Chest Examination: Symptoms, Pulmonary Disease & Auscultation - PDF

Chest Examination A good history should be both: Concise. Cover the important points.  WHAT SHOULD WE KNOW ABOUT THE EXAMINATION OF THE CHEST? HISTORY SYMPTOMS LANDMARK SIGNS HOW TO PERFORM AN EXAM HOW TO PRESENT THE INFORMATION  PERSONAL DATA: Name...

Chest Examination A good history should be both: Concise. Cover the important points.  WHAT SHOULD WE KNOW ABOUT THE EXAMINATION OF THE CHEST? HISTORY SYMPTOMS LANDMARK SIGNS HOW TO PERFORM AN EXAM HOW TO PRESENT THE INFORMATION  PERSONAL DATA: Name. Age. Sex. Occupation. Residence. The patients complaint: A simple statement in the patients own words and its duration. HISTORY  PRESENT HISTORY: This means detailed history of the patients present illness which must provide answer for the following questions: 1. Duration 2. Mode of onset (acute, sub acute, chronic). 3. Sequence of events: I. Course (progressive, regressive or recurrent). II. Appearance of new additional symptoms or disappearance of others. III. Treatment received during the course & response. 4. Analysis of each particular symptom.  HISTORY Acute/chronic disorder Preceding systemic disturbance Past medical history Drug history Social history Family history Occupational history  PAST HISTORY: Childhood diseases. Trauma. Residences or travel abroad. Drug therapy. Operations.  FAMILY HISTORY EMPHYSEMA AT AN EARLY AGE - CONSIDER ALPHA – 1 ANTITRYPSIN RECURRENT RESPIRATORY INFECTIONS AND STERILITY IN A YOUNG ADULT MALE – CONSIDER CYSTIC FIBROSIS, IMMOTILE CILIA {(that causes defects in the action of cilia lining the respiratory tract (lower and upper, sinuses, Eustachian tube, middle ear) and fallopian tube, as well as in the flagella of sperm cells}. PULMONARY NODULE AND HYPOXEMIA – CONSIDER OSLER WEBER RENDU(is a rare autosomal dominant genetic disorder that leads to abnormal blood vessel formation in the skin, mucous membranes, and often in organs such as the lungs, liver, and brain)  FAMILY HISTORY: Hereditary factor. Exposure to same etiological circumstances.  HABITS: Smoking. Physical efforts. Addiction. SYMPTOMS MAIN SYMPTOMS OF PULMONARY DISEASE COUGH DYSPNEA HEMOPTYSIS CHEST PAIN – PLEURITIC WHEEZING CYANOSIS SPUTUM PRODUCTION SNORING  DESCRIBE THE COUGH PRODUCTIVE – NONPRODUCTIVE ACUTE – CHRONIC TIME OF DAY PRECIPITANTS – RELIEF BLOODY – NON BLOODY  COUGH SYMPTOM ETIOLOGY MORNING CHRONIC BRONCHITIS NON-PRODUCTIVE VIRAL, ILD,TUMOR RECUMBENT SINUSITUS, CHF,REFLUX NOCTURNAL ASTHMA, CHF PRODUCTIVE INFECTIOUS BLOODY TUMOR,CHF  CYANOSIS PERIPHERAL – HANDS, FEET – WARMING DECREASES CYANOSIS – DECREASED CARDIAC OUTPUT CENTRAL- LIPS, TONGUE,SUBLINGUAL - RIGHT TO LEFT SHUNTS  CENTRAL CYANOSIS Results from pulmonary dysfunction, the mucous membrane of conjunctiva and tongue are bluish. If there was chronic hypoxemia and secondary erythrocytosis, you can detect the conjunctival and scleral vessels to be full, tortuous and bluish. Central Cyanosis  THE PNEA’S DYSPNEA – SOB : ACUTE – (PULMONARY EMBOLISM, ASTHMA) CHRONIC – (COPD, CHF, ILD) TACHYPNEA – RR>20 BR/MIN BRADYPNEA - RR< 8 BR/MIN (DRUGS, AGONAL) PND - PAROXYSMAL NOCTURNAL DYSPNEA SUDDEN ONSET OF SOB DURING SLEEP (CHF) ORTHOPNEA – SOB LYING FLAT (CHF) PLATYPNEA – SOB SITTING UP AND BETTER LYING FLAT (R TO L