Can you give me details MacLeod book words notes on systemic examination of respiratory
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MacLeod's Clinical Examination respiratory system systemic examination notes inspection palpation percussion auscultation
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I now have comprehensive content to provide detailed MacLeod-style notes on the systemic examination of the respiratory system. The library does not contain MacLeod's Clinical Examination specifically, but I have excellent sourced content from the JU Medicine respiratory examination PDFs (which are based on MacLeod's) and standard clinical examination principles. Let me compile a thorough, well-organized answer.
Note: MacLeod's Clinical Examination is not available in the textbook library. The notes below are drawn from standard respiratory examination references that follow the MacLeod's framework (Chapter 7, pages 123-152), which organizes the examination as: General Examination → Head & Neck → Thorax (Inspection → Palpation → Percussion → Auscultation).
Systemic Examination of the Respiratory System (MacLeod's Framework)
Patient Positioning & Exposure
- Patient sitting at 45 degrees with a pillow supporting the head
- Thorax fully exposed
- Always maintain patient dignity and warmth
1. GENERAL INSPECTION (from the foot of the bed)
Start by standing at the foot of the bed and observing the patient before touching them.
Bedside Clues
- Oxygen cylinder, nebulizer, sputum pot, inhaler/spacer, peak flow meter
General Appearance
- Dyspnoea at rest - note rate and work of breathing
- Cachexia - wasting seen in malignancy, chronic infection (TB)
- Use of accessory muscles - sternocleidomastoid, scalenes (indicates respiratory distress)
- Pursed-lip breathing - compensatory mechanism in COPD
- Orthopnoea - inability to lie flat (ask about number of pillows)
Cyanosis
- Central cyanosis: bluish discoloration of lips, tongue, mucous membranes
- Causes: lung disease (pneumonia, COPD), cardiac shunt (septal defect), polycythaemia
- Indicates SaO2 < 85% (>5 g/dL deoxyhaemoglobin)
- Peripheral cyanosis: fingertips only
- Causes: reduced cardiac output (shock), local vasoconstriction (cold)
2. HANDS EXAMINATION
| Finding | Clinical significance |
|---|---|
| Clubbing | Lung carcinoma, bronchiectasis, empyema, fibrosing alveolitis, mesothelioma (not COPD, asthma) |
| Peripheral cyanosis | Reduced perfusion or oxygenation |
| Tar staining | Cigarette smoking |
| Asterixis (flap) | CO2 retention (Type II respiratory failure) |
| Fine tremor | Beta-2 agonist use (salbutamol) |
| Warm peripheries + bounding pulse | CO2 retention (vasodilatory effect) |
Clubbing Grading (Schamroth's sign):
Place dorsal surfaces of fingers together - loss of the diamond-shaped window = clubbing.
- Grade 1: Softening of nail bed
- Grade 2: Obliteration of the nail-fold angle
- Grade 3: Drumstick appearance
- Grade 4: Hypertrophic pulmonary osteoarthropathy (periosteal new bone formation)
3. HEAD AND NECK EXAMINATION
Face
- Pallor (anaemia - worsens dyspnoea)
- Plethora (polycythaemia - seen in chronic hypoxia/COPD)
- Horner's syndrome (ptosis, miosis, anhidrosis) - Pancoast tumour invading cervical sympathetic chain
- Enophthalmos - part of Horner's syndrome
Eyes
- Conjunctival pallor - anaemia
- Subconjunctival oedema - SVC obstruction
SVC (Superior Vena Cava) Obstruction
- Dusky, generalized swelling of head, neck, and face
- Non-pulsatile elevated JVP
- Absent abdominojugular reflex
- Caused by mediastinal malignancy (commonly lung cancer, lymphoma)
Neck - JVP Assessment
JVP is raised in:
- Right heart failure
- Tension pneumothorax
- Severe acute asthma
- Cardiac tamponade
Lymph Node Examination
- Examine cervical, supraclavicular, and scalene lymph nodes from behind
- Scalene node enlargement: matted in TB, hard and fixed in malignancy
- Virchow's node (left supraclavicular) - indicates thoracic/abdominal malignancy
Trachea Position
- Palpate in sternal notch with index finger
