Examination Flashcards
Pneumonia O/E
- Expansion: reduced on the affected side.
- Vocal fremitus: increased on the affected side (in other chest disease this sign is of very little use!).
- Percussion: dull, but not stony dull.
- Breath sounds: bronchial.
- Additional sounds: medium, late or pan-inspiratory crackles as the pneumonia resolves.
- Vocal resonance: increased.
- Pleural rub: may be present.
Atelectasis
Trachea: displaced towards the collapsed side.
• Expansion: reduced on the affected side with flattening of the chest wall on the same side.
• Percussion: dull over the collapsed area.
• Breath sounds: reduced, often without bronchial breathing above the area of atelectasis when a tumour is the cause, because the airways are not patent.
Pleural effusion
- Trachea and apex beat: displaced away from a massive effusion.
- Expansion: reduced on the affected side.
- Percussion: stony dullness over the fluid.
- Breath sounds: reduced or absent. There may be an area of bronchial breathing audible above the effusion due to compression of overlying lung.
- Vocal resonance: reduced.
Pneumothorax
- Expansion: reduced on the affected side.
- Percussion: hyperresonance if the pneumothorax is large.
- Breath sounds: greatly reduced or absent.
- There may be subcutaneous emphysema.
- There may be no signs if the pneumothorax is small (less than 30%).
Tension pneumothorax
- The patient is often tachypnoeic and cyanosed, and may be hypotensive.
- Trachea and apex beat: displaced away from the affected side.
- Expansion: reduced or absent on affected side.
- Percussion: hyperresonant over the affected side.
- Breath sounds: absent.
- Vocal resonance: absent.
COPD
usually not cyanosed but are dyspnoeic, and used to be called ‘pink puffers’. The signs result from hyperinflation.
• Barrel-shaped chest with increased anteroposterior diameter.
• Use of accessory muscles of respiration and drawing in of the lower intercostal muscles with inspiration.
• Drowsiness or even coma may be a sign of CO 2 retention indicating a worsening of the patient’s chronically increased CO 2 levels. It may be caused by the administration of oxygen supplements (look for the oxygen mask), which further diminishes the patient’s respiratory drive. d This is type II respiratory failure.
• CO 2 retention also leads to warm peripheries, bounding pulses and sometimes a flapping tremor.
• Palpation: reduced expansion and a hyperinflated chest, Hoover’s sign, tracheal tug.
• Percussion: hyperresonant with decreased liver dullness.
• Breath sounds: decreased, early inspiratory crackles.
• Wheeze is often absent.
• Signs of right heart failure may occur, but only late in the course of the disease.
Chronic bronchitis
- Loose cough and sputum (mucoid or mucopurulent), particularly in the morning shortly after wakening, and lessening as the day progresses.
- Cyanosis: these patients were sometimes called ‘blue bloaters’ because of the cyanosis present in the latter stages and associated oedema from right ventricular failure.
- Palpation: hyperinflated chest with reduced expansion.
- Percussion: increased resonance.
- Breath sounds: reduced with end-expiratory high- or low-pitched wheezes and early inspiratory crackles.
- Signs of right ventricular failure.
Generalised emphysema
• Pursed-lip breathing (this occurs in emphysema and not in chronic bronchitis): expiration through partly closed lips increases the end-expiratory pressure and keeps airways open, helping to minimise air trapping.
What are the (3) Cs in interstitial lung disease Px?
- Cough (dry)
- Clubbing
- Crackles.
Interstitial lung disease
- General: dyspnoea, cyanosis and clubbing may be present.
- Palpation: expansion is slightly reduced.
- Auscultation: fine (Velcro-like) late inspiratory or pan-inspiratory crackles heard over the affected lobes.
- Signs of associated connective tissue disease: rheumatoid arthritis, systemic lupus erythematosus, scleroderma, Sjögren’s e syndrome, polymyositis and dermatomyositis.
TB
- Primary: A Ghon focus with hilar lymphadenopathy, Usually no abnormal chest signs are found, but segmental collapse, due to bronchial obstruction by the hilar lymph nodes
- Post-primary: often no chest signs. classical symptoms of cough, haemoptysis, weight loss, night sweats and malaise
- Miliary: Fever, anaemia and cachexia. dyspnoeic, and pleural effusions, lymphadenopathy, hepatosplenomegaly or signs of meningitis
Mediastinal compression
- Tracheal compression: stridor, usually accompanied by respiratory distress.
- Recurrent laryngeal nerve involvement: hoarseness of the voice.
- Horner’s syndrome .
- Paralysis of the phrenic nerve: dullness to percussion at the affected base, which does not change with deep inspiration (abnormal tidal percussion), and absent breath sounds suggest a paralysed diaphragm due to phrenic nerve involvement.