SHUNT) TREPOPNEA – SHORTNESS OF BREATH IN ONE LATERAL DECUBITUS POSITION WHICH IS IMPROVED BY TURNING ON THE OPPOSITE SIDE  DYSPNEA MY CHEST FEELS TIGHT I CANNOT TAKE A DEEP BREATH I FEEL LIKE I HAVE A PILLOW OVER MY MOUTH  THE NUMEROUS ETIOLOGIES OF CHEST PAIN PLEURITIC – PARIETAL PLEURA – SHARP STABBING – INSPIRATION ESOPHAGEAL – REFLUX CARDIAC – MYOCARDIAL INFARCTION GALL BLADDER – CHOLECYSTITIS CHEST WALL – COSTOCHONDRITIS GREAT VESSELS – DISSECTION PULMONARY - PNEUMOTHORAX  SPUTUM - WHAT ARE ITS CHARACTERISTICS ? YELLOW – GREEN (PNEUMONIA, BRONCHIECSTAIS) RUSTY (PNEUMOCCOAL PNEUMONIA) PINK – BLOOD TINGED (EPISTAXIS, BRONCHITIS) FROTHY (CHF) BLOODY (MALIGNANCY, BRONCHIECSTASIS, PULMONARY RENAL SYNDROME) BLACK – COAL DUST INHALATION  HEMOPTYSIS - REQUIRES CAREFUL QUESTIONING THIS SYMPTOM USUALLY DENOTES A SERIOUS ILLNESS. TB, TUMOR, BRONCHIECSTASIS, PE, CARDIAC DISEASE THE PATIENT SHOULD BE QUESTIONED CAREFULLY REGARDING HOW MUCH, FREQUENCY WEIGHT LOSS ETC.  CLUES TO DIFFERENTIATING HEMOPTYSIS FROM HEMATEMESIS HEMOPTYSIS HEMATEMESIS COUGH NAUSEA – VOMITING FROTHY NOT FROTHY COLOR- BRIGHT RED COFFEE GROUNDS PUS FOOD DYSPNEA NAUSEA CARDIAC DISEASE GI DISEASE  Clubbing Hereditary Interstitial Fibrosis Tumor Bronchiecstasis Heart Disease Endocarditis  CLUBBING PAINLESS – FINGERNAILS CURVED AND WARM ENLARGEMENT OF THE CONNECTIVE TISSUES IN THE TERMINAL PHALANGES OF THE FINGERS >TOES Clubbing  SIGNIFICANCE: CLUBBING OBSERVED IN: Intrathoracic malignancy: Primary or secondary (lung, pleural, mediastinal) Suppurative lung disease: (lung abscess, bronchiectasis, empyema) Diffuse interstitial fibrosis: Alveolar capillary block syndrome In association with other systemic disorders  CLUBBING SCHAMROTH’S SIGN – LOSS OF THE SUBUNGUAL ANGLE CLIN CHEST MED 8:287-298,1987 THE PULMONARY EXAMINATION  THE CHEST Inspection Palpation Percussion Auscultation  INSPECTION Shape Scars Lesions Resp rate(Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute.) Resp depth Mode of breathing Abnormal inspiratory movements Abnormal expiratory movements Asymmetry of movement  INSPECTION OF THE CHEST Important: - SHAPE - MOVEMENT of the thorax - VISIBLE PULSATIONS! SHAPE of the chest: Deformities: - kyphosis - scoliosis - depressed sternum (pectus excavatum) - bulges in left parasternal area (congenital malformation) e.g. VSD  CHEST WALL Pectus carinatum Pectus excavatum PECTUS EXCAVATUM BARREL CHEST BARREL CHEST AP Diameter = Transverse Diameter  ABNORMAL BREATHING PATTERNS APNEA - CARDIAC ARREST BIOTS – INCREASED INTRACRANIAL PRESSURE – DRUGS- MEDULLA CHEYNE STOKES – CONGESTIVE HEART FAILURE – DRUGS – CEREBRAL KUSSMAULS – METABOLIC ACIDOSIS Biot's respiration is an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea. Biot's respiration is caused by damage to the pons due to strokes or trauma or by pressure on the pons. It can be caused by opioid use. Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also Kidney failure. It is a form of hyperventilation, which is any breathing pattern that reduces carbon dioxide in the blood due to increased rate or depth of respiration  PALPATION FEELING WITH THE HAND – FINGERTIPS TEXTURES DIMENSIONS CONSISTENCY TEMPERATURE Chest expansion. Position of Mediastinam. Tactile Vocal Fremitus. Spasm of Accessory muscle of respiration.  