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Flashcards in *17 Physical Examination of the Lungs Deck (31):
1

Physical exam compartmentalization

  • Inspection
  • Palpation
  • Percussion
  • Auscultation

  • Inspection
    • Inspection begins even before laying hands on the patient
    • You might note body posture, tobacco smells, cough, throat clearing, all of which may be diagnostic clues
  • Palpation
    • One palpates the chest in search of asymmetry of excursion, masses, temperature differences, crepitation, and differences in fremitus
  • Percussion
    • A percussion note is resonant (over the lung), hyperresonant (over emphysematous lung), tympanitic (over the gastric bubble), or dull (over pleural effusion or consolidated lung)
    • A pneumothorax may give hyperresonance or an amphoric note
      • The latter is a low-pitched hollow sound like one might hear percussing a bottle or jar (Latin amphora: bottle; jar)
  • Auscultation

2

Inspection:
Surface structures:
Symmetry and shape of the thorax

  • Disorders of symmetry and position
    • Kyphosis
    • Scoliosis
    • Prior thoracic surgery (resections)
  • Disorders of shape
    • Pectus excavatum
    • Pectus carinatum
  • These musculoskeletal abnormalities can have a profound and deleterious effect on pulmonary function

3

Inspection:
Surface structures:
Tracheal position

  • The position of the trachea can give important clues to intrathoracic pathology
  • The trachea deviates toward the side of volume loss and away from space occupying disease
    • For example, the trachea will deviate toward atelectasis and away from a tension pneumothorax

4

Inspection:
Surface structures:
Intercostal spaces

  • Normally, the intercostals spaces bulge inward during inspiration and outward during expiration
  • Intercostal retractions are exaggerated in patients who must generate highly negative intrathoracic pressures during the respiratory cycle
    • This is observed in patients with obstructive airway disease or pulmonary fibrosis
  • Exaggerated bulging of the intercostal muscles occurs in patients whose lungs are not emptying efficiently as is seen in obstructive airway disease

5

Inspection:
Surface structures:
Skin

  • One evaluates for...
    • Surgical scars
    • Rashes
      • Shingles is a common cause of chest pain and would demonstrate a dermatomal rash following the path of the intercostal nerve
    • Wounds
      • Infections such as actinomyces and nocardia can cause cutaneous fistulas
  • Pay attention to scars
    • They are the hieroglyphics of the patient’s history
    • There are few things more embarrassing things than presenting a patient with a pulmonary complaint to an attending and missing the fact that the patient had prior thoracic surgery

6

Inspection:
Respiratory rate

  • Normally, you will take the respiratory rate with the vital signs
    • One should measure the respiratory rate unobtrusively so that the patient is not aware (such as when taking a pulse or listening to the heart) since many patients breathe faster if they are consciously aware of their breathing
  • The normal rate is 14-18
    • In general, a rate greater than 20 is abnormal

7

Inspection:
Respiratory pattern:
Cheyne-Stokes respiration

  • Pattern of apnea alternating with crescendo increases in rate and amplitude of respirations
  • Seen in patients with congestive heart failure and in various neurological disorders (stroke, infection)
  • Pathophysiology in congestive heart failure
    • Increased circulatory time to the brain that results in a delay in signaling changes in PaCO2 to the respiratory center
    • Increased sensitivity of the chemoreceptors in the respiratory center to PaCO2, resulting in exaggerated response to changes in arterial carbon dioxide

8

Inspection:
Respiratory pattern:
Kussmaul's respirations

  • Deep regular breaths, whether the rate is slow, normal, or fast
  • Typically seen in metabolic acidosis (particularly diabetic ketoacidosis and uremia)
  • Most effective in compensating for acidosis since dead space is minimized and therefore CO2 elimination (as a compensation for the acidosis) is most efficient

9

Inspection:
Respiratory pattern:
Others

  • Biot’s breathing
  • Central neurogenic hyperventilation
  • Apneustic breathing
  • Ataxic breathing

  • Biot’s breathing
    • Similar to Cheyne-Stokes in that it is characterized by periods of alternating apnea
    • But the respiration pattern is one of deep regular breaths that terminate abruptly
      • In contrast to Cheyne-Stokes where there is a crescendo-decrescendo pattern in both rate and depth
    • Seen in patients with meningitis
  • Central neurogenic hyperventilation
    • Pattern of rapid deep hyperpnea
    • Often seen in patients with brainstem injury from midbrain to pons
    • Relatively rare
  • Apneustic breathing
    • Characterized by a prolonged inspiratory cramp
    • Rare finding but one of great value in that it localizes the neurological injury to the mid to lower pons
  • Ataxic breathing
    • Completely irregular both in the depth and pace of respiration
    • Patients with damage at the level of the medulla may manifest this type of breathing

10

Inspection:
​Respiratory effort

  • Observe the patient for sternocleidomastoid muscle use in respiration
  • The use of sternocleidomastoid muscles correlates with severity of respiratory impairment
  • In general, use of sternocleidomastoid muscles suggests that the FEV1 is reduced to 30% of normal

11

Inspection:
Respiratory paradox

  • During normal respiration, the abdominal wall moves outward as one takes a breath due to displacement of the abdominal contents caused by the descent of the diaphragm
  • Respiratory paradox (or thoracoabdominal paradox) occurs when the diaphragm weakens and is pulled up by the negative intrathoracic pressure generated by the accessory muscles of respiration (sternocleidomastoids)
    • The abdominal wall moves inward as the diaphragm moves up
    • This is a sign of impending respiratory failure

12

Palpation:
Chest excursion

  • Palpate chest excursion from behind with hands on the sides and have the patient take a deep breath
  • One may see asymmetric expansion in patients with paralyzed diaphragm, localized pain, fibrosis, or airspace disease

13

Palpation:
Crepitation

  • Latin crepit-: to creak, to crackle
  • Caused by subcutaneous air
  • Subcutaneous air due to thoracic disease generally implies a bronchopleural fistula
  • Subcutaneous air may be found in trauma patients with fractures of the trachea, bronchi, or ribs, patients with pneumothorax, and patients with airflow obstruction

14

Palpation:
Fremitus

  • General
  • What increases and decreases fremitus
  • Right vs. left upper lobe

  • General
    • Latin fremere: to roar, to murmur
    • Vibration that is felt through the chest wall
    • Vocal fremitus is vibration caused by the vocal cords that is transmitted to the chest wall
      • Detected by placing hands on the chest and having the patient say ninety-nine, boys, toys, etc.
  • What increases and decreases fremitus
    • Solids and liquids transmit sound and vibration better than air
    • Therefore, patients with consolidation of the lung have increased fremitus
    • Patients who have airway obstruction from tumor have decreased fremitus
    • Patients who have pneumothorax or pleural effusion have decreased fremitus
      • The presence of effusion moves the airways (and the source of the vibration) farther from the chest wall thereby making the vibration less perceptible to the examiner
  • Fremitus in the right upper lobe is more intense than the left upper lobe
    • This is because the trachea is in direct contract with the right upper lobe but is separated by the aorta from the left upper lobe
    • The opposite would be true in someone with a right-sided aortic arch

15

Auscultation:
Breath sounds:
Vesicular

  • Latin vesicular: small blister or bladder
  • Breath sounds made by normal alveoli
  • Characterized by a longer inspiratory phase than expiratory phase
  • Audible over the anterior and posterior chest
  • Normal
    • No pathological process causes vesicular breath sounds

16

Auscultation:
Breath sounds:
Bronchial

  • Reflect conduction of sound from the large airways and indicate that there is a solid connection between the large airways and your stethoscope
  • Have a longer expiration than inspiration
  • Always pathological
  • Reflect consolidation (e.g. pneumonia) of the lung
  • To simulate bronchial breath sounds, one listens over the trachea

17

Auscultation:
Breath sounds:
Bronchovesicular

  • Intermediate between vesicular and bronchial
  • The inspiratory and expiratory phases are roughly equal
  • The presence of bronchovesicular sounds suggests a small degree of consolidation

18

Auscultation:
Adventitious sounds:
American thoracic society (ATS) classification

  • Course crackle
    • Common synonyms
    • Acoustic characteristics
  • Fine crackle
    • Common synonyms
    • Acoustic characteristics
  • Wheeze
    • Common synonyms
    • Acoustic characteristics
  • Rhonchus
    • Common synonyms
    • Acoustic characteristics

  • Course crackle
    • Common synonyms
      • Course rale
    • Acoustic characteristics
      • Discontinuous
      • Interrupted explosive sounds (loud, low in pitch)
      • Early inspiratory or expiratory
  • Fine crackle
    • Common synonyms
      • Fine rale
      • Crepitation
    • Acoustic characteristics
      • Discontinuous, interrupted explosive sounds
      • Less loud than above and of shorter duration
      • Higher in pitch than coarse crackles or rales
      • Mid- to late inspiratory
  • Wheeze
    • Common synonyms
      • Sibilant rhonchus
    • Acoustic characteristics
      • Continuous sounds
      • Longer than 250 msec, high-pitched
      • Dominant frequency of 400 Hz or more, a hissing sound
  • Rhonchus
    • Common synonyms
      • Sonorous rhonchus
    • Acoustic characteristics
      • Continuous sounds
      • Longer than 250 msec, low-pitched
        Dominant frequency about 200 Hz or less, a snoring sound

19

Auscultation:
​Adventitious sounds:
Rales

  • French: rattle
  • Crackling sounds (aka crepitations)
  • Rales and crackles are synonymous
  • Some clinicians divide rales into fine or coarse rales
    • While there is a qualitative spectrum of rales, these distinctions are in no way absolute
  • Rales usually reflect the presence of parenchymal diseases such as heart failure, pneumonia, or fibrosis

20

Auscultation:
​Adventitious sounds:
Rhonchi

  • Greek rhonch-: to snore
  • Lower pitched continuous sounds
  • A continuous, low-pitched sound
  • Most often heard in expiration
  • Reflects the presence of airway disease such as asthma, COPD, or secretions

