- Tracheitis
- Medistanitis
- Medistinal tumor
- Mestinal emphysema
Respiratory Examination-symptoms

Non central chest pain:-

-Costo condritis
-Bornholm disease- Pleurisy & myalgia
due to Coxsackie B virus infection
-Spinal nerve root involvement-
Vertebral disease, Herpes zoster
-Pleurisy –due to Tuberculosis,
Pneumonia, Malignant invasion, Pulmonary
infarction
- Pneumothorax
-Muscular
Respiratory Examination-symptoms

Any part of Chest:-

-Trauma
-Cellulites
-Abscess
C-Character Of Pain/ Aggravating & relieving
factors-
Pleural Pain:- Localized, sharp, stabbing
& aggravated by Deep breathing & coughing
Pain due to chest wall disorders- Pain
may be similar to Pleural pain but is also
aggravated by movement & there is local
tenderness.
Respiratory Examination-symptoms

Central Chest Pain:- May be sharp,

Stabbing, piercing, compressing, severe or
constant dull aching. Pain of trachiatis and
pericarditis are exaggerated by deep
breathing. Esophageal pain may be related to
food. Myocardial pain may aggravate by
exertion.
D-Radiation of pain:- cardiac pain radiates to
neck, jaw, arm, back or upper abdomen. Pain
of diaphragmatic pleurisy radiates to tip of
shoulder
Respiratory Examination-symptoms

5- Hemoptysis:- Coughing up of blood.

A- Duration
B-Amount
C-Character of blood- fresh/Altered
D-Association- Epistaxis, Malena
Important causes of hemoptysis:- Tuberculosis,
Bronchial carcinoma, Pulmonary infarction,
Bronchiactasis, Mitral stenosis, Acute
bronchitis, Pulmonary embolism, Good
pasture syndrome.
Respiratory Examination-symptoms

B- Amount of Blood:- Streaks of blood with

sputum can came from upper airway disease

Massive hemoptysis:- 100-600ml blood in 24

hours (According to different literatures)
Respiratory examination-symptoms

C & D- to differentiate between hemoptysis &

hematemesis
Feature Hemoptysis Hematemesis
Preceded by Cough Nausea
History of Cough Abdominal discomfort
Color Bright red , frothy Altered, Coffee colored
Melena Absent Present (Requires more than
50ml bleeding proximal to
Cecum
Food particle Absent May be present

pH Alkaline Acidic
Respiratory Examination-symptoms

• Bright Red Blood is also present if bleeding is

from Pharynx & esophagus
• Dark red blood with clot may be present in
case of Profuse bleeding from esophagus &
peptic ulcer
6-Fever:- It indicates infection.
-High fever is present in pneumonia
-Evening/night fever with sweating is
found in tuberculosis.
Respiratory Examination-symptoms

7-Wheeze :- Audible ronchi- some times patient

complain that musical sound comes from
his/her breath
8- Stridor:- noisy breathing due to large air way
narrowing (Larynx, Trachea or main bronchus)
usually during inspiration.
Respiratory System-General Exam
Important points to be noted during General
Examination
1-Pallor/ Polycythemia
2-Cynosis
3-Clubbing
4-Edema
5-Cervical lymph adenopathy.
Pallor/Polycythemia
Cyanosis
Clubbing
Edema
 --
System Examination (Respiratory):-
1-Inspection
2-Palpation
3-Percussion
4- Auscultation
 Respiratory Examination- Inspection
Inspection of chest:- Headings:-
A- Dyspnoea- (as a sign)
B- Respiratory Rate & Rhythm
C-Shape & Symmetry of Chest
D-Any Scar
E-Any Skin lesion
F-Inter costal spaces
G- Venous prominences
H-Trail’s Sign
I-Movement of chest
J-Visible pulsations
Respiratory System-Inspection