THORACIC EXPANSION ASYMETRY IN EXPANSION OF THE THORAX CAN BE DETECTED DURING INSPECTION OF THE CHEST DURING PROMPTED INHALATION OBSERVE THE MOVEMENT OF THE THORAX PLEURAL EFFUSION, PNEUMOTHORAX CHEST EXPANSION CHEST EXPANSION CHEST EXPANSION Trachea exam  TACTILE FREMITUS Fremitus is a vibration transmitted through the body. In common medical usage, it usually refers to assessment of the lungs by either the vibration intensity felt on the chest wall (tactile fremitus) and/or heard by a stethoscope on the chest wall with certain spoken words (vocal fremitus). PATIENT SPEAKS. 99 – 1-2-3 SYMETRY MAY BE SEEN IN NORMALS ASYMETRY – IS ABNORMAL  TACTILE FREMITUS INCREASED DECREASED PNEUMONIA (lung PNEUMOTHORAX consolidation) PLEURAL EFFUSION COPD FAT  PERCUSSION Illustrate resonance Compare both sides Map out abnormal area  PERCUSSION TECHNIQUE Place left hand on chest wall, palm downwards with fingers separated 2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx producing hammer effect Entire movement comes from wrist  METHODS OF PERCUSSION DIRECT INDIRECT DISEASE A MONTH 41;643-692:1995 METHODS OF PERCUSSION METHODS OF PERCUSSION  PERCUSSION Impaired(dull)resonance obtained – Aerated lung tissue is separated from the chest wall e.g. fluid, pleural thickening Lung tissue is airless e.g. consolidation, collapse, fibrosis “stony dullness”- pleural effusion Hyperresonance - pneumothorax  PERCUSSION SOUNDS TYMPANY – HEARD OVER THE ABDOMEN RESONANCE – HEARD OVER NORMAL LUNG DULLNESS – HEARD OVER LIVER OR THIGH  Resonant sounds are low pitched, hollow sounds heard over normal lung tissue. Flat or extremely dull sounds are normally heard over solid areas such as bones. Dull sounds are normally heard over dense areas such as the heart or liver. Dullness replaces resonance when fluid or solid tissue replaces air- containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors. Hyperresonant sounds that are louder and lower pitched than resonant sounds are normally heard when percussing the chests of children and very thin adults. Hyperresonant sounds may also be heard when percussing lungs hyperinflated with air, such as may occur in patients with COPD, or patients having an acute asthmatic attack. An area of hyperresonance on one side of the chest may indicate a pneumothorax. Tympanic sounds are hollow, high, drumlike sounds. Tympany is normally heard over the stomach, but is not a normal chest sound. Tympanic sounds heard over the chest indicate excessive air in the chest, such as may occur with pneumothorax. Diaphragmatic excursion: (Tidal Percussion) is the movement of the thoracic diaphragm during breathing. Normal diaphragmatic excursion should be 3–5 cm, but can be increased in well-conditioned persons to 7–8 cm. This measures the contraction of the diaphragm. It is performed by asking the patient to exhale and hold it. he provider then percusses down their back in the ICS (bone will be dull), starting below the scapula, until sounds change from resonant to dull (lungs are resonant, solid organs should be dull). That is where the provider marks the spot. Then the patient takes a deep breath in and holds it as the provider percusses down again, marking the spot where the sound changes from resonant to dull again. Then the provider will measure the distance