Physical Examination of the Respiratory System PDF

PHYSICAL DIAGNOSIS MODULE 4. TRANS 01 PHYSICAL EXAMINATION OF LE 2...

PHYSICAL DIAGNOSIS MODULE 4. TRANS 01 PHYSICAL EXAMINATION OF LE 2 10/01/23 THE RESPIRATORY SYSTEM NORMAN MAGHUYOP, M.D. OUTLINE LANDMARKS I. Introduction 1. Anatomy 2. Histology 3. Physiology II. Manifestations of Respiratory Dysfunction a. History Taking b. Risk Factors c. Onset d. Quantification e. Associated Symptoms f. Family History g. Exposure and Vaccination III. Physical Examination Techniques a. Inspection b. Palpation c. Percussion d. Auscultation IV. Interpretation of PE findings an putting it all together LEGEND Figure 1. Anterior view of landmarks Must Lecture Book Know [lec] [bk] OBJECTIVES I. At the end of this lecture, the future Bedan doctor should know the following: 1. Important concepts pertaining to the normal structures and functions of the respiratory system. 2. Techniques of physical examination of the respiratory system. 3. Correlations of physical examination findings with pathophysiologic processes INTRODUCTION A. ANATOMY OF THE RESPIRATORY SYSTEM Figure 2. Anterior view of lungs CONDUCTING SYSTEM  From the nasal cavity and pharynx (upper airways) down to the  ☤ In the performance of PE, you need to be able to locate anatomic larynx, trachea, main bronchi, down to distal bronchioles (lower landmarks. This is important because as you know, the PE is airways) external and you want to be able to approximate the location of the  In charge of conducting or bringing fresh gas in and out of the lungs PE findings to the structure underneath and you could be guided by surface anatomy GAS EXCHANGE SYSTEM  ☤ For example: in the anterior aspect of the patient, the following landmarks (refer to Figure 2) are important to be able to delineate  Terminal bronchioles, alveolar ducts, and alveoli which lobe is most likely affected by which abnormal findings you  The deoxygenated blood gets oxygen from the inhaled air and this are able to detect. Most of the anterior left chest is occupied by left occurs in the terminal bronchioles, alveolar ducts and alveoli upper lung while on the right side, right upper and right middle lung  Where gas exchange occurs from the atmospheric O2 to the is demarcated by 4th rib. bloodstream and from bloodstream, CO2 is expelled whenever we exhale  This is important because we could actually attempt to localize any problem anatomically meaning you could diagnose whether there’s a problem in conducting system or gas exchange system depending on PE findings Figure 3. Posterior view of landmarks [PD] Arcinue, Bermundo, Cuevas TH Cantos Page 1 of 10  MODULE 4. TRANS 01 LE 2 PHYSICAL EXAMINATION OF THE RESPIRATORY SYSTEM 10/01/23 B. HISTOLOGY Figure 4. Posterior view of lungs  ☤ Going to the posterior aspect, in the left side, the left upper lung and left lower lung is demarcated by 5th rib and same is true for Figure 7. Respiratory System right upper lung and right lower lung. So, if you want to evaluate the lower lungs, they are accessible posteriorly. And again  The airways branches into smaller component until it reaches the haphazard yung pagperform mo ng PE or incomplete, ang inexamine niyo lang ay anterior aspect lung then you won’t be able gas exchange system so after about several branching, it then reaches the alveolus to detect findings in the right lower lung or conversely, ang  Terminal bronchioles divide into 2-5 alveolar ducts, each of which inexamine niyo lang ay posterior aspect, you will miss PE findings in the left and right upper lung consists of 10-16 alveoli.  ☤ This is a crucial structure because this is where gas exchange  ☤ Important to note is that the right upper lung and left lower lung is actually still accessible posteriorly but it is covered by the scapula occurs. The alveolus is surrounded by pulmonary capillaries and so baka mas mahirap magexamine ng right upper lung and left bathe in deoxygenated blood. And by the time they pass through the alveolus, CO2 has diffused into the alveoli and O2 has diffused lower lung posteriorly but you may position the patient so that the scapula can be moved laterally exposing the left and right upper into the RBCs to be distributed to the rest of the body lung  Alveoli has 3 cell types o Type I, the lining cell accounts for 95% of the alveolar surface area o Type II cell produces surfactant, a mixture of phospholipids, which maintains alveolar stability o The macrophage acts as phagocytic defense vs infection o The adult respiratory system contains approximately 300 million alveoli o The surface area of the alveolo-capillary membrane available for Oxygen-Carbon Dioxide exchange is approximately 70-85 m2 C. PHYSIOLOGY Figure 5 Right lateral view of the Lung  Right middle lobe is best accessed laterally Figure 8. Process of Gas Exchange Figure 6 Left lateral view of the Lung  Primary function of the Respiratory System is GAS EXCHANGE  Exchange of oxygen and carbon dioxide between the alveoli and pulmonary circulation  Aerobic metabolism is important because the body is able to produce more ATPs per substrate compared to anaerobic metabolism. You are still able to produce ATP even without O2 butthe process is less efficient meaning you produce less ATPs compared to aerobic metabolism plus there’s the danger of accumulating lactic acid which could result to metabolic acidosis which will impair many important functions because acidosis can [PD] Arcinue, Bermundo, Cuevas TH Cantos Page 2 of 10  MODULE 4. TRANS 01 LE 2 PHYSICAL EXAMINATION OF THE RESPIRATORY SYSTEM 10/01/23 destroy important enzymes in the body. Severe lactic acidosis can actually cause death of a patient D. ASSOCIATED SYMPTOMS  Breathing is largely an automatic act controlled in the brainstem  Morning cough, excess sputum – chronic bronchitis and mediated by the muscles of respiration  Eructation, frequent indigestion – GERD  The dome-shaped diaphragm is the primary muscle of respiration  Change in sputum character – bronchitis  When it contracts, it descends in the chest and enlarges the  Systemic signs? I.e., Weight loss, anorexia, fever thoracic cavity. It compresses the abdominal contents, pushing the abdominal wall outward  Muscles in the rib cage and neck expand the thorax during E. FAMILY HISTORY inspiration, especially the parasternals and scalenes  Cystic Fibrosis  During inspiration there is an increase in volume, there is a  Lung cancer decrease in intrathoracic pressure than the atmospheric pressure  Alpha-1-antitrypsin deficiency because of the pressure difference, papasok ‘yung air from the o Associated with Emphysema environment  Important in malignancies and genetic abnormalities.  During systole, deoxygenated blood returning from the body’s cells is pumped from the right ventricle through the arterial pulmonary circulation to the alveolar capillaries F. EXPOSURE AND VACCINATION  Histoplasmosis, Blastomycosis  CO2 diffuses from the capillary blood across alveolo-capillary  Tuberculosis - “Close” vs “Casual” contacts membrane and enters the alveolar air  At-risk for specific organisms?  Simultaneously, oxygen from inspired atmospheric air in the alveolus crosses the alveolar capillary membrane and enters the  Vaccination History pulmonary capillary blood PHYSICAL EXAMINATION MANIFESTATIONS OF RESPIRATORY  Suspected abnormalities arising from data gathered from the history are confirmed DYSFUNCTION  Determine which structure or function is involved  Provides a significant amount of information in the diagnosis of  Use all senses patients with respiratory complaints  PE of the respiratory system mostly involves analysis of vibration  Usual complaints that we hear from patients are: and sound transmission o Dyspnea o Cough o Hemoptysis CHARACTERISTICS OF SOUND o Cyanosis  Loudness  Focus on respective organ system  Pitch o ☤ But all systems are interrelated  Quality  The purpose of the physical examination is to identify the physical signs of disease VELOCITY OF SOUND VARIES WITH THE MEDIA o ☤ The advantage of this is that these are objective findings as opposed to the history which are subjective meaning (1) you  Air – 331.45 m/s (normal)  Water 1450 m/s could verify the information gathered from history or (2) you could detect or identify manifestations of diseases that were  Glass – 5,500 m/s not elicited in the history taking process. So pwedeng yung  🖊 Sound travels fastest in a solid media, slowest in air and problems are identified during the PE consequently the quality of transmission: highest quality in solid,  ☤ With regards to the history, you should be able to get the lowest quality in gas complete attributes of a history.  ☤ Mnemonic: OPQRST (Onset, Precipitating, Quality, Severity, ETHICS Timing)  Nonmaleficence or primum non nocere (“First, do no harm”) o Most important A. RISK FACTORS  Beneficence (“do good” for the patient)  Tobacco-related disease make up ~40% of ALL cardiopulmonary  Autonomy – all maneuvers must be with the informed consent of symptoms the patient; right to decide for his/her own body o (# of sticks/day) / (number of sticks per pack) x (# years  Confidentiality – all information must be kept secret smoked) = pack-years  Justice – what we treat for one patient we must do for all. We must o >15 pack-years: increased cardiovascular risk always give our best. No matter the social status, religion, etc. o >30 pack-years: increased risk for COPD, lung cancer  Important steps before starting the PE process:  Opportunity to counsel on smoking cessation o Explain the process o o ASK ADVICE o o = Explain importance Obtain consent o Respect patient privacy = o ASSIST  Occupational history o Explain before each action o Conduct self with dignity  Truthfulness, humility, honesty B. ONSET  “not written not done”  Sudden onset – Pulmonary Embolism, Pneumothorax o 🖊 If you did not do it, do not write it!  Gradual onset – COPD  The physical examination should be performed methodically ang  Cyclical – Asthma thoroughly, with consideration for the patient’s comfort and modesty. C. QUANTIFICATION  The result of the examination, like the details of the history, should  Quantify severity of illness (dyspnea) be recorded at the time they are elicited, not hours later when they are subject to the distortions of memory [PD] Arcinue, Bermundo, Cuevas TH Cantos Page 3 of 10  MODULE 4. TRANS 01 LE 2 PHYSICAL EXAMINATION OF THE RESPIRATORY SYSTEM 10/01/23  The key to a thorough and accurate physical examination is developing a systematioc sequence of examination  The skillful clinician is: o Thorough without wasting time o Systematic without being rigid  🖊 Example: lack of equipment or the patient disagrees, we should not avoid taking the PE. We should be able to adjust with the end goal in mind to diagnose the patient. o Gentle yet not afraid to cause discomfort should this be required  PRACTICE!! POSITIONING  Posterior – patient sitting with arms folded across chest and Figure X. Surface Landmarks hands resting on opposite shoulders  🖊 We also need to evaluate the lateral portion to check for any o 🖊 This is done so that the scapula can be winged out and abnormalities, especially in the right middle lobe. we have access to the posterior aspects of the right upper and left upper lobes  Anterior – patient either supine or sitting INITIAL SURVEY  Observe rate, rhythm, depth and effort of breathing LANDMARKS o 🖊 Normal breathing is when you cannot even notice that the  Make use of the landmarks in localizing where you want to patient is breathing perform the PE  Inspect for signs of respiratory difficulty o Assess for cyanosis o Listen to patient’s breathing for audible wheezing o Inspect the neck for SCM or other accessory muscle contraction, supraclavicular retraction, position of trachea o 🖊 When the following are observed, stop the history taking and PE and immediately send the patient to the ER  Observe shape of the chest  Most important: is the patient in distress? Is there an emergent problem? Should he be in the emergency room instead of the clinic?  Are his lips blue? Are his fingernails dusty?  