1- Inspection:-
A- Dyspnoea:- whether the patient is Dyspneic or
not ?
-Patient is said to be dyspnoec if accessory
muscles of respiration are in action
Accessory muscles of Respiration:-
- Ala nasi
-Sternocleidomastoid
-Scalene
- Trapezeous
Accessory Muscles of Respiration
Ala Nasi
Accessory muscles of Respiration
Accessory Muscles of Respiration
 B-Respiratory Rate & Rhythm
The normal respiratory rate in adult during rest is
12-20/ minute The respiration :pulse ratio is 1:4.
Tachypnoea:- Increased respiratory rate
above 20/ minute.
Hyperventilation:- Increased rate of
breathing at rest so that body eliminates more
carbon dioxide than it produces. This leads to
hypocapnia leading to respiratory alkalosis
Cause- Psychological stress, anxiety, panic
disorder, high altitude and respiratory illness like
Asthma, Pneumonia etc,
 --
Hyperpnoea:- Increase in rate of
respiration which is proportional to the
increase in metabolic rate.
Cheyne Stoke Respiration:- There is cyclic
increase & decrease in respiratory effort and
rate with a short period of complete apnea.
Causes:- Severe Heart failure
- Narcotic poisoning
-Neurological disorder
- Elderly during sleep
 --

Kussmaul Breathing:-Deep and

labored breathing. It is respiratory
compensation for a metabolic acidosis

Cause:- Severe metabolic acidosis

-Diabetic keto acidosis
- Renal Failure (Uremia)
C-Shape & Symmetry of Chest
Normal shape of chest is Elliptical & bilaterally
symmetrical. The AP to Transverse ratio is 1:2
 Abnormal shape & symmetry of chest

Barrel Chest:-AP diameter of chest increases

and the shape of chest becomes barrel like
from normal elliptical.
Found in Emphysema, COPD
Barrel Chest
Kyphosis, Lordosis, Scoliosis

-These are primarily deformity of vertebral

column
-They may reduce ventilatory capacity of lung
and increase work of breathing
-The position of trachea and Apex beat may
change without any abnormality
Kyphosis
Lordosis
Scoliosis
 --
Pigeon Chest (Pectus carinatum):- Lower part of
sternum is projected forwards.
Causes:-Chronic respiratory disease in child
hood, Rickets.
 --
Funnel Chest(Pectus Excavatum):- Localized
depression of lower part of sternum or whole
sternum.
Cause:- Developmental anomaly.
 --
Harrisons Sulcus:- Symmetrical Horizontal groove
above the costal margin which are themselves
usually everted
Cause:- in drawing of ribs due to respiratory
diseases in child hood
 --
Drooping of shoulder & localized flattening
Cause- Fibrosis of lungs
- Collapse of lung
 --
-Localized swelling:- Abscess, Tumor
D-Any Scar- previous operation, Trauma
E-Any skin lesion
F-Intercostal spaces:-
Full- Pleural effusion
- Pneumothorax
- COPD
Recession:- (In drawing of intercostal
spaces during inspiration)-Obstructive airway
disease- Asthma, Chronic bronchitis
 --

G- Venous prominences:-
- Vena cava obstruction
 --
H-Trail’s Sign:-Unilateral Prominence of sternal
head of sternoclidomastois:- It indicates that
the trachea is shifted to that side.
 --
Trail’s Sign
 --
I-Movement of chest:- Normally the movement
of chest is bilaterally symmetrical. If the
movement appears to be diminished on one
side, that side is likely to be the side of chest
pathology
- Paradoxical Respiration:- Thorax &
abdomen moves in opposite direction
( Normally the move in same direction)
Cause:- Paralysis of Diaphragm
 --

Flail Chest:- In fracture of multiple

ribs, there in a paradoxical movement of the
fractured part( Inwards during inspiration &
outwards during expiration)

J-Visible pulsations:- Apex Beat

- Left Parasternal area
-Epigatrium
Site of Pulsations
 --
Apex beat:- This is the outmost and down most point of
definite cardiac pulsation . In normal situation it is
visible in left 5th intercostal space just medial to mid
clavicular line.
Left parasternal pulsation:- pulsation just to the left of
sternum. It is found in cases of Right Ventricular
hypertrophy.
Epigastric pulsation: Pulsation in epigastric region of
abdomen
-Causes:- Pulsation of Aorta in thin person
- Aneurism of Abdominal aorta
-Right Ventricular Hypertrophy.
- Pulsatile liver in Tricuspid Regurgitation
 System Examination -Chest
2-Palpation of Chest
Confirm the findings of Inspection
A-swelling & Tenderness
B-Lymph Nodes
C- Position of Trachea & Apex beat
D-Other Pulsations- Left parasternal, Epigastric
E-Chest Movement
F-Chest Expansion
G-tactile vocal Fremitus
System exam-Chest-Palpation

A-Swelling and tenderness-

- Local mass
-Abscess
-Musculo skeletal tenderness
B- Lymph nodes:- Spread of malignancy,
Tuberculosis
-Cervical
-Supraclavicur
-Axillary
System exam-Chest-Palpation