21

Auscultation:
​Adventitious sounds:
Wheezing

  • Old Norse hvaesa: to hiss
  • Occurs when there is turbulent airflow through the airways as in obstructive airway disease or bronchial obstruction from tumor or foreign body

22

Auscultation:
​Adventitious sounds:
Pleural friction rubs

  • Caused by inflammatory disease of either or both pleural surfaces and result from those surfaces rubbing against each other
  • Usually has both an inspiratory and expiratory component
  • Caused by pneumonia, pulmonary embolism, rheumatologic disease, and malignant disease

23

Auscultation:
Voice changes:
Bronchophony

  • Means “bronchus sound”
  • Consolidated lung transmits sound better than normally aerated lung
  • Vocalized words sound muffled and indistinct when auscultated at the periphery of normal lung
    • In contrast, when listening over consolidated lung, the words sound as if they are much closer to the ear and the syllables are clearly distinguishable

24

Auscultation:
Voice changes:
Whispered pectoriloquy

  • Pectoriloquy literally means “chest-speaking”
    • Latin roots: pectoro: chest; and loquy: speak
  • Present when the patient’s whispered words (not just syllables as in the case of bronchophony) are audible at the periphery of the lung
  • As with bronchophony, it is a sign of consolidated lung

25

Auscultation:
Voice changes:
Egophony

  • Greek ego: goat
  • Change in timbre of a sound
    • Timbre is the quality of a musical note
    • It is what allows you to differentiate a trombone from a trumpet even if they play the same note at the same intensity
  • Present when the patient vocalizes the letter “e” but it is heard as an “a” at the periphery of the lung
  • Sign of consolidated lung

26

Summary

  • If the trachea deviates, it deviates...
  • The further away the lung is from your stethoscope (effusion or pneumothorax),...
  • Consolidated vs. aerated lung
  • Fluid 
  • Obstruction of the airways (with a mucus plug or tumor)
  • Adventitious sounds 
  • If there is no air entry to a region of the lung (from tumor or mucus plug),...

  • If the trachea deviates, it deviates...
    • To the side of volume loss (atelectasis)
    • Away from the side of a space occupying lesion (pneumothorax or massive effusion)
  • The further away the lung is from your stethoscope (effusion or pneumothorax),...
    • The more diminished the breath sounds
  • Consolidated vs. aerated lung
    • Consolidated lung (pneumonia) transmits sound and vibrations better than aerated lung (tubular breath sounds, bronchophony, egophony, whispered pectoriloquy, and increased fremitus are all variations on this theme)
  • Fluid
    • Dull to percussion (pleural effusion and consolidated lung)
  • Obstruction of the airways (with a mucus plug or tumor)
    • Decreases transmission of breath sounds and vibration to the chest wall
  • Adventitious sounds
    • Abnormal and reflect parenchymal disease (rales/crackles) or airway disease (wheezing and rhonchi)
  • If there is no air entry to a region of the lung (from tumor or mucus plug),...
    • There are no adventitious sounds

27

Salient physical exam findings for common conditions:
Small pleural effusion

  • Tracheal deviation
  • Fremitus
  • Percussion
  • Breath sounds
  • Pectoriloquy
  • Rales
  • Wheezing

  • Tracheal deviation: no
  • Fremitus: decreased
  • Percussion: dull
  • Breath sounds: decreased
  • Pectoriloquy: no
  • Rales: no
  • Wheezing: no

28

Salient physical exam findings for common conditions:
Atelactasis and branchial plug

  • Tracheal deviation
  • Fremitus
  • Percussion
  • Breath sounds
  • Pectoriloquy
  • Rales
  • Wheezing

  • Tracheal deviation: left
  • Fremitus: decreased
  • Percussion: dull
  • Breath sounds: decreased
  • Pectoriloquy: no
  • Rales: no
  • Wheezing: no

29

Salient physical exam findings for common conditions:
Massive consolidation

  • Tracheal deviation
  • Fremitus
  • Percussion
  • Breath sounds
  • Pectoriloquy
  • Rales
  • Wheezing

  • Tracheal deviation: none
  • Fremitus: increased
  • Percussion: dull
  • Breath sounds: bronchial
  • Pectoriloquy: yes
  • Rales: yes
  • Wheezing: no

30

Salient physical exam findings for common conditions:
Pulmonary fibrosis

  • Tracheal deviation
  • Fremitus
  • Percussion
  • Breath sounds
  • Pectoriloquy
  • Rales
  • Wheezing

  • Tracheal deviation: none
  • Fremitus: normal
  • Percussion: normal
  • Breath sounds: normal
  • Pectoriloquy: no
  • Rales: yes
  • Wheezing: no

31

Salient physical exam findings for common conditions:
Wheezing

  • Tracheal deviation
  • Fremitus
  • Percussion
  • Breath sounds
  • Pectoriloquy
  • Rales
  • Wheezing

  • Tracheal deviation: none
  • Fremitus: normal
  • Percussion: normal
  • Breath sounds: normal
  • Pectoriloquy: normal
  • Rales: no
  • Wheezing: yes

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