Is there audible wheezing? Stridor is a wheeze that is predominantly inspiratory and louder in the neck than in the chest. It indicates a partial obstruction of the trachea or larynx and is an emergent problem. Figure X. Landmarks  Contraction of the sternocleidomastoid? Supraclavicular  🖊 Anterior: This is important in reporting your findings. The retractions? reporting should be 2-dimensional, it could be mid sternal, mid  If with no emergent problems, we can proceed. clavicular, or anterior axillary and what ICS you detected. For  Do his ill-fitting clothes suggest weight loss? Does he smell of example, 2nd ICS left mid clavicular line. cigarettes? Does he have bad breath suggestive of gingivitis or a  🖊 Lateral: Composed of anterior axillary, mid-axillary, and predisposition for a lung abscess? posterior axillary. For example: stab wound at the 5th ICS right anterior axillary line * SURFACE PROJECTIONS Figure X, Patterns of breathing  Normal RR: 12-20/min  Tachypnea (RR > 20/min) o Rapid, shallow breathing  Hyperpnea Figure X. Surface projection. Posterior and Anterior view o Rapid, deep breathing o Hyperventilation o Medical term: Kussmaul’s breathing (seen in lactic acidosis  🖊 Take note that the inferior border of the right and left lower or metabolic acidosis) lobe can vary with respiration and depending upon the respiratory  Bradypnea (RR < 12/min) cycle. o Abnormally slow breathing  Ataxic breathing [PD] Arcinue, Bermundo, Cuevas TH Cantos Page 4 of 10  MODULE 4. TRANS 01 LE 2 PHYSICAL EXAMINATION OF THE RESPIRATORY SYSTEM 10/01/23 o Biot’s breathing o Irregularly irregular (no pattern) o ☤ probability CNS problem  Cheyne-stokes breathing o Regular rate, irregular depth o MAY be normal o 🖊 there is hyperpnea then pabagal ng pabagal then mag apnea then ulit nanaman. Baka may CNS problem ang patient.  Sighs o Hyperventilation syndrome/normal o 1 sigh per 200 breaths o may 1 deep breath na ginagawa ang patient  Most of the patterns if present can give us a clue on the underlying abnormality such as: Figure X. Phenotypes of COPD o Kussmaul’s - Metabolic acidosis o Cheyne-stokes - CHF, acute mountain sickness (respiratory  🖊 There are phenotypes that are considered classic for specific alkalosis), menigitis, CVA, pontine damage diseases. For example, COPD. Merong two classical phenotypes o Biot’s - Increased ICP, drug-induced respiratory depression, (not for clinical categorization, it is just for historical purposes) Blue brain damage usually medullary level bloater (right) is cyanotic, edematous, and not tachypneic. Pink o Kussmaul’s and Biot’s = consider CNS problem puffer (left) tachypneic but not cyanotic. Both have certain characteristics and clinical features for specific diseases, and this can give a clue into underlying pathology but not a diagnostic criteria. Only early clues for evaluation.  Clues to increased work of breathing o Nasal flaring E o Intercostal/Supraclavicular retractions o Accessory muscle use o Pursed-lipped breathing o Disrupted speech  🖊 is it a full paragraph, whole sentences, only phrases, words, or no words at all? o - Thoraco-abdominal dissociation  🖊 Normally when a patient inhales, the abdomen Figure X. Finger Clubbing decreases. if not, it is thoraco-abdominal dissociation  Assess if the patient needs emergency care!  🖊 Presence of finger clubbing can point to chronic respiratory disease, chronic cardiovascular disease, or malignancy or cardiopulmonary disease Figure X. Chest Configuration Figure X. Cyanosis  🖊 When we describe chest configuration, you need to know the  🖊 Cyanosis is best detected in areas with thin skin such as the normal, and the normal is the lateral diameter is larger than the lips, nail beds, or tongue anteroposterior diameter. If mas larger ang anteroposterior diameter that is the Barrel chest which is common in COPD [PD] Arcinue, Bermundo, Cuevas TH Cantos Page 5 of 10  MODULE 4. TRANS 01 LE 2 PHYSICAL EXAMINATION OF THE RESPIRATORY SYSTEM 10/01/23 - Use the ball or ulnar surface of the hand (bony surface of the hand) - Palpate and compare symmetric areas - Assess if transmitted palpable vibrations are increased or decreased or absent (when the patient speaks, compare the left and the right, see if equal, greater than, or less than) Figure X. Cross Section of the Thorax  🖊 If there is depression in the lower part of the sternum, it is called funnel chest or Pectus Excavatum which can result in Figure X. Test for excursion compression of the great vessels. If protruded, and sternum is displaced anteriorly that is Pectus Carinatum which can point to  “Feel the breathing” certain genetic abnormalities. 