C-Trachea & Apex Beat:-( Position)

Normal Trachea:- Slightly deviated to Right.
Normal apex beat:- Left 5th intercostal space
just medial to mid clavicular line.
Palpation of Trachea
 System exam -Chest-Palpation
Method of palpation of Trachea:-
-Keep the head of patient slightly flexed
-Put index & ring fingers on sternal ends of
clavicles
- Palpate Trachea with middle finger. Try to
insinuate the middle finger on both sides of
trachea alternately. It will be difficult to
insinuate the finger on the side of deviation of
trachea where as it can be easily insulated on
the opposite side
 System exam -Chest-Palpation
Method of Palpation of Apex beat:-
-First place the palm over precordium. It will
give idea about the intercostal space in which
there is apical pulsation
- Now put the ulnar boarder of hand in that
intercostal space
- Finally locate the apex by finger tip
- While keeping the finger tip on the apex from
other hand count the intercostal space in
which it is located .
System exam -Chest-Palpation
Apex Beat
System exam-Chest-Palpation

Causes of shift of Trachea & Apex Beat:-

Only Trachea- Fibrosis or Collapse on the same side
Only Apex:- Thoracic deformity, Left or Right
ventricular hypertrophy, Dextrocardia, Small
pleural effusion on opposite side.
Sift of both Trachea & Apex:-
On the same side:- - Fibrosis of lungs
- Collapse of lungs
On the opposite side:- Pleural effusion
- Pneumo thorax
- Hydro Pneumothorax
 System exam -Chest-Palpation
D-Other pulsations
- Left Parsternal heave- Put the ulnar boarder
of hand along the left sternal boarder. If
pulsation is felt it indicates- RVH, Severe LAE
 System exam -Chest-Palpation
-Epigastric Pulsation:- Place index finger on
epigatrium and press the tip of finger upwards
under the xiphoid process
 System exam -Chest-Palpation

- If the pulsation is felt on the tip of the finger

as something is pushing down-cause-RVH
- If pulsation is felt on the pulp of finger as some
thing is pushing upwards- Cause- Aortic
pulsation. (May be either the person is lean &
thin or there is an aneurism of abdominal
aorta.)
Chest Exam-Palpation

E-Chest movement:- Movement of both sides is

compared. Normally it is equal.
System exam-Chest-Palpation Chest movement
System exam-Chest-Palpation Chest movement
System exam-Chest-Palpation

Chest movement is compared on both side in

upper & lower part of chest both anteriorly
and posteriorly
There in no cause of increase of
chest movement
If chest movement is decreased on
any side & area ,than that side or area of
chest is likely to be pathological
System exam-Chest-Palpation

F-Chest Expansion:- It is expansion of the total

chest and is measured by measuring tape at
the level of 4th ICS in males and just below
breasts in females during full expiration & full
inspiration
System exam-Chest-Palpation

Normal chest expansion is 5-8cm. Below 2 cm. it

is definitely abnormal.
Causes of decreased expansion:- Any
diffuse broncho pulmonary disease like-
-Emphysema
-Bronchial asthma
-Ankylosing spondylitis
-Diffuse pulmonary fibrosis
Chest-Exam-Palpation

G-Tactile vocal fremitus :- It is the vibration

transmitted to the chest wall from the vocal
cord.
-The patient is asked to say one-one-one
or ninety nine- ninety nine and vibration on
the chest wall is felt by the ulner boarder of
hand. The vibration is compared in
corresponding areas of two sides of chest
--
Vocal fremitus
Chest Exam-Palpation

Causes of Decreased Vocal fremitus:-

- Emphysema
-Thickened Pleura
-Pleural Effusion
-Pneumothorax (Except open)
-Collapse (bronchus not patent)
Chest Exam-Palpation

Causes of Increased Vocal fremitus:-

Localized:- -Consolidation
-Large Empty Cavity with patent
bronchus
-Open type of Pneumothorax
( Broncho pleural fistula)
- Collapse with patent bronchus
- Fibrosis pulling the major
bronchus near the chest wall
- Above the level of Pleural effusion
 3-Percussion
Percussion is a method of tapping on a surface to
determine the underlying structure. If air is
present under the surface it gives a resonant
note. If there is solid or liquid, Dull or stony dull
note is produced.
- On bone like clavicle direct percussion (Without
placing pleximeter) is done.
- On other areas middle finger of one hand is placed
firmly in contact of the surface (called pleximeter)
and is tapped by middle finger (Plexor) of the
other hand by action of wrist)
Chest Exam- Percussion

