Physical exam findings for pulmonary conditions Flashcards
What are the key physical exam findings for pleural effusion?
- Decreased breath sounds
- Dullness to percussion
- Decreased tactile fremitus
- Tracheal deviation away if large
Why does pleural effusion cause dullness to percussion?
Fluid accumulation in the pleural space absorbs sound, leading to dullness.
Why is tactile fremitus decreased in pleural effusion?
Fluid in the pleural space impairs the transmission of vibrations from the bronchial tree to the chest wall.
How does pleural effusion affect tracheal position?
The trachea remains midline unless the effusion is large, in which case it shifts away from the affected side.
What are the key physical exam findings for lung consolidation?
- Increased breath sounds (crackles/rales)
- Dullness to percussion
- Increased tactile fremitus
- trachea remains midline
Why does consolidation cause increased breath sounds?
Fluid-filled alveoli conduct sound more efficiently, leading to louder breath sounds.
What are the characteristic lung sounds in consolidation?
Increased breath sounds, bronchial breath sounds, egophony, whispered pectoriloquy, and crackles (rales). Bronchial breath sounds are loud, high-pitched, and similar to tracheal sounds. They are heard in consolidation due to increased sound transmission through fluid-filled alveoli. Egophony is when a patient says ‘E’ but it sounds like ‘A’ upon auscultation. It occurs due to enhanced transmission of high-frequency sounds through fluid-filled lung tissue. Whispered pectoriloquy is when whispered words are heard more clearly than normal due to increased sound transmission through consolidated lung tissue.
Why does consolidation cause increased tactile fremitus?
Solidified lung tissue (due to infection/inflammation) transmits vibrations more effectively than air-filled lungs.
What are the key physical exam findings for pneumothorax?
- Decreased breath sounds
- Hyperresonance to percussion
- Decreased tactile fremitus
- Tracheal deviation away in tension pneumothorax
Why does pneumothorax cause hyperresonance to percussion?
Excess air in the pleural space increases resonance during percussion.
What is the difference between simple and tension pneumothorax on physical exam?
Tension pneumothorax pushes the trachea away from the affected side, while simple pneumothorax does not cause significant deviation.
What are the key physical exam findings for atelectasis?
- Decreased breath sounds
- Dullness to percussion
- Decreased tactile fremitus
- Tracheal deviation toward the affected side if large
Why does atelectasis cause tracheal deviation toward the affected side?
Collapsed lung tissue creates negative pressure, pulling the trachea toward the affected lung.
What are the key physical exam findings for COPD/emphysema?
- Decreased breath sounds
- Hyperresonance to percussion
- Decreased tactile fremitus
- Trachea remains midline
Why do COPD and emphysema cause hyperresonance to percussion?
Air trapping and hyperinflation increase lung compliance, leading to hyperresonance.
Why are breath sounds decreased in emphysema?
Destruction of alveolar walls reduces airflow and sound transmission through the lungs.
Which conditions cause dullness to percussion?
Pleural effusion, consolidation, and atelectasis.
Which conditions cause hyperresonance to percussion?
Pneumothorax and COPD/emphysema.
Which conditions cause increased tactile fremitus?
Consolidation (e.g., pneumonia).
Which conditions cause decreased tactile fremitus?
Pleural effusion, pneumothorax, atelectasis, and COPD/emphysema.
Which conditions shift the trachea away from the affected side?
Large pleural effusion and tension pneumothorax.
Which conditions shift the trachea toward the affected side?
Large atelectasis.
What is digital clubbing?
A deformity of the nails characterized by increased convexity, broadening, and hypertrophic changes of the distal fingers.
What are other terms used for digital clubbing?
Hippocratic fingers, drumstick fingers, watch-glass nails.
What is the proposed pathophysiology of digital clubbing?
Increased vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF) leading to increased connective tissue proliferation and periosteal changes. Another proposed pathology for digital clubbing includes the fact that platelets tend to be broken up within the lung and when you have decreased lung parenchyma or diseased parenchyma and vessels, platelets are not broken up as effectively in the lung and so they end up in the distal extremities such as the fingers and start to break up there increasing the amount of cytokines in the fingertips.
Which pulmonary conditions are associated with digital clubbing?
Lung cancer (especially non-small cell carcinoma), interstitial lung disease (e.g., pulmonary fibrosis), pulmonary tuberculosis, pulmonary lymphoma, and bronchiectasis.
Why does lung cancer cause digital clubbing?
Tumor cells release growth factors (VEGF, PDGF) that promote distal phalangeal hypertrophy and periosteal changes.
Why is digital clubbing seen in interstitial pulmonary fibrosis?
Chronic hypoxia and increased VEGF/PDGF stimulate connective tissue proliferation in the distal fingers.
Is digital clubbing seen in COPD?
No, digital clubbing is NOT typically associated with COPD unless lung cancer is also present.
Which cardiovascular conditions are associated with digital clubbing?
Cyanotic congenital heart disease (e.g., Tetralogy of Fallot, Eisenmenger syndrome), infective endocarditis, and chronic heart failure.
Why does cyanotic congenital heart disease cause digital clubbing?
Long-standing hypoxia triggers VEGF release, promoting digital clubbing and hypertrophic osteoarthropathy.
How does infective endocarditis lead to digital clubbing?
Chronic infection and inflammation lead to increased platelet-derived growth factor (PDGF) and connective tissue proliferation.
What is hypertrophic osteoarthropathy (HOA)?
A syndrome characterized by digital clubbing, periostitis, and painful joint swelling, often associated with lung cancer.
What is the relationship between digital clubbing and hypertrophic osteoarthropathy?
Clubbing is often the first sign of HOA, which progresses to distal extremity bone and joint pain.
What are the clinical features of digital clubbing?
Loss of the angle between the nail and nail bed (>180°), increased nail convexity, sponginess of the nail bed, and widening of the fingertips.
How is digital clubbing assessed on physical exam?
The Schamroth sign (loss of the diamond-shaped gap between the opposing nails when placed together).
Is digital clubbing reversible?
It can be reversible if the underlying cause is treated early, but in chronic cases, it may persist.
Which major conditions cause digital clubbing?
Lung cancer, interstitial lung disease, pulmonary fibrosis, cyanotic congenital heart disease, infective endocarditis, and hypertrophic osteoarthropathy.
Does COPD alone cause digital clubbing?
No, clubbing in a patient with COPD suggests an alternative diagnosis, such as lung cancer or bronchiectasis.
What is the most common malignancy associated with digital clubbing?
Non-small cell lung carcinoma (NSCLC), especially adenocarcinoma.
