What is the 5th most common presenting complaint?
What else would a patient with chronic cough have as a complaint?
Musculoskeletal related complaints
What is defined as, Acute Cough?
Less than 3 weeks
What is the majority of acute cough due to?
VIRAL INFECTION Others: - Inhaled irritants (food, liquid) - Allergies (smoke exposure) - Medications - Bacterial Pneumonias
What is defined as, "Chronic Cough?"
Greater than 3 weeks
What is the the usual list for due to "chronic cough?"
- Postnasal Drip: 40%
- Asthma: 25-35%
- GERD*** : 20%
- Chronic Bronchitis: 5-10%
- Bronchiectasis: 4& of cases
What should you ask when dealing with a "Chronic Cough?"
Ask if it has changed over that period of time, clear throat, exposed to smoke inhalation, positional, or associated complaints (headaches, rib or chest pain, fainting, incontinence, back or leg pain when coughing)
What is sputum?
Mucous and shit that comes out of hocking up stuff
What is mucoid sputum defined as?
Thin, Frothy, Clear
- Asthma, Chronic Bronchitis, Emphysema, Viral Pneumonia, Pulmonary Edema
What is Purulent Sputum defined as?
Yellow/Green, Thick, Odor - Bronchiectasis, Lung Abscess, Bacterial Pneumonia, TB
What is Heompysis Sputum defined as?
Red, Frothy - Lung Cancer, Pulmonary Infarct, TB
What would you expect if someone walks in your office and has Dyspnea (shortness of breath)
2/3 of patients have cardiac or pulmonary disorder
If a patient has chest pain upon inspiration what would they have?
Possible Musculoskeletal Disorder (Hx of Trauma/overuse)
If a patient has tightness of chest what could a patient have?
Cardiac problem or just Anxiety
If a patient is out of breath through ONLY activity, what would you expect?
Possible pulmonary or Cardiac Problem
If a patient has difficulty breathing WITHOUT exertion (position related) what would you expect?
CLASSIC PULMONARY CONGESTION; CONGESTIVE HEART FAILURE
In regards to dyspnea, what would demand immediate medical evaluation?
A sudden onset of difficulty breathing associated with chest pain in suggestive of:
- Pulmonary Embolism**
- Myocardial Infarction
What is the order of the Respiratory Physical Exam?
When further questioning a patient suffering with SOB dyspnea, what else would be the symptoms associated with Cardiac, Pulmonary, and or Cancer?
Night sweats, pain, chest pressure, discomfort, ankle edema, diaphoresis (sweating), cyanosis SEVERITY: Disrupts activities
Air Hunger or Kussmaul’s Respirations*****
Extremely deep ventilation such as occurs in patient with acidosis attempting to increase ventilation of alveoli and exhale more carbon dioxide *** test
What is cyanosis?
Blue color of mucous membranes, extremities - Lack of oxygen to distal appendages
What is a color change and features associated with Pale or Pallor?
White color of mucous membranes Eg. Shock, Blood Loss
What is a color change and features associated with Flushing of the skin?
Red color of the mucous membrane Eg. Increased blood flow due to muscle contraction
What would FOUL odor of someone's breath indicate?
tonsillitis, sinusitis, gingivitis, lung abscess, dental cavities, or gastroesophageal reflux
What would ACETONE (fruity smell) of someone's breath indicate?
Diabetes or acetone, alcohol, phenol, or salicylate ingestion
What would MUSTY ODOR (raw liver smell) of someone's breath indicate?
Severe liver disease
Should you mention something to a patient with alcohol or weed on their breath?
When observing respiration rate, what do we observe?
Rate, Rhythm, Depth, Effort
What is the average respiratory rate?
12-20 times per minute
What would be signs of distressed breathing?
Increased labored breathing and use of accessory muscles • Intercostal retractions, leaning forward, flaring of nostrils, gasping
What would you observe in the symmetry of thoracic musculature?
The muscles of respiration should be used without accessory muscles
What are the secondary muscles of Respiration?
- Pectorals Major and Minor
When looking at abnormalities in chest diameter, what can happen?
Increase in A-P diameter. Ribs are more HORIZONTAL** - Seen in CHRONIC**** (decades)
What conditions are chronic abnormalities of the chest?
Emphysema, kyphosis, chronic airflow limitation
What is the aka for Pigeon Chest?
