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Wednesday, July 5, 2017

Complete Chest Examination (Respiratory System): How to describe.



>>May be first you want to see how to write a history of COPD.

Elderly  gentleman, ill looking, thin built (with Temporal hollowing, Buccal Hollowing, Supraclavicular, suprasternal hollowing, Subclavicular hollowing, with thin limbs, thin skin and prominently visible vessels) lying in semirecumbent position with IV canula of 20G and nasal prongs delivering 3l of O2/min is conscious, cooperative and well oriented to time, place and person.

On general physical examination, there is central cyanosis with peripheral cyanosis.
Bilateral pitting edema extending upto the mid thigh is present which is non tender with normal overlying skin. Sacral edema is present.
But no clubbing, no pallor, no icterus seen. Hydration status of the patient is normal. Accessible Lymph nodes are not palpable.

On examination of the vital signs,
Pulse is 70 beats/min taken on right radial artery, regular, catacrotic, euvolemic, no radio radial and radio femoral delay. All the peripheral pulses are palpable, and no carotid bruit heard. Condition of the arterial wall is normal.
Blood pressure measured on the right arm in sitting position was 130/80 mm of mercury.
Temperature taken on right axilla was 37.2oC.
Respiratory rate is 22/min, thoracoabdominal type with nasal flaring, pursed lip breathing and use of accessory muscles of respiration.
JVP was elevated and was 5 cm from the manubriosternal angle in the semirecumbent position.


On examination of the respiratory system

On Inspection of the upper respiratory tract , no DNS, Polyp, discharge or congestion present on the nose. Nasal flaring and Pursed lip breathing present. Use of accessory muscles of respirations seen (with prominent SCM, Scalene, trapezius. Rectus abdominis, pectoralis). The oral cavity looks grossly normal with no congestion, ulcerations on posterior pharynx and bilateral tonsils looks grossly normal.

On inspection of Lower respiratory system, shape of the chest is tending to barrel. 
Trachea is present in the midline.
Bilateral symmetry of chest wall is seen. Bilateral equal movement with respiration present.
Apical Impulse is not visible.
No other visible pulsation, scar marks and dilated vessels seen.
Presence of Supra and Infrascapular hollow is present and equal in both side. 
Prominent and Horizontal ribs with widened and hollow intercostal space seen but no intercostal indrawing, no subcostal indrawing and no intercostal fullness.
Spine is centrally placed and no skeletal deformity present. No drooping of Shoulder. 

On palpation, Trachea is centrally placed. Apical impulse is not palpable.
Chest movement is bilaterally equal.
On measurement of the chest, chest expansion on inspiration was 84.5cm and expiration was  82cm with inspiratory expiratory difference of 2.5cm. The Anteropostero Diameter was 35 cm and Transverse diameter is 40cm and AP to Transverse ratio being 7:8(tending  to barrel). 
The Right hemithorax is 41 cm and left hemithorax is 41 cm.
Increased vocal fremitus palpable in the right subcostal  area.

On percussion, dull note was present over the right sub mammary region.  Resonant sound heard on the other area all over the  chest.
Liver dullness started from 6th right Intercostal area in the midclavicular line.
Cardiac Dullness was not obliterated.

On Auscultation,  Bilaterally decreased air entry with prolonged expiration is present. Bronchial breath sound heard over the right sub mammary region along with Crackles present. Increased vocal fremitus present with aegophony on right sub mammary region.

Provisional diagnosis: COPD with right inframammary consolidation.





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