Areas of percussion:-
Anterior- Clavicle (Direct Percussion)
-Below clavicle:- 2nd to 6th ICS
Lateral (Axillary)- 4th to 7th ICS

Posterior- on Trapezius
- Supra scapular
- Inter scapular
-Infra scapular- up to 9th ICS
Chest Exam- Percussion
Chest exam- Percussion- Anterior
Chest-examination – percussion-Trapezius
Chest Examination- Percussion
 Chest Examination- Percussion

Liver Dullness:- Starts in

Mid clavicular line- 5th ICS
Mid axillari line- 7th ICS
Mid Scapular Line- 9th ICS
Cardiac Dullness-
3rd,4th & 5th ICS.
 Chest Examination- Percussion

Observation in percussion:-
-Percussion note on normal Lungs- Resonant.

- Liver dullness starts- 5th ICS in front, 7th ICS in

axilla and 9th ICS posteriorly

- Cardiac dullness is present in 3rd to 5th ICS

anteriorly
 Chest Examination- Percussion
Hyper resonant :-
-Emphysema
-Pneumothorax (Tympanatic)
-Large, empty, thin walled cavity communicating
with bronchus.
Impaired/Dull:-
-Pleural thickening
-Consolidation
-Collapse
-Fibrosis
Stony Dull:- Pleural Effusion.
 -percussion
Chest Examination

Tidal Percussion:- percuss down the back of chest

till the liver dullness starts. Percuss with full
expiration & full inspiration. Normally during
inspiration the dullness goes down. This is
because of downward movement of diaphragm
during inspiration
- Loss of tidal percussion:-
-Paralysis of diaphragm
-Supra diaphragmatic pathology
like pleural effusion
4-Auscultation
Areas
Chest Exam- Auscultation - Axillary
 Chest Examination- Auscultation
Position of Patient:-
-It is better to examine the patient in sitting or
standing position
-A full phase of breathing ( full inspiration + full
expiration should be heard.
Anterior Chest Examination:- Keep both arm on side
of patient
Axillary Examination:- Keep both hand of the
patient on his/her head
Posterior Chest Examination- Place right hand of the
patient on left shoulder and left hand on right
shoulder of the patient
 Chest Examination- Auscultation
Points to be noted during Auscultation:-
A- Breath sound-
-Audible/not audible
-Intensity- Increased/ Decreased
-Character- Vesicular/ Bronchial
B-Added sounds:-
-Ronchi (Wheeze)
- Crepitations
-Pleural friction rub
-Suction Splash
-Post tussive suction
 Chest Examination -Auscultation
C-Vocal Resonance:-
-Normal
- Increased (Bronchophony)
-Whispering pectoriloquy
-Aegophony.
 Chest examination- Auscultation

A-Breath Sound:- (Production)- Breath sound is

produced by vibration of vocal cords due to
turbulent flow of air through the
larynx(Bronchial Sound). As this sound passes
through the lung tissue, some of the higher
frequencies are selectively filtered out and the
sound becomes quieter. We hear this modified
sound as vesicular breath sound through the
stethoscope placed on the chest wall
 Chest Exam- Auscultation
Intensity of Breath sound:-
Decreased:-
Generalized:-
- Thick Chest wall
- Emphysema
Localized:- -Marked Pleural Thickening
-Pleural effusion(may be absent)
-Pneumothorax (Except Open Type)
-Collapse ( Absorption- when
large bronchi occluded)

Increased:- Consolidation
 Chest Examination- Auscultation
Character of Breath Sound:-
Auscultation within 2-3 cm from midline should
be avoided as stethoscope may pick up sound
transmitted directly from trachea or main
bronchus. Here a mixed quality of sound ( bronco
vesicular or bronchial)may be heard in normal
condition.
Main Types of Breath Sound:-
a) Vesicular
b) Bronchial
c) Broncho vesicular. (Mixed Character.
Usually near midline of chest)
 Chest Exam- Auscultation
Difference between Vesicular & Bronchial
Breath Sound:-
Vesicular Bronchial
 Chest Exam- Auscultation
Vesicular Breath Sound Bronchial Breath Sound
1-The Expiratory phase is The Expiratory phase is as long
shorter than the inspiratory as and as loud as inspiratory
phase (1/2) phase
2-There is no gap between There is a definite gap between
inspiratory & expiratory phase inspiratory & expiratory Phase

3- The character of the sound is The character of sound is harsh

Rustling and low pitched & aspirate & high pitched.

4-At the site of auscultation the At the site of auscultation the

Vocal resonance is normal vocal resonance is increased.
 Chest Exam- Auscultation
Vesicular breath sound:- Is normal breath sound
heard over normal lungs
Bronchial Breath sound:- Normally heard over
trachea, may be heard in midline of chest.
-On chest wall
bronchial breath sound is heard when the lung
tissue between the airway and chest wall
becomes firm or solid. The sounds are
transmitted more readily and the filtering
effect of lung parenchyma is lost.
 Chest Exam- Auscultation
Common Causes of Bronchial Breath Sound :-
- Consolidation
-Large, Empty cavity
- Open type of pneumo thorax
(Broncho Pleural Fistula)
-Collapse of lungs with patent bronchus
(Compression Collapse)
-Localized fibrosis when bronchus is pulled
near chest wall
- Above the level of pleural effusion
 Chest Exam- Auscultation
B- Added Sounds:-
a) Ronchi (Wheeze):- It is continuous, musical sound
produced due to passage of air through narrowed
airways, usually more pronounced during expiration
Polyphonic Ronchi:- It is common type of
wheeze, heard widespread over the chest particularly
during expiration
- It is characteristic of
diffuse airway obstruction like-
- Bronchial Asthma
-COPD
- Chronic Bronchitis
-Pulmonary Edema
 Chest Exam- Auscultation

Monophonic Ronchi:- Localized

ronchi due to localized narrowing of single
bronchus. It may be inspiratoty or expiratory
or both & may change in intensity in different
position.
Causes:-

- Tumor
-Foreign body
 Chest Examination -Auscultation
b) Crepitation (Crackles,Rales):- Intermittent, crackling or
bubbling sound produced due to passage of air through
fluid filled airways or opening up of previously closed
alveoli. Commonly heard during inspiration Found in
may pulmonary and cardiac diseases:-
- Bronchitis.(Acute, Chronic)
-Tuberculosis
-Bronchiactasis
-Interstitial lung disease
-Fibrosis
-Consolidation (Early & Resolution)
- Heart failure
-Pulmonary edema
 -Auscultation
Chest Examination

Fine crepitation are late inspiratory and coarse are

usually early inspiratory.
Fine crepitation suggest an interstitial process and
are found in pulmonary fibrosis, interstitial lung
disease, heart failure etc.
Post tussive crepitation:- Crepts which persists
after coughing. It indicate Infiltration like early
Tuberculosis, Heart failure, Interstitial lung
disease etc.
Velcro Crepts:- Crepitation heard in cases of
interstitial pulmonary fibrosis
.
 Chest Exam -Auscultation
Difference between crepitation & Ronchi
Sl.No Crepitation Ronchi
1 Intermittent sound Continuous sound
2 Crackling or bubbling Musical Sound
sound
3 Due to passage of air Passage of air through
through fluid filled narrowed airways
airways or opening of
previously closed
alveoli
4 Commonly heard Commonly heard during
during Inspiration expiration
 Chest Exam -Auscultation
c)- Pleural friction rub:- A superficial Leathery or
creaking/ rubbing ,usually localized sound
produced by movement of two layers of inflamed
pleura. It is best heard towards the end of
inspiration and just after the beginning of
expiration.- Heard in cases of pleurisy in cases of:-
-Tuberculosis
- Lodar Pneumonia
-Pulmonary infarction
-Malignant infiltration
 Chest Exam -Auscultation
Diff. between crepts and pleural friction Rub:-
Sl. No. Crepitation Pleural Friction Rub
1 No pain at the site Pain at the site

2 Best heard during inspiration Best heard during end inspiration

and just after beginning of
expiration
3 Changes on coughing Do not change on coughing
4 Do not change on change of Change on change of posture
posture
5 Deep sound Superficial sound
6 No change on increase the Changes on increasing the
pressure of stethoscope pressure of the stethoscope
 Chest Exam- Auscultation

