*17 Physical Examination of the Lungs Flashcards
1
Q
Physical exam compartmentalization
- Inspection
- Palpation
- Percussion
- Auscultation
A
- 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
Q
Inspection:
Surface structures:
Symmetry and shape of the thorax
A
- 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
Q
Inspection:
Surface structures:
Tracheal position
A
- 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
Q
Inspection:
Surface structures:
Intercostal spaces
A
- 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
Q
Inspection:
Surface structures:
Skin
A
- 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
Q
Inspection:
Respiratory rate
A
- 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
Q
Inspection:
Respiratory pattern:
Cheyne-Stokes respiration
A
- 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
Q
Inspection:
Respiratory pattern:
Kussmaul’s respirations
A
- 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
Q
Inspection:
Respiratory pattern:
Others
- Biot’s breathing
- Central neurogenic hyperventilation
- Apneustic breathing
- Ataxic breathing
A
- 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
Q
Inspection:
Respiratory effort
A
- 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
Q
Inspection:
Respiratory paradox
A
- 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
Q
Palpation:
Chest excursion
A
- 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
Q
Palpation:
Crepitation
A
- 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
Q
Palpation:
Fremitus
- General
- What increases and decreases fremitus
- Right vs. left upper lobe
A
- 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
Q
Auscultation:
Breath sounds:
Vesicular
A
- 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