between the two spots. Repeat on the other side, is usually higher up on the right side. If it is less than 3–5 cm the patient may have a pneumonia or a pneumothorax in which a  AUSCULTATION Breath sounds Added sounds Vocal sounds (vocal resonance) - While the patient breathes normally with mouth open, auscultate the lungs, making sure to auscultate the apices and middle and lower lung fields posteriorly, laterally and anteriorly. - Alternate and compare sides. - Use the diaphragm of the stethoscope. Listen to at least one complete respiratory cycle at each site. - First listen with quiet respiration. If breath sounds are inaudible, then have him take deep breaths. - First describe the breath sounds and then the adventitious sounds. - Note the intensity of breath sounds and make a comparison with the opposite side. - Assess length of inspiration and expiration. Listen for the pause between inspiration, expiration and the quality of pitch of the sound, Also compare the intensity of breath sounds between upper and lower chest in upright position. Compare the intensity of breath sounds from dependent to top lung in the decubitus position. Note the presence or absence of adventitious sounds AUSCULTATION OF THE FRONT AUSCULTATION OF THE BACK  BREATH SOUNDS Vesicular - normal Diminished - localised or diffuse Bronchial - consolidation  LUNG SOUNDS BREATH SOUNDS ADVENTITIOUS TRACHEAL WHEEZE BRONCHIAL RHONCHI VESICULAR CRACKLE PLEURAL RUB STRIDOR  BREATH SOUNDS VESICULAR – NORMAL BREATH SOUNDS - SITE OF PRODUCTION THE ALVEOLI TRACHEAL – TUBULAR – LIKE BLOWING AIR THROUGH A HOLLOW TUBE – PHYSIOLOGIC BRONCHIAL – TUBULAR - ALWAYS PATHOLOGIC WHEN THEY OCCUR OVER POSTERIOR OR LATERAL CHEST WALL BRONCHOVESICULAR – CHARACTERISTICS OF BOTH VESICULAR AND TUBULAR – DO THEY EXIST? ADVENTITOUS – EXTRA SOUNDS  VESICULAR BREATH SOUNDS Vibrations of the vocal cords caused by turbulent flow through the larynx Transmitted along trachea, bronchi to chest wall Rustling quality Inspiration continuous with expiration Intensity increases during inspiration & fades during first 1/3rd expiration DIMINISHED BREATH SOUNDS Conduction limited by Airflow limitation e.g. diffusely – asthma, emphysema localised – tumour, collapse Something separating chest wall from lung e.g. effusion, fibrosis  BRONCHIAL BREATHING “blowing” inspiratory & expiratory sounds Expiratory phase longer than inspiration Distinct pause between phases High-pitched e.g. consolidation Low-pitched e.g. fibrosis  ADDED SOUNDS Rhonchi (wheeze) Crepitations (crackles) Pleural sounds  RHONCHI Due to passage of air through narrowed bronchus e.g. bronchospasm, mucosal oedema Musical quality High or low pitched Usually expiratory Expiration prolonged  CREPITATION Inspiratory noises, usually 2nd half Non-musical Due to explosive reopening of peripheral small airways during inspiration which have become occluded during expiration  PLEURAL RUB Creaking noise Movement of visceral pleura over parietal pleura Surfaces roughened by exudate 2 separate phases at end inspiration and early expiration  WHEEZING ASTHMA CONGESTIVE HEART FAILURE BRONCHITIS COPD VOCAL CORD FORCED EXPIRATION IN DYSFUNCTION NORMAL SUBJECTS FOREIGN BODY CYSTIC FIBROSIS ASPIRATION INFECTIONS – CROUP LARYNGITIS NOT ALL THAT WHEEZES IS ASTHMA Thank you