Describe Pectus Carinatum?
Sternum is abnormally prominent, severe cases interfere with heart and lung action
What is the aka for funnel chest?
What is Pectus Excavatum?
• Congenital malformation of the chest wall by a funnel shaped depression with its apex over the lower end of the sternum
• Caused by a shortening of the central diaphragm which pulls the sternum backward during inhalation
What should you check in regards to the ribs?
Slope (down to the floor almost perpendicular (90 degrees)
Unilateral lag of the ribs could indicate:
Phrenic Nerve problem
What would cause BULGING of the intercostal spaces?
- Seen on Expiration
- Air outflow Obstruction or compression by a mass
What would cause Retraction of the intercostal spaces?
- Seen on INSPIRATION - Air in-flow obstruction, asthma, bronchiolitis, emphysema
What does flail chest result in?
A patient with a blunt chest injury will cause ____ ?
More than 2 ribs to fracture in 2 places
Blunt force trauma results in paradoxical breathing, what is this?
- Injured area collapse in
- Uninjured chest wall moves out
- Injured area moves out
- Uninjured chest wall moves in
What are bulbous enlargements of the soft parts of terminal phalanges?
Clubbing of nails
What is the angle of the nail bed in clubbing of the nails?
Approaches or exceeds 180 degrees (normal is 160)
How does clubbing of the nails occur?
Lack of oxygen getting to the distal tissues
The pathophysiological mechanism of clubbing is _____ ?
What is something to determine if someone has clubbing of the nails?
What are "large scars?"
What is something minor that can cause difficulty in chest expansion?
Lack of skin elasticity - Burns, operations, lacerations, and scarring
Why do we use the posterior thorax exam?
TO EXPOSE AS MUCH LUNG FIELD AS POSSIBLE****
In order to better expose the triangle of auscultation, what might we ask the patient to do?
What do we palpate in the thorax?
Thoracic muscles, tissues, skeleton - Feel for pulsations, tenderness, bulges, depressions, masses
VERBALS: Pain, masses, tenderness, sensations, further assess any abnormalities
What can cause chest pain and tenderness?
- Herpes Zoster before appearance of eruption
- Pleurisy = Inflammation of the pleura
What do we determine masses/swelling with?
What refers to a Palpable VIBRATION transmitted through the bronchopulmonary tree from the larynx to the surface of the chest wall when the patient speaks?
What is the normal outcome of tactile fremitus?
Normal: BILATERAL SYMMETRICAL VIBRATION
- 99/Blue Moon
- Ulnar Surface and/or ball of hand
What is the abnormal outcome of tactile fremitus?
Decrease or Absent Fremitus = EXCESS AIR
- There is no mass for the resonant word to travel through
- Example: Emphysema, bronchial obstruction (air trap)
What is the abnormal outcome of tactile fremitus? (increased)
INCREASED FREMITUS = Increased Mass
- Feels courser or rougher as travels thru more cells
- Example: Pneumonia, fluid, tumor
Respiratory Excursion's main point:
Evaluate thoracic expansion during respiration
- Watch thumbs diverge approximately at T8-T 10
What is normal outcome of respiratory excursion?
What is abnormal?
Bilateral symmetric movement
Abnormal: Loss of symmetry
- Possible Phrenic Nerve Paralysis
Where should the trachea be positioned?
Midline above suprasternal notch
Something like Lung consolidations (pneumonia etc.) results in ____ ?
NO tracheal deviation
What lymph node is most commonly associated with malignancy of the breast?
What is the posterior fold of the axillary lymph nodes?
What are the 4 components when checking lymph nodes?**
SIZE: Large? Small?
Consistency: Soft? Hard?
Mobility: Mobile? Fixed?
Condition: Tender? Non-Tender?
What is a normal lymph node supposed to feel like?
If a lymph node is infected, what will it feel like?
Enlarged, Tender, Soft, Mobile****
If a lymph node has Cancerous properties, what are those?
Enlarged, NON-tender, Hard, Fixed
When percussing the chest thorax how many fingers are on the chest wall?
How is percussion done with posterior thorax?
How is percussing the Anterior Thorax done?
What do normal lungs sound like when percussed?
What do lungs with Hyper-Resonance might have?
TOO much air
What would dullness/flatness percussing of the lungs possibly indicate?
Pneumonia, atelectasis, asthma
What is the normal measurment of the diaphgram?
What would possibly indicate "unusual measurments" when doing Diaphragmatic Excursion?
Pulmonary: Emphysema - bilateral findings
Abdominal: Ascites, tumor
Pain: Fractured Rib
- Neuro: PHRENIC NERVE PARALYSIS**
Auscultating the diaphgram is done how?
Most common mistake
How does the patient breathe when auscultating the diaphragm?
In and out through the MOUTH (using diaphragm of stethascope)
What is the breath characterized by?
Normal breath sounds are classifed by _____ ?
What does the majority of the lung field sound like?
- Pitch: LOW
- Duration: Inspiration > Expiration
- Intensity: Soft
Where would the bronchovesicular sound be found?
- Pitch: Intermediate
- Duration: Expiration = Inspiration
- Intensity: Intermediate
Where would the bronchial sounds be found?
- Pitch: High
- Duration: Expiration > Inspiration
- Intensity: Loud
Describe "Crackles" type breathing
Discrete discontinuous sounds can be find, medium or course
- Loud on Inspiration
- Will NOT clear with throat clearing
- Possible condition: Pneumonia (fluid in alveoli)
Describe wheezes breath sounds
High pitched musical sound (whistle) on inspiration or expiration
- Due to high velocity airflow thru narrow/obstructed airway
- Possible condition: Asthma
Describe "friction rubs" sounds
Dry, crackly, grating, low pitched sound during E or I
- Outside respiration. Tree; due to inflammed rubbing surfaces
- Possible Condition: Pleursy
Describe the "Rhonchi" sound
Sounds like a "snore", deep tone
- Larger airway obstruction
- Possible Condition: COPD, chronic bronchitis
What is Vocal Resonance used for?
USED TO CONFIRM CONSOLIDATION OR EXTRA MASS IN THE LUNGS
- Dullness on percussion on the lungs, or changes in tactile fremitus
What are confirmation signs of CONSOLIDATION***?
Greater clarity and increased loudness of spoken sounds like "99" are defined as BRONCHOPHONY
Greater clarity and increased intelligibly of a whispered word like, "99" is defined as _____ ?
Increased Intensity of the spoken voice is increase and there is nasal quality (E becomes A) it is defined as _____ ?
What is the procedure regarding costochondritis?
Hypothenar edge of both sides of the sternum and apply gradual increasing pressure
Inflammation of the costochondral cartilages of the upper front of the chest that involves SWELLING of the joint in people over 50 years of age, usually women:
Key word is SWELLING*
Tietze's Syndrome is bilateral or Unilateral?
Can you adjust someone with Intercostal Neuritis?
- Pain will be irregular in upper chest, underarm and around shoulder blades. Taking deep breaths and wearing clothing can be painful
What is the procedure of a rib fracture?
One hypothenar is applied to sternum with gradual increasing pressure
What are the exam findings of Pneumonia?
Crackles and Rhonchi are common with diminished breath sounds.
Dullness in percussion bc increased mass; Increased tactile fremitus
Increased respiration and pulse rate
Describe the main points of bronchitis:
More common than pneumonia
- Cough 1-4 weeks, not usually sick
- Inflammation of the large airways (Increased mucus secretions)
- Exam Findings: Increased temp & Respiratory rate
What is a long term lung disease that takes years to develop?
- Alveoli are damaged and destroyed by loss of elasticity, and their walls break down and sacs become larger - hyper - inflating the lung causing air to become trapped
Emphysema, Tactile Fremitus:
Emphysema, Respiratory Excursion:
Percussion in Emphysema:
Hyper resonant: Too much air
Diaphragmatic Excursion: Reduced
What is known to be sudden onset with chest pain with inhalation?
- Adventitious breath sound rubbing**
What is a collapsed lung?
What could cause atelectasis?
Outside compression like tumor or airway obstruction.
Percussion: DULL or FLAT
What is usually due to blunt or penetrating chest injury?
Pneumothorax (air rushes in and collapses lung)
- May panic and go into shock, happens quickly and is MEDICAL EMERGENCY
Pulmonary Embolism main points:
Difficult to diagnose but is LETHAL
- Sudden Chest Pain, Dyspnea, tachypnea, tachcardia, hemoptysis
- Caused by blood clot that travel to the lungs from LEGS
(BIRTH CONTROL OR AIRPLANE RIDE)