Respiratory

History and
Examination

Prepared by: Shahad Althagb

Presented by: Shahd Alsalamh
Meshari Alzeer
Jehad Alorainy
 Objectives of This Lecture

1. To Learn how to take focus history of Respiratory system.

2. Develop approach to the most common symptoms of Respiratory system.
3. To learn how to Perform Respiratory examination.
4. Be familiar with normal Lung sounds and with abnormal Lung sounds.
01 “Every history should have
the same structure”

Respiratory
History
1. Personal information (name, age, gender,
nationality, occupation, residence)
2. Chief complaint Basic
3. History of presenting illness
4. Past medical history (asthma, COPD, TB)
Structure of
5. Past surgical history
6. Family history (asthma)
History
7. Social history (smoking, Shisha, alcohol)
8. Medications (ACEi, steroids)
Taking
9. Allergies (drugs, food, pets, fumes)
10. Blood transfusion
11. Immunization
12. Systemic review
13. Summary
 Common Respiratory Presentations

Cough Chest pain Dyspnea Wheezing

Hemoptysis Night sweat

Hyperventil
& fever Hoarseness
ation

The most common ones are in red.

“There are some symptoms that can happen as result of Respiratory
diseases or Cardiac (Like chest pain, Dyspnea, Wheezing,etc) that's why
you have to exclude both causes to get your diagnosis.”
02 “It is not always what it seems.”

Approach to Most
Common Symptoms of
Respiratory Systems
Cough
 Questions You Should Ask
1 Duration

Acute (Less than 3 weeks) Chronic (More than 3 weeks)

● Asthma.
● Upper respiratory tract infection
● Gastroesophageal reflux disease.
(Pneumonia).
● Lung airway disease: COPD,
● Exacerbation of COPD.
Bronchiectasis, tumor, foreign body
● Sinusitis.
● Lung parenchymal disease: interstitial
● Allergic rhinitis.
lung disease, lung abscess
● Drugs: ACE inhibitors.
 Questions You Should Ask
2 Character

Started as Dry then

Dry Cough Productive Cough
Productive

● ACE inhibitors
● Pneumonia
● Interstitial lung fibrosis ● Complicated pneumonia
● Bronchiectasis
● Gastroesophageal reflux
 Questions You Should Ask
2 Character

If there is a sputum, ask about the following:

Amount
(spoon per Diurnal
Color Foul smell
day) variation

Purulent
Pink
Dark
(Increased in morning;
Frothy
(Bronchiectasis, abscess) bronchiectasis)
(Bronchiectasis, (Pulmonary (Abscess)
pneumonia) edema)
 Questions You Should Ask
3 Aggravating and Relieving Factors

Immediately after eating or Awakening from sleep

Dust, smoking Worsen at night drinking (GERD, (HF, regurgitation)
(asthma, HF) tracheoesophageal fistula)
Hemoptysis
 Questions You Should Ask
1 Duration

2 Amount

3 Smell

4 Old or fresh, clots or streaks

5 Mucus
 Dyspnea
The awareness that an abnormal amount of work is required for breathing
 Questions You Should Ask
1 Duration

Sudden Acute: over hours Over days/months Intermittent

● Cardiac ● COPD.
● Pneumothorax tamponade. ● Heart failure. ● Asthma.
● Pneumonia ● Pneumonia ● Anemia. ● Pulmonary
● Anaphylaxis ● Pulmonary ● Pleural oedema.
● PE oedema. effusion.
 Questions You Should Ask
2 Association & Progression

Orthopnea & PND Sharp chest pain Productive cough & Fever

● To exclude cardiac
● Pneumothorax ● Pneumonia
causes of dyspnea;
● Bronchiectasis
Heart failure
 Other Symptoms

Wheezing Chest pain Night sweats

Asthma, COPD,Heart failure (Cardiac wheezing). As in TB.
-Could be heard in Inspiratory or expiratory Analyze it as SOCRATES Drenching sweating: the patient needs
phase. to change cloths as they become wet.
Past History
1. Chronic illness: Asthma, pneumonia
2. Medical: TB, pneumonia, chronic bronchitis, AIDS, DM
3. Surgical interventional procedures: bronchoscopy, thoracoscopy, lung
biopsy, spirometry, pneumonectomy, chest tube
Medications
1. On any medications?
2. ACEi, BB, steroids
03 “ It always seems impossible until it is done.”