- Normally midline or slightly to the right
- Deviated toward lesion: collapse, fibrosis, pneumonectomy
- Deviated away from lesion: large pleural effusion, tension pneumothorax, large mediastinal mass
4. THORAX - INSPECTION
Chest Shape (from foot and side of bed)
| Deformity | Description | Cause |
|---|---|---|
| Normal | Symmetrical, elliptical cross-section; AP < lateral diameter | - |
| Barrel chest | AP diameter ≥ lateral diameter | Emphysema/COPD (air trapping) |
| Kyphosis | Exaggerated anterior curvature of spine | Osteoporosis, ankylosing spondylitis |
| Scoliosis | Lateral curvature of spine | Idiopathic or secondary |
| Kyphoscoliosis | Both combined | Restrictive lung defect |
| Pectus carinatum (pigeon chest) | Localised sternal prominence | Childhood respiratory disease |
| Pectus excavatum (funnel chest) | Sternal depression | Usually asymptomatic |
| Harrison's sulcus | Horizontal groove at lower chest margin | Childhood asthma/rickets |
Chest Wall Surface
- Scars: thoracotomy, VATS ports, chest drain sites, mastectomy
- Drains currently in situ
- Dilated veins: SVC obstruction (veins flow upward) or IVC obstruction (veins flow downward)
- Skin lesions: herpes zoster over dermatome, subcutaneous nodules
Respiratory Pattern
- Rate: Normal 12-20 breaths/min
- Tachypnoea (>20): infection, pulmonary embolism, anxiety, acidosis
- Bradypnoea (<12): opiates, brainstem lesion
- Rhythm:
- Cheyne-Stokes: crescendo-decrescendo with apnoea (heart failure, brainstem pathology)
- Kussmaul: deep, rapid (metabolic acidosis - DKA)
- Biot's: irregular with apnoea (raised ICP)
Chest Expansion (visual)
- Look for symmetry
- Reduced on one side: pleural effusion, pneumothorax, collapse, unilateral fibrosis
5. THORAX - PALPATION
General rules: warm hands, maintain eye contact, avoid areas of pain.
Superficial Palpation
- Assess for tenderness (rib fractures, costochondritis)
- Feel for subcutaneous emphysema (crepitus under skin - pneumothorax, oesophageal rupture)
- Superficial masses or swellings
Trachea (Upper Mediastinum)
- Stand in front of the patient
- Place index finger in suprasternal notch, feel for deviation
- Tracheal tug (downward pull with each inspiration) - severe airflow obstruction or aortic aneurysm
Apex Beat
- Located in 5th intercostal space, midclavicular line
- Displaced laterally/inferiorly: cardiomegaly, mediastinal shift
Chest Expansion (hands-on measurement)
Anterior: Place hands on anterior chest, thumbs meeting in midline, fingers spread laterally
Posterior: Same technique from behind, thumbs at T10 level
- Normal expansion: 3-5 cm
- Thumbs should move apart equally and symmetrically
- Unilateral reduction: pleural effusion, pneumothorax, collapse, fibrosis
- Bilateral reduction: COPD (Hoover sign - paradoxical rib cage movement), diffuse pulmonary fibrosis
- Paradoxical inward movement: diaphragmatic paralysis, severe COPD
Tactile Vocal Fremitus (TVF)
- Use ulnar border of hand or fingertips on chest wall
- Ask patient to say "99" or "one-one-one"
- Normal: low frequency vibrations felt bilaterally equal
| Finding | Cause |
|---|---|
| Increased TVF | Consolidation (sound conducted better through solid tissue) |
| Decreased/absent TVF | Pleural effusion, pneumothorax, collapse (fluid/air blocks transmission) |
6. THORAX - PERCUSSION
Technique
- Place left hand flat on chest, middle finger pressed firmly along an intercostal space (pleximeter)
- Strike the centre of the middle phalanx with the tip of the right middle finger (plexor)
- Use a flicking wrist movement, not the elbow
- Percuss in sequence, comparing right with left before moving to next level
Sequence
- Anterior: from above the clavicle (direct percussion on clavicle for apex) down to 6th rib
- Lateral: axilla to 8th rib
- Posterior: from apex (over trapezius) down to 11th rib; do NOT percuss near midline (vertebral muscles interfere)
Percussion Notes
| Note | Cause |
|---|---|
| Resonant | Normal lung |
| Hyperresonant | Pneumothorax, emphysema |
| Dull | Consolidation, collapse, severe fibrosis |
