Transcript PSD Thorax and Lungs - Continuing Medical Implementation Inc.

PSD Thorax and Lungs
Respiratory Physical Exam
Joel Niznick MD FRCPC
adapted from
UCSD: A Practical Guide to Clinical Medicine
http://medicine.ucsd.edu/clinicalmed/lung.htm
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Inspection
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Cyanosis
Clubbing
Respiratory rate
Respiratory pattern
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Normal
Restricted
Obstructed
Cheynes-Stokes
Painful
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• Chest configuration
– Pigeon chest (pectus
carinatum)
– Barrel chest
– Funnel chest (pectus
excavatum)
– Harrison’s sulcus
– Kyphosis
– Scoliosis
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Cyanosis
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Differential Diagnosis
of Clubbing
• Cyanotic congenital heart disease
• Lung disease
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Cystic fibrosis
Interstitial fibrosis
Malignancy
Sarcoidosis
Bronchiectasis
• Hyperthyroidism
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Emphysema
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Pectus excavatum
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Barrel chest
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Kyphosis
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Scoliosis
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Lobar surface markers
anterior chest
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Lobar surface markers
posterior chest
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Lobar surface markers
Right lateral view
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Lobar surface markers
Left lateral view
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Inspection
• Rate rhythm depth effort
• 14-20/min
• Supraclavicular retraction and SC mastoid
retraction
• Posterior shape, symmetry, deformities
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Palpation
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Lymph Nodes
Tracheal location, shift
Cutaneous lesions
Expansion
• Palpate tactile fremitus
– “99,99,99”
– Increased, decreased,
absent
– Resonant, dull
– Upper lobes
– Middle lobes
– Posterior lobes
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Tracheal Deviation
• Ipsilateral
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Atelectasis
Fibrosis
Lung collapse
Pneumothorax
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• Contralateral
– Pleural effusion
– Hemothorax
– Tension pneumothorax
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Percussion
• Apices to bases
– Intensity, pitch duration- resonant or dull
– Diaphragmatic dullness & respiratory excursion ~ 5-6
cm
– Dull: liver, spleen, heart, consolidation/collapse
– Stony dull: Pleural effusion/thickening
– Resonant: air filled lung
– Hyper-resonant: emphysema, pneumothorax
– Tympanitic: Gas filled viscus
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Ohio State University
Interactive Guide to Physical Exam
Click on image and scroll down page
http://familymedicine.osu.edu/products/physicalexam/exam/
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Auscultation
• Breath sounds
– Bronchial
• over sternum
• Duration
• Pitch
• Intensity
– Bronchovesicular
• 1-2 interspace anteriorly
• interscapular
– Vesicular
• Most of lung fields
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Ohio State University
Interactive Guide to Physical Exam
Click on image and scroll down page
http://familymedicine.osu.edu/products/physicalexam/exam/
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Adventitial sounds
• Wheezes - continuous
– Rhonchi
• Crackles- intermittent
– Fine
– Course
– Rales
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Changes in voice sounds
Signs of consolidation
• Bronchophony “99,99,99”
• Egophony “e,e,e” sounds like “ay,ay,ay”
• Whispering pectorliloquay
Additional sounds
• Pleural rubs
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Conditions
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Consolidation
Collapse
Pleural effusion
Pneumothorax
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Describe the Physical Signs of
LLL Pneumonia
• Inspection
• Palpation
– Trachea
– Expansion
– Fremitus
• Percussion
• Auscultation
– Broncophony
– Egophony
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Describe the Physical Signs of
LLL Collapse
• Inspection
• Palpation
– Trachea
– Expansion
– Fremitus
• Percussion
• Auscultation
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Describe the Physical Signs of
Right Pleural Effusion
• Inspection
• Palpation
– Trachea
– Expansion
– Fremitus
• Percussion
• Auscultation
• Whispering pectorliloquay
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Describe the Physical Signs of
Right Pneumothorax
• Inspection
• Palpation
– Trachea
– Expansion
– Fremitus
• Percussion
• Auscultation
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Describe the Physical Signs of
Right Tension Pneumothorax
• Inspection
• Palpation
– Trachea
– Expansion
– Fremitus
• Percussion
• Auscultation
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Signs in Respiratory Disease
Abnormality
Chest wall
movement
Percussion
note
Breath sounds
Vocal
Resonance
Added sounds
Consolidation
Decreased on
affected side
Dull
Bronchial
Increased
Crepitations
Collapse
Decreased on
affected side
Dull
Decreased or
absent
Decreased or
absent
None
Effusion
Decreased on
affected side
Stoney dull
Decreased or
absent
Decreased or
absent
May be pleural
rub
Pneumothorax
Decreased on
affected side
Normal or
hyper-resonant
Decreased or
absent
Decreased or
absent
None
Emphysema
Decreased on
both sides
Normal or
hyper-resonant
Decreased
Normal or
decreased
None
Decreased on
Normal or
both sides
hyper-resonant
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Prolonged
expiration
Normal
Rhonchi
Asthma
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COPD
Clinical Features
• Cough, sputum, dyspnea
• Pursed lip respiration (Forced expiratory time > 6
seconds)
• Hyperinflation- increased AP diameter/ hyperresonance
• Barrel chest
• Reduced breath sounds
• Wheezes and rhonchi
• Hoover sign (paradoxical indrawing of the lateral
rib margin seen during inspiration)
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Pulmonary Fibrosis
Clinical Features
• Dyspnea on exertion
• Non-productive cough
• Clubbing (50% in idiopathic fibrosis)
• Fine bibasilar inspiratory crackles (Velcro)
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