Pleural Rub, Pleuro-pericardial rub &Pericardial

Rub
Pleural Rub- Not audible on holding breath
Pleuro-Pericardial Rub:- Character & intensity
changes on holding breath
Pericardial friction rub:- No change on holding
breath
 Chest Examination- Auscultation

d)Suction Splash:- In case of

hydropneumothorax put the Stethoscope at
the junction of Hyper resonance & stony
dullness & shake the patient vigorously. A
splashing sound is heard due to splashing of
fluid within the pleural space
Other condition where splashing sound is
heard:-- Gastric outlet obstruction
 Chest examination- Auscultation

e)Post tussive suction:- It is heard in case of

empty cavity having elastic wall and
communicating with bronchus . Stethoscope is
put on chest above the cavity and patient is
asked to cough vigorously. After coughing
when the patient inspires a hissing sound is
heard due to suction of air in to the cavity.
Not a common finding, but if present, is
diagnostic of cavity.
 Auscultation

C) Vocal Resonance:- It is resonance of sound

on the chest made by the voice.
-Same thing is palpated as Vocal fremitus and
auscultated as vocal resonance.
-The patient is asked to say one-one-one or
ninety nine- ninety nine and vibration on the
chest wall is heard through the stethoscope.
- On normal lungs the sound is muffled and
indistinct.
 Chest Examination - Auscultation
-If vocal resonance decreases the intensity
decrease or may not be audible at all
-If vocal resonance is increased the sound is heard
more clearly.(Bronchophony)
-Whispering pectoriloquy:- The patient is asked to
whisper one-one-one or ninety nine-ninety nine
repeatedly. The sound is heard very clearly as
some one is whispering in your ear.
-Aegophony:- The sound gets a nasal tone. This is an
unusual physical finding.
 Auscultation

Causes of Decreased Vocal Resonance:-

(Same as causes of decreased Vocal fremitus )

- Emphysema
-Thickened Pleura
-Pleural Effusion
-Pneumothorax (Except open)
-Collapse (bronchus not patent)
 -Auscultation
Chest Examination

Causes of increased vocal Resonance:-

(same as causes of increased Vocal fremitus)
-Consolidation
-Large Empty Cavity with patent
bronchus
-Open type of Pneumothorax
( Broncho pleural fistula)
- Collapse with patent bronchus
- Fibrosis pulling the major
bronchus near the chest wall
- Above the level of Pleural effusion
-
 Write 3 causes/ points for each
1- Sudden Dyspnoea

