complete pulmonary exam

Question 1

Dyspnea

Answer 1

subjective sensation of being out of breath

Question 2

In cough, distinguishing between ___ and ___

Answer 2

chronic and subacute

Question 3

Relevant History

Answer 3

ROS: pulmonary, constitutional PMH: respiratory dz, immunization (influenza, pneumococcal) Medications (esp inhalors) FH: respiratory dz esp asthma, emphysema, cancer SH: tobacco exposure (first or second hand)

Question 4

Approach to Dyspnea - Differential Diagnosis

Answer 4

• Pulmonary (airways, alveoli, PE, fluid or air in pleural space) - Cardiac (atypical angina, congestive heart failure) - Chest wall - Upper airway - Deconditioning (out of shape)

Question 5

Common Causes of Cough

Answer 5

• Post-nasal drip - Asthma - GERD - Respiratory infection - Chronic bronchitis (COPD) - Neoplasia, cancer

Question 6

Tachypnea

Answer 6

respiratory rate > 20

Question 7

Hyperventilation

Answer 7

total ventilation per minute is higher than normal; could be lots of shallower breaths or large volume fewer breaths; Can be due to anxiety or response to metabolic acidosis

Question 8

side where right middle lobe and upper lobes best heart

Answer 8

anterior side (anterior side is often skipped in physical exam but important info can be missed if it’s skipped)

Question 9

general order of examination in each area

Answer 9

Inspection, palpation, percussion, auscultation

Question 10

Tracheal deviation

Answer 10

clinical sign that results from unequal intrathoracic pressure within the chest cavity. … Meaning, that if one side of the chest cavity has an increase in pressure (such as in the case of a pneumothorax) the trachea will shift towards the opposing side.

Question 11

clubbing pulmonary exam

Answer 11

Enlarged distal finger; thought to be due to chronic pulmonary conditions

Question 12

Palpation to see if lungs are filling

Answer 12

Put thumbs together on patient’s back and then ask them to take deep breath; check the separation between thumbs to see if equal on both sides

Question 13

auscultation bell or diaphragm in pulmonary exam

Answer 13

diaphragm for whole exam (higher sounds)

Question 14

Crackles (aka rales)

Answer 14

fluid in alveoli

Question 15

Wheezing

Answer 15

narrowed airways; increased resistance to airflow

Question 16

Whispered pectoriloquy

Answer 16

patient whispers “ninety-nine”

Question 17

Egophany

Answer 17

have patient say “E”, in pneumonia and consolidation will sound like an “a”

Question 18

evaluating chest x-ray of lung process

Answer 18

ABCDE: Air, bones, cardiac, diaphragm, effusion

Question 19

Pneumothorax physical exam

Answer 19

Inspection – increased volume of involved side Percussion – hyperrresonance; more air on side than we’d expect; more hollow

Auscultation – decreased breath sound and vocal resonance

Question 20

Pleural Effusion physical exam

Answer 20

Inspection

• Decreased expansion

Percussion

• Dullness

Auscultation

• Absent breath sounds
• Decrease vocal resonance

Question 21

Pneumonia physical exam

Answer 21

• Inspection – splinting = pt not taking deep breath due to pain
• Percussion – dullness
• Auscultation – crackles, bronchial breath sounds, increased vocal resonance, egophany, whispered pectoriloquy; area of infection is trigger for these exam findings
• Infected lung increased transmission of some sounds (like whispers)
• Crackles most common we’d hear

Question 22

Emphysema

Answer 22

• Alveoli interstitial tissue gets destroyed by toxins
• Can get impaired airflow in bronchioles
• Air can get in but hard to get out; air trapping
• Higher volume of air in lung than normal
• Can even see “barrel chest”; increase in anterior/posterior diameter in pt chest

Question 23

Chronic Obstructive Pulmonary Disease (COPD) physical exam

Answer 23

Inspection – AP diameter increased, accessory muscle use

Percussion – increased resonance throughout, decreased diaphragm movement

Auscultation – decreased breath sounds and heart sounds (excessive air can insulate sounds), wheezes, prolonged expiration (form narrowing of airways)

Question 24

Congestive Heart Failure pulmonary findings

Answer 24

• Crackles/rales – usually in dependent lung fields
• Wheezing

Question 25

Posterior Pulmonary Exam

Answer 25

\_\_\_ Inspect thorax \_\_\_ Palpate thorax -- making sure lungs expanding/contracting equally \_\_\_ Palpate spine/musculature -- checking for masses, tenderness, abnormalities \_\_\_ Percuss 4 areas on each side -- can help if patient crosses arms across chest \_\_\_ Auscultate 4 areas on each side -- full inhalation and exhalation at each location

Question 26

Anterior Pulmonary Exam

Answer 26

\_\_\_ Inspect thorax \_\_\_ Percuss 3 areas on each side \_\_\_ Auscultate 3 areas on each side

Question 27

Advanced/Specialized Pulmonary Exam

Answer 27

\_\_\_ Check for vocal resonance over each lobe\* -- how someone's voice sounds transmitted through the lungs; sound changes if there's consolidations; have patient say "ninety-nine"; look to see if there's a spot in the lung that makes sound more distinct (clearer is consolidation; sounds farther away is pneumothorax or effusion) \_\_\_ Check for egophony (E to A changes)\* \_\_\_ Check for whispered pectoriloquy\* -- patient whispers "ninety-nine" \_\_\_ Identify the descent of the diaphragms (excursion); find before inhalation and then after deep breath; keep note of how far down it goes on each side; in COPD there wouldn't be movement of diaphragm \_\_\_ Check for prolonged expiratory phase; forced expiration; long and slow in COPD; can listen over the trachea to listen for wheezes during exhale