Respiratory
Examination
 WIPPPER Code

W I I P
Wash your
Introduce yourself Identify the patient Permission
hands
 WIPPPER Code

P P E R
Privacy Position Exposure Stand to the right of
the patient
(sitting) Full exposure of trunk
Local
Examination 1
Inspection

2 Palpation

3 Percussion

4 Auscultation
 Inspection
Inspection of Description Illustration

● Barrel shaped: the AP

diameter is more than
transverse diameter:
hyperinflation (emphysema).
Pectus Excavatum
Shape and ● Pectus Excavatum (funnel
Symmetry shape); depressed sternum:
Marfan' syndrome.
● Pectus Carinatum (pigeon
Pectus Carinatum
shaped); prominent sternum:
chronic pulmonary disease.
Tracheostomy scar
● Chest tube (tube
thoracostomy).
Scars
● Tracheostomy.
● Sternotomy.
 Inspection
Inspection of Description Illustration

Skin Erythema & ● Caused by chemotherapy: lung

thickening cancer, lymphoma.

● Abdominothoracic.
Breathing type -
● Thoracoabdominal.
 Palpation
Palpation of Description

It can be impalpable in case of (TEDD):

● Thick chest wall.
● Emphysema.
Apex beat
● Effusion.
● Dextrocardia.
● Death.
 Palpation
Palpation of Description Illustration

Put your index and ring fingers on

sternoclavicular junctions, while your middle
finger is on the trachea:
● Trachea will be pulled to the site of
lesion in lung collapse, interstitial
Tracheal pulmonary fibrosis (IPF).
deviation ● It will be pushed away from the site
of the lesion in the presence of
pleural effusion, or tension
pneumothorax.
● Comment (if there is no deviation):
trachea is centrally located.

Press the trachea and ask the patient to

Tracheal tug take deep inspiration, your finger will be
pulled down in severe airway obstruction.
 Palpation
Palpation of Description Illustration

Tactile & vocal Ask the patient to say

fremitus either “44” or “99”
 Palpation
Palpation of Illustration

Supraclavicular
lymph nodes
 Palpation
Palpation of Illustration

Chest
expansions
Percussion
 Percussion
Percussion (always compare both sides):

Start in the supraclavicular area,

Percuss directly on the clavicles, then just below them.
Percuss in the intercostals spaces.
Percuss on the axillae and their middle zones.
 Percussion
Comment:

Hyperresonant Resonant Dull (consolidation) Stony dull

● Over liver area

● Pneumothorax ● Normal ● Tumor
● Pleural effusion
● Emphysema ● Fibrosis
● Infection
 Auscultation
WE HAVE TWO LUNGS SO ALWAYS COMPARE!!

1. Switch to the bell of your stethoscope in the supraclavicular area because the
sounds are low-pitched there.

2. Continue the auscultation with the diaphragm, starting from the second
intercostal space.
 Auscultation
WE HAVE TWO LUNGS SO ALWAYS COMPARE!!

Auscultation Areas
 Auscultation
WE HAVE TWO LUNGS SO ALWAYS COMPARE!!

Types of breathing:

1. Vesicular (normal breathing): inspiratory phase is longer than the expiratory one, no gap in
between, heard anywhere peripherally in the chest.

2. Bronchial: inspiratory and expiratory phases are equal, with a gap in between, heard normally
over the trachea, and if there is consolidation.

3. Asthmatic: expiratory phase is longer, with wheezes, and gap in between

Normal lung
sounds:
Bronchial
Normal lung
sounds:
Vesicular
 Auscultation
WE HAVE TWO LUNGS SO ALWAYS COMPARE!!

Added Sounds:

Disorder Breath sound Added sound

Pneumonia Bronchial Crackles

Pneumothorax Absent Absent

Bronchial Normal or
Wheezing
Asthma reduced
 Auscultation
WE HAVE TWO LUNGS SO ALWAYS COMPARE!!

Added Sounds:
Thanks

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