2-Dyspnoea with chest pain

3-Central (Retrosternal) Chest Pain

4-Causes of Hemoptysis

5-Accessory muscles of Respiration

 -
6- causes of Shift of Trachea

7-Causes of Increased Vocal fremitus/ Resonance

8- Adventitious sounds in Resp. Auscultation

9- Localized decrease in intensity of Breath Sound

10-Condition where Bronchial Breath Sound found

 Choose 1 most appropriate answer
1- Which is not a feature of Respiratory Illness?
a) Breathlessness
b) Palpitation
c)Chest Pain
d)Loud P2
2)Foul smelling sputum is a feature of?
a)Chronic Bronchitis
b) Emphysema
c)Bronchial Asthma
d) Bronchiectasis
 -
3)In resp. illness “Good days and Bad days” is
associated with?
a)Bronchial Asthma
b) Pneumoconiosis
c)Chronic Bronchitis
d)Emphysema
4) Evening fever with sweating is a feature of?
a)Tuberculosis
b) Pneumonia
c) Bronchiectasis
d) Chronic Bronchitis
 -
5) What is normal Breathing : Pulse ratio at Rest?
a) 1 : 2
b) 1 : 3
c) 1 : 4
d) 1 : 5
6) Cyclic increase and decrease in respiratory effort
and rate with a period of Apnea is called?
a)Hyperpnoea
b) Cheyne stoke Breathing
c) Kussmaul Breathing
d)Paradoxical Respiration
 -
7) Drooping of Shoulder is commonly found in?
a)Chronic Bronchitis
b) Emphysema
c)Interstitial Lung Disease
d) Tuberculosis
8) Normal Liver Dullness starts in?
MCL Mid Axill.Line Mid Scap.Line
a) 3rd--------------------5th------------------------------------7th
b) 4th-------------6th------------------------8th
c) 5th ------------7th------------------------9th
d) 6th------------8th-----------------------10th
 -
9) Which do not cause intercostal fullness?
a) Bronchial Asthma
b)Emphysema
c) Pleural Effusion
d) Pneumothorax
10) Normal Trachea is ?
a) Exactly central
b) Slightly deviated to Right
c) Slightly deviated to Left
d) Not Palpable
 -
11) Which is not a feature of Cor pulmonale ?
a)Left Parasternal heave
b) Epigatric Pulsation
c) Loud P2
d) Wide & Fixed Splitting of 2nd Heart Sound
12) Breath Sound is Produced in ?
a)Larynx
b)Trachea
c)Main Bronchus
d) Bronchioles
 -
13)Which is not a cause of decreased Vocal
fremitus ?
a) Emphysema
b) Collapse with patent Bronchus
c) Thickened Pleura
d) Pleural effusion
14) Obliteration of hepatic & cardiac dullness is
feature of ?
a)Chronic Bronchitis
b) Emphysema
c)Pneumoconiosis
d) Asbestosis
 -
15) Hyper resonance on percussion not found in?
a)Consolidation
b) Large Empty Cavity
c) Pneumothorax
d) Emphysema
16) Stony Dullness on percussion is found in ?
a) Consolidation
b) Cavity
c)Collapse
d) Hydrothorax
 -
17) We ask the Patient to put both hands on head
for?
a) Direct Percussion
b) Anterior Chest Percussion
c) Axillary chest Percussion
d)Inter scapular Percussion
18) Not true for Bronchial Breath sound?
a)Prolonged Expiration
b) Gap between inspiration & expiration
c) Low pitched Rustling Character
d) Increased Vocal Resonance at the site
 -
19) Which is not true for Ronchi ?
a) Intermittent sound
b) Musical Sound
c)Due to narrowed airways
d) Common during Expiration
20) Ronchi is not heard in ?
a) Bronchial Asthma
b)Chronic Bronchitis
c) COPD
d) massive Pleural effusion
 -
21) Post Tussive suction is a feature of ?
a) Consolidation
b) Collapse
c) Cavity
d) Fibrosis
22) Suction Splash is found in?
a) Pneumothorax
b)Left ventricular out flow obstruction
c) Gastric Outlet obstruction
d) Pericardial effusion
 -
23) Pleural friction rub may be heard in?
a) Massive Pleural Effusion
b) Large Pneumothorax
c)Large Cavity
d) Lobar Pneumonia
24) Mark Odd Statement
a) Decreased Vocal fremitus
b) Dull on percussion
c)Bronchial Breath Sound
e) Increased Vocal Resonance
 -
25) Mark odd statement
a) Bronchophony
b)Whispering pectoriloquy
c) Nasophony
d) Aegophony
-
 -
1- Sudden Dyspnoea
*Foreign body in airway
*Acute Asthma
*Pulmonary Embolism
*Pulmonary Edema
*Pneumothorax
 -
2-Dyspnoea with chest pain
* Ischemic Heart Disease
*Pulmonary Embolism/ Infarction
*Pleurisy
*Pneumonia
*Pneumothorax
 -

