Respiratory System Examination Format: History Taking

Earlier, we discussed Fever and the General clinical history taking format. Today, it is going to be the respiratory system! The respiratory system is one of the most examined organ systems in clinical postings and clinical practice. Apart from asking questions and answers to the patient for the history, we should be able to perform a well-organized examination of the patient so that we do not miss a single point.

In today’s version of the respiratory system examination, we will go step-wise to reveal the importance of every aspect. For convenience, the respiratory system has been divided into two parts

• The Upper Respiratory Tract
  • It involves the nasal cavity, nasopharynx, sinuses, oropharynx, and larynx.
• Lower Respiratory Tract
  • It consists of the trachea, lobar bronchus, segmental bronchus, alveolar sac, and generations of the tracheobronchial tree.

We will discuss the Rule of Four- Inspection, Palpation, Percussion, and Auscultation.

Chief Complaints

The patient can present with any of the following chief complaints, after which you have to decide whether you are going to examine the respiratory system for further clinical questions and answers:-

Major symptoms

1. Cough
2. Sputum
3. Hemoptysis
4. Chest pain
5. Breathlessness
6. Wheeze/Stridor

Minor symptoms

1. Fever
2. Heaviness in chest
3. Hoarseness of voice
4. Swelling of feet (associated with heart sound 3,i.e, HS3, Ascites and Hepatomegaly will point to Cor pulmonale)
5. Epistaxis, Sinusitis, Running nose, Sneezing
6. Syncope, Bone pain, Fatigue, Altered mentation
7. General- Loss of appetite or weight (may mean cancer), Sleep, Fatigue, Bladder, Bowel

Other Important Signs

Other important signs from the patient are never to be missed, for they hold significant value in respiratory system examination:

1. DECUBITUS (position of the patient on the bed)- A tripod sitting position can hint toward respiratory discomfort
2. CYANOSIS- may indicate severe respiratory distress
3. CLUBBING- may indicate chronic lung disease
4. TEMPERATURE
5. PULSE- bradycardia, and tachycardia
6. FACE (eg. Cushingoid due to steroids or moon face in Superior vena cava syndrome)
7. ANAEMIA
8. LYMPHADENOPATHY– may indicate infection or cancer
9. JUGULAR VENOUS PRESSURE (JVP)
10. PERIPHERAL OEDEMA
11. HEPATOMEGALY
12. SWOLLEN CALF- Deep venous thrombosis from calves can cause pulmonary embolism

Upper Respiratory Tract Examination

1. NOSE- Congestion, Discharge (Rhinorrhoea), Hypotrophied turbinates, Bleeding spots, Polyps, Deviated nasal septum, Alae nasae for nasal flare,i.e, nostrils widening
2. MOUTH- Mouth breathing (eg. Adenoids) or purse lip respiration as seen in Chronic Obstructive Pulmonary Disease
3. AIR SINUSES- Check tenderness over maxillary, ethmoidal and frontal sinuses (can’t check for sphenoid)
4. PHARYNX- Check throat, gum, teeth, posterior pharyngeal wall, post nasal drip (person feels like a cough in his throat due to accumulation of mucus in the throat), nasopharynx, tonsils, halitosis (bad breath from the mouth)
5. LARYNX- Not checked physically, may require laryngoscopy

Lower Respiratory Tract Examination

We follow the four rules of- Inspection (observation without touching), Palpation (touching and feeling), Percussion (tapping fingers), and Auscultation (using the stethoscope).

So the first one goes as:

Inspection

1. The shape of the chest- Inspect the patient in standing as well as lying down position. Check for Symmetry, Barrel shaped chest (seen in severe COPD and asthma), Pigeon chest (Pectus carinatum), Funnel chest (Pectus excavatum), Kyphosis, Scoliosis, and Lordosis.
2. Movement of the chest- Notice symmetry (decreased movement on a side can mean lung collapse), and paradoxical inward motion of the abdomen during respiration.
3. Apical impulse- seen in the tangential view over the precordium.
4. Respiration- check the following for respiration:
   • Rate- Normal rate in adults is 14-18, in children- 14-25, and approximately 40 in newborns. A respiration rate over 20 can mean Tachypnoea and below 10 can mean Bradypnoea.
   • Rhythm- Breathing pattern by the movement of the chest. It can be Normal, Irregularly irregular (Biot’s), Regularly regular (Cheyne-stokes,i.e, apnoea for 30 seconds after periods of hyperpnoea), or Miscellaneous like Kussmaul, Stertorous, Prolonged inspiration, and Prolonged expiration.
   • Type- Respiration can be Thoracic (predominantly in females due to more use of chest muscles), Abdominal (predominantly in males), Abdomino-thoracic, or Paradoxical respiration (seen in diaphragmatic palsy, patient’s abdomen comes out in expiration.
   • Depth- It can be Normal, Shallow (seen in narcotic poisoning), or Deep (Hyperpnoea, Hyperventilation, eg. in metabolic acidosis.
   • Pattern- Wheeze (expiratory), Stridor (inspiratory), Shallow breathing, Mouth breathing, Sighing (deep inspiration-pause-deep expiration, Gasping (dying breath), Purse lip respiration.
5. Venous prominence over the chest.
6. Fullness (Unilateral/Bilateral) or Depression (Localized/Generalized.
7. Supraclavicular and infraclavicular fossa.
8. Level of nipples- Same or not?
9. Use of Accessory muscles- Sternomastoid and Scalene.
10. Wheeze or stridor.
11. Intercostal space suction.
12. Skin- look front and back for:-
    • Front- Gynaecomastia, Pigmentation, Swelling, Oedema
    • Back- Scoliosis, Kyphosis, Dropping of the shoulder, Winging of scapula, Symmetry of interscapular areas, and Venous prominence

Palpation

Place your palm and fingers to palpate over regions for:

1. Surface temperature
2. Tenderness over chest
3. Position over the trachea and tracheal rug (finger placed on trachea moves inferiorly with each respiration as seen in COPD)
4. Chest expansion- Put your hand in the front of the chest, so the thumbs lie on the sternum and fingers beneath the axilla, and ask the patient to breathe (decreased movement of thumb on one side can mean lung collapse)
5. Apex beat
6. Vocal fremitus- Place palm on the trachea and ask patient to say 123
7. Tactile fremitus- Place palm over regions of the chest and ask the patient to say 123
8. Pleural rub if palpable- feels like friction such as in pleurisy

Percussion

Place the pleximeter finger (index finger) of one hand and tap it with the index finger of the other hand and notice the resonance over regions of intercostal spaces and clavicle (only the index finger may be used to tap the clavicle).

There may be Dullness or Hyper-resonance:

• Causes of Dullness- Consolidation, Pneumonia, Tuberculosis, Atelectasis, Hemothorax, Empyema
• Causes of Hyper-resonance- Pneumothorax, Emphysema, Chronic obstructive pulmonary disease

Auscultation

Place stethoscope over regions of the chest and auscultate for:

1. Breath sounds- Vesicular, Bronchial, Bronchovesicular.
2. Vocal resonance- increased or decreased, Whispering pectorilquy (increased loudness of whispering during auscultation), Aegophony (E to A transition due to solidification of the lung)
3. Adventitious sounds- Abnormal sounds such as Rhonchi, Crepitations, Wheeze, Stridor, and Pleural rub (like hairs rubbing).