Major components of pulmonary physical exam
- inspection
- palpation
- percussion
- ausculation
Possible findings for inspection portion of pulmonary PE
- vital signs: heart rate (60- 90 bpm), blood pressure (140/90 or less), temperature (37.0 celsius), respiratory rate (12-20 per minute), oxygen saturation (> 93% in Denver)
- abnormal findings: Accessory muscle use, tripodding, paradoxical abnominal movement, pursed lip breathing.
- Are they cyanotic (peripheral = acrocyanotic)?
- Clubbing?
- Skeletal shape?
- Are they cyanotic (peripheral = acrocyanotic)?
- Clubbing?
- Skeletal shape?
Possible findings on palaption portion of physical exam
-
Tactile fremitus
-
Decreased
-
pneumothorax
-
pleural effusion
-
obstructed bronchus (atelectasis - compression of part of lung)
-
Increased: lung consolidation: water, pus, blood - anything that fills alveoli with fluid
-
position of trachea
-
atelectasis, fibrosis, resection pulls trachea toward lesion
-
pleural effusion, tension pneumothorax pushes trachea away from lesion
Tactile fremitus
-
Decreased-
pneumothorax
-
pleural effusion -
obstructed bronchus (atelectasis - compression of part of lung)
-
-
Increased: lung consolidation: water, pus, blood - anything that fills alveoli with fluid
position of trachea
-
atelectasis, fibrosis, resection pulls trachea toward lesion
-
pleural effusion, tension pneumothorax pushes trachea away from lesion
Possible findings on percussion portion of physical exam
-
Dull: effusion, consolidation, atelectasis
-
Resonant: Pneumothorax, bullae, emphysema
-
Diaphragmatic excursion- detect paralysis
Dull: effusion, consolidation, atelectasis
Resonant: Pneumothorax, bullae, emphysema
Diaphragmatic excursion- detect paralysis
Normal breath sounds
-
Vesicular: soft and low pitched, heard through inspiration and stop ⅓ into expiration, heard through normal chest
-
Bronchovesicular: moderate pitch and itnensity, heard during inspiration, gap, expiration, over bronchi
-
Bronchial: high pitched, over trachea
-
Bronchovesicular and Bronchial heard over periphery are abnormal - pneumonia and atelectasis
Vesicular: soft and low pitched, heard through inspiration and stop ⅓ into expiration, heard through normal chest
Bronchovesicular: moderate pitch and itnensity, heard during inspiration, gap, expiration, over bronchi
Bronchial: high pitched, over trachea
Bronchovesicular and Bronchial heard over periphery are abnormal - pneumonia and atelectasis
Abnormal breath sounds
- Rales
- Rhonchi
- Wheezes
- Egophany
- Stridor (inspiratory & expiratory)
- Friction Rub
Rales characteristics/causes
- ~ "velcro sound" or popping sounds
- pulmonary edema
- pneumonia
- ILD
Rhonchi characteristics/causes
- snoring-like sound
- caused by air flowing through airways partially obstructed by mucous
Wheezes characteristics/causes
- high-pitched and musical sound
- caused by airflow through narrowed airway
- asthma
- bronchiolitis
- COPD
- asthma
- bronchiolitis
- COPD
Egophany characteristics/causes
- "E" sound ==> "A" sound
- usually caused by fluid-filled area as in pneumoni
Stridor characteristics/causes
- musical sounds heard w/o stethescope - inspiratory or expiratory ==> upper airway pathology
- Inspiratory = laryngospasm, laryngeal edema, subglottic stenosis, vocal cord dysfunction
- Expritory: central airway obstruction w/in thorax
-
Stridor = urgent evaluation!
Stridor = urgent evaluation!
Friction rub characteristics/causes
- harsh sound during inspiration, like rubbing an inflated balloon
- infection, malignancy, pulmonary infarct, lupus pleuritis.
Pneumonia PE findings
- decreased breath sounds
- rales
- consolidation w/increased fremitus, egophany, bronchophony ("99""), dullness to percussion
- fever
- tachypnea
Pleural effusion PE
- dullness to percussion
- decreased/absent tactile fremitus
- decreased breath sounds
- no voice transmission
Atelectasis PE findings
- Low PaO2
- cyanosis
- tachypnea
- tachycardia
Pneumothorax PE findings
- decreased or absent breath sounds on affected side
- decreased chest wall motion
- hyperresonance to percussion
- decreased fremitus
- tachycardia common
- hypotension, cyanosis and tachycardia ==> tension pneumothorax
Asthma PE findings
- wheezes (generally expiratory)
- normal fremitus
- normal percussion
COPD PE findings