3-Central (Retrosternal) Chest Pain

*Ischemic Heart Disease
*GERD
*Pericarditis
*Medistinitis
*Medistinal Emphysema
*Aortic Dissection
 -
4-Causes of Hemoptysis
*Tuberculosis
*Brochiactasis
*Pulmonary Infarction
*Bronchogenic Carcinoma
*Mitral Stenosis
 -
5-Accessory muscles of Respiration
*Ala nasi
*Sternoclidomastoid
*Scalene
*Trapezius
 -
6- causes of Shift of Trachea
*Fibrosis
*Collapse
*Hydrothorax
*Pneumothorax
*Hydro- pneumothorax
 -
7-Causes of Increased Vocal fremitus/ Resonance
*Consolidation
*Large Empty Cavity
*Open Type of Pneumothorax
*Collapse with Patent Bronchus
*Fibrosis pulling major bronchus near chest
wall
 -
8- Adventitious sounds in Resp. Auscultation
*Crepitations (Crackles, Rales)
*Ronchi ( Wheezes)
*Pleural friction Rub
*Pleuro pericardial Rub
*Post Tussive suction
*Suction Splash
 -
9- Localized decrease in intensity of Breath
Sound
*Marked Pleural Thickening
*Pleural effusion
*Pneumothorax (Except Open Type)
*Absorption collapse (Obstruction in
airway)
 -
10-Conditions Where Bronchial Breath Sound
found
*Consolidation (Tubular Bronchial)
* Large Cavity ( Cavernous Bronchial)
*Open Pnemothorax/ Broncho Pleural
Fistula (Amphoric Bronchial)
*Collapse with Patent Bronchus
*Localized fibrosis pulling major Bronchus
near chest wall
*Some times above the level of Pleural
Effusion
 -
1- Which is not a feature of Respiratory Illness?
a) Breathlessness
b) Palpitation
c)Chest Pain
d)Loud P2
2)Foul smelling sputum is a feature of?
a)Chronic Bronchitis
b) Emphysema
c)Bronchial Asthma
d) Bronchiectasis
 -
3)In resp. illness “Good days and Bad days” is
associated with?
a)Bronchial Asthma
b) Pneumoconiosis
c)Chronic Bronchitis
d)Emphysema
4) Evening fever with sweating is a feature of?
a)Tuberculosis
b) Pneumonia
c) Bronchiectasis
d) Chronic Bronchitis
 -
5) What is normal Breathing : Pulse ratio at Rest?
a) 1 : 2
b) 1 : 3
c) 1 : 4
d) 1 : 5
6) Cyclic increase and decrease in respiratory effort
and rate with a period of Apnea is called?
a)Hyperpnoea
b) Cheyne stoke Breathing
c) Kussmaul Breathing
d)Paradoxical Respiration
 -
7) Drooping of Shoulder is commonly found in?
a)Chronic Bronchitis
b) Emphysema
c)Interstitial Lung Disease
d) Tuberculosis
8) Normal Liver Dullness starts in?
MCL Mid Axill.Line Mid Scap.Line
a) 3rd--------------------5th------------------------------------7th
b) 4th-------------6th------------------------8th
c) 5th ------------7th------------------------9th
d) 6th------------8th-----------------------10th
 -
9) Which do not cause intercostal fullness?
a) Bronchial Asthma
b)Emphysema
c) Pleural Effusion
d) Pneumothorax
10) Normal Trachea is ?
a) Exactly central
b) Slightly deviated to Right
c) Slightly deviated to Left
d) Not Palpable
 -
11) Which is not a feature of Cor pulmonale ?
a)Left Parasternal heave
b) Epigatric Pulsation
c) Loud P2
d) Wide & Fixed Splitting of 2nd Heart Sound
12) Breath Sound is Produced in ?
a)Larynx
b)Trachea
c)Main Bronchus
d) Bronchioles
 -
13)Which is not a cause of decreased Vocal
fremitus ?
a) Emphysema
b) Collapse with patent Bronchus
c) Thickened Pleura
d) Pleural effusion
14) Obliteration of hepatic & cardiac dullness is
feature of ?
a)Chronic Bronchitis
b) Emphysema
c)Pneumoconiosis
d) Asbestosis
 -
15) Hyper resonance on percussion not found in?
a)Consolidation
b) Large Empty Cavity
c) Pneumothorax
d) Emphysema
16) Stony Dullness on percussion is found in ?
a) Consolidation
b) Cavity
c)Collapse
d) Hydrothorax
 -
17) We ask the Patient to put both hands on head
for?
a) Direct Percussion
b) Anterior Chest Percussion
c) Axillary chest Percussion
d)Inter scapular Percussion
18) Not true for Bronchial Breath sound?
a)Prolonged Expiration
b) Gap between inspiration & expiration
c) Low pitched Rustling Character
d) Increased Vocal Resonance at the site
 -
19) Which is not true for Ronchi ?
a) Intermittent sound
b) Musical Sound
c)Due to narrowed airways
d) Common during Expiration
20) Ronchi is not heard in ?
a) Bronchial Asthma
b)Chronic Bronchitis
c) COPD
d) massive Pleural effusion
 -
21) Post Tussive suction is a feature of ?
a) Consolidation
b) Collapse
c) Cavity
d) Fibrosis
22) Suction Splash is found in?
a) Pneumothorax
b)Left ventricular out flow obstruction
c) Gastric Outlet obstruction
d) Pericardial effusion
 -
23) Pleural friction rub may be heard in?
a) Massive Pleural Effusion
b) Large Pneumothorax
c)Large Cavity
d) Lobar Pneumonia
24) Mark Odd Statement
a) Decreased Vocal fremitus
b) Dull on percussion
c)Bronchial Breath Sound
e) Increased Vocal Resonance
 -
25) Mark odd statement
a) Bronchophony
b)Whispering pectoriloquy
c) Nasophony
d) Aegophony
 Chest Examination- Auscultation

Medistinal Crunch (Hamman’s Sign):- Crackles

that are synchronized with the heart beat and
not respiration. Heard in Pneumo medistinum.