🖊Ito yung sinasabi ko na assessment for chest expansion if the patient inhales you should be able to feel the breathing kapag hindi gumagalaw then there is chest lag notice that the thumb kapag nag- INSPECTION exhale magkadikit sila kapag nag-inhale maghihiwalay yung thumb na  Deformities or asymmetries (left and right aspect) yun kasi neg-eexpand yung lungs, kapag may side na hindi gumalaw  Retraction of interspaces then your conclusion will be there is chest lag in that lung.  Impaired respiratory movement or lag (chest wall moves with  Palpable vibration of the chest wall from sounds transmitted from inspiration and exhalation) the phonating larynx  Other abnormalities (scars [traumatic or surgical and should be 🖊 What you do you put the bony part of your hand sa symmetrical reported], tattoos, sinus tracts, clubbing, etc.) parts ng lungs then ask patient to say ninety-nine” or “tres-tres”  ninety-nine” or “tres-tres”  Compare symmetry  Abnormally MAY be increased or decreased  Some probabilities for abnormal findings: - Tenderness (Rib fracture, costochondritis) - Crepitus (Subcutaneous emphysema) - Chest lag (Atelectasis, massive pleural effusion, pneumothorax) - Increased fremitus (Consolidation or atelectasis with the patient airway) 🖊 Above normal ang transmission ng vibration meaning the lungs becomes solid - Decreased fremitus (Emphysema, pneumothorax, pleural effusion, consolidation, or atelectasis with blocked airway) 🖊Ibig sabihin hindi maganda yung (vibration) transmission PERCUSSION  Defines density of underlying structures by differences in Figure X. Deformities or asymmetries sound wave conduction 🖊Dito percuss yung chest wall tapos tingnan kung paano  🖊 If there is a visible mass, you should describe the size, nagbabounceback yung vibration na produced with percussion of the borders, and description of the underlying skin. chest wall.  🖊 Photos can be taken, just be wary of the patient's  Position plexor and pleximeter correctly confidentiality  Identify percussion notes and compare symmetric area s PALPATION  Identify tender areas (examine the tender/painful area last) Examine tender areas last. Hulihin examine yung masakit na part unahin yung hindi masakit because there is a possibility na kapag nasaktan yung patient baka hindi na siya magpa-evaluate which could result in a incomplete evaluation  Assess any observed abnormalities such as masses or sinus tracts (mass attributes – size mobility, consistency, skin changes, and location) Palpate and describe the consistency, measure the size, assess Figure X. Areas for percussion and auscultation the mobility, tenderness, if there is warmth  Test for chest expansion (chest lag)  Areas for percussion and auscultation - Position thumbs at the 10th rib 🖊Read Bates for sites of percussion - Assess chest excursion as the patient inhales deeply  How to perform percussion: 🖊 You feel the movement of the chest wall kapag hindi gumagalaw - (1) Hyperextend the middle finger of your left hand, known as the then there is chest lag which could point to a problem in the chest wall pleximeter finger expansion - (2) Press its digital interphalangeal joint firmly on the surface to  Test for tactile fremitus be percussed [PD] Arcinue, Bermundo, Cuevas TH Cantos Page 6 of 10  MODULE 4. TRANS 01 LE 2 PHYSICAL EXAMINATION OF THE RESPIRATORY SYSTEM 10/01/23 - Avoid surface contact by any part of the hand as this dampens our vibration - (3) Position your right forearm quite close to the surface with the hand cocked upward - The middle finger should be partially flexed, relaxed, and poised to strike. - (4) With a quick, sharp but relaxed wrist motion, trike the pleximeter finger with the right middle finger with flexor finger 🖊 Wrist ang pagbend hindi sa elbow - Aim at your distal interphalangeal joint Figure X. Areas for percussion and auscultation - Strike using the tip of the flexor finger, not the finger pad. - Your finger should be almost at right angles to the pleximeter 🖊 Same areas of percussion ang recommended sa auscultation. - (5) Withdraw your striking finger quickly to avoid damping the Auscultate in between the ribs not in the ribs. Position patient well vibrations you have created especially in the posterior side kasi nakaharang yung scapula. Don’t forget the lateral aspects of the patient.  