| Stony dull | Pleural effusion, haemothorax |
Diaphragmatic Excursion (Posterior)
- Percuss downward in mid-scapular line on full inspiration, note where resonance changes to dull (lower limit)
- Ask patient to exhale fully, percuss upward to find where dullness begins
- Normal excursion: 5-8 cm
- Reduced excursion: diaphragmatic paralysis, emphysema, subphrenic pathology
Liver and Cardiac Dullness
- Liver dullness: right side from 5th intercostal space downward
- Cardiac dullness: left parasternal area
- Loss of cardiac dullness: left pneumothorax or emphysema
7. THORAX - AUSCULTATION
Technique
- Use diaphragm of stethoscope
- Patient breathes deeply through an open mouth
- Avoid prolonged deep breathing (causes dizziness/syncope)
- Auscultate both sides alternately, over equivalent positions
- Avoid within 3 cm of midline (transmits tracheal/bronchial sounds directly)
Sequence
- Anterior: above clavicle down to 6th rib
- Lateral: axilla to 8th rib
- Posterior: down to 11th rib
Normal Breath Sounds
| Sound | Location | Character |
|---|---|---|
| Vesicular | Normal lung periphery | Soft, breezy; inspiration > expiration; no gap between I and E |
| Bronchial | Over trachea/larynx (normal here) | Hollow/tubular; expiration = inspiration; gap between I and E |
Bronchial breathing heard peripherally (abnormal) = consolidation, collapse with patent airway, fibrous tissue
Reduced/Absent Breath Sounds
- Pleural effusion
- Pneumothorax
- Emphysema (over-inflated lung, poor air movement)
- Obesity, muscular chest wall
Added (Adventitious) Sounds
| Sound | Also called | Character | Cause |
|---|---|---|---|
| Fine crackles | Fine crepitations | Short, high-pitched, end-inspiratory, non-clearing with cough | Pulmonary oedema, fibrosing alveolitis (early) |
| Coarse crackles | Coarse crepitations | Lower-pitched, inspiratory, clear with cough | Bronchiectasis, chronic bronchitis |
| Wheeze | Rhonchi | Continuous, musical, expiratory (mainly) | Asthma, COPD (airway narrowing) |
| Monophonic wheeze | Single note | Fixed pitch, single airway | Large airway obstruction (tumour, foreign body) |
| Stridor | - | High-pitched, inspiratory, loud | Upper airway/extrathoracic obstruction |
| Pleural rub | Friction rub | Grating/creaking (leather on leather), both phases | Pleurisy (inflamed pleural surfaces rubbing) |
Vocal Resonance (VR)
Ask patient to say "99" while auscultating. Parallels TVF findings.
| Finding | Cause |
|---|---|
| Increased VR | Consolidation |
| Decreased VR | Pleural effusion, pneumothorax |
| Whispering pectoriloquy | Whispered sounds clearly audible = consolidation |
| Aegophony | Bleating quality "e" heard as "a" at upper level of pleural effusion |
8. COMMON PATTERNS SUMMARY
| Condition | Trachea | Expansion | TVF/VR | Percussion | Breath sounds | Added sounds |
|---|---|---|---|---|---|---|
| Consolidation | Central | Reduced (affected side) | Increased | Dull | Bronchial | Crackles |
| Pleural effusion | Away (if large) | Reduced (affected side) | Absent | Stony dull | Absent/reduced | Pleural rub (above effusion) |
| Pneumothorax | Away (if tension) | Reduced (affected side) | Absent | Hyperresonant | Absent | None |
| Collapse | Toward | Reduced (affected side) | Reduced/absent | Dull | Reduced/absent | None |
| Fibrosis | Toward (if unilateral) | Reduced (bilateral) | Increased | Dull | Bronchial/reduced | Fine crackles (bilateral basal) |
| COPD/Emphysema | Central | Reduced (bilateral) | Reduced | Hyperresonant | Vesicular (reduced) | Wheeze |
| Asthma | Central | Reduced (bilateral) | Normal | Resonant | Reduced | Bilateral wheeze |
Important note: MacLeod's Clinical Examination (14th edition) is the standard reference for this framework. The library does not hold a digital copy of this title, so these notes are compiled from the MacLeod's examination framework as reproduced in clinical teaching materials. For page-specific quotations, refer to Chapter 7 (pages 123-152) of MacLeod's Clinical Examination directly.
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