Stethoscope - Ideal length = 10-12 inches - Earpieces must fit tightly and placed into the ears in an anterior direction  Auscultatory technique: - Always compare both sides of the chest - Include the tracheal area using the bell - There are auscultatory sites in the posterior chest wall and on the anterior chest wall Figure X. Percussion  When you listen to the lung sounds, determine loudness, * pitch, and inspiratory to expiratory ratio. BREATH SOUNDS TRACHEAL AND BRONCHIAL BREATH SOUNDS  Loud, high-pitched sounds normally heard over the trachea and mainstem bronchi  Produced by turbulent airflow patterns  IE ratio: 1:2 to 1:3  Sound frequency – 200-2,000 Hz  Heard over chest wall on either side of the sternum from 2 nd to 4th ICS anteriorly and along vertebral column from 3rd to 6 th ICS posteriorly Figure X. Percussion notes and their characteristics 🖊 the percussion note can be described by their intensity, pitch, and VESICULAR BREATH SOUNDS duration. These are some examples kung ano ang pakiramdam non.  Produced by the changes in airflow patterns, quieter than 🖊 Please take note of the table above as it is high yield bronchial/ tracheal BS.  Inspiratory component arises from sounds generated by turbulent  Some pathologies that could result from abnormal airflow within the lobar and segmental bronchi percussion:  Expiratory component from the larger more central airways - Resonant (Normal, asthma, ILD)  Sounds are attenuated as they move peripherally along the air - Dull (Consolidation, pleural effusion) passages - Hyperresonant (Emphysema, pneumothorax)  Inspiration is heard clearly, immediately followed by expiration which quickly fades as airflow rates rapidly decline and turbulent AUSCULTATION airflow is directed towards the central airways  Assess breath sounds (make the patient inhale and exhale)  IE ratio = 3:1 to 4:1 - Identify and locate vesicular breath sounds  Sound frequency = 200 to 600 Hz - Identify and locate broncho-vesicular breath sounds  Normally heard over most lung fields - Identify and locate bronchial breath sounds 🖊 Usually quieter than the bronchial and tracheal sounds.  Assess adventitious sounds 🖊 Sound that we hear in the lungs that are not breath BRONCHIALVESICULAR BREATH SOUNDS sounds  Heard anteriorly and posteriorly over large central airways - Identify, locate, and characterize crackles  Pitch & duration – between vesicular and bronchial breath sounds - Identify, locate, and characterize wheezes  IE ratio = 1:1 - Identify, locate, and characterize rhonchi  Assess transmitted voice sounds BRONCHIAL BREATH SOUNDS 🖊 Assess How the voice is transmitted into the lungs - Identify bronchophony  Occurs when lung tissue is between the central airways and chest - Identify egophony wall becomes airless because of conditions that increase lung - Identify whispered pectoriloquy density, thus enhancing transmission of breath sounds which become louder, and more tubular with IE ratio = 1:1 or 1:2 🖊 Example is pneumonia  Breath sounds of central origin are well transmitted with no alveolar attenuation [PD] Arcinue, Bermundo, Cuevas TH Cantos Page 7 of 10  MODULE 4. TRANS 01 LE 2 PHYSICAL EXAMINATION OF THE RESPIRATORY SYSTEM 10/01/23  Seen in consolidation, atelectasis, and fibrosis (which increase RHONCHI lung tissue density by fluid accumulation, lung collapse, or fibrotic  Low-pitched snoring sound. “low-pitched wheezes”. Continuous scarring) sounds are heard primarily during expiration and are caused by #  fluid/secretion partially blocking large airways. Seen in bronchitis  Sonorous rhonchus - MEDIASTINAL CRUNCH  Best heard in the left lateral position, it arises from air entry into the - mediastinum causing mediastinal emphysema (pneumomediastinum).  It usually produces severe central chest pain and may be spontaneous I Figure X. Table comparing the four breath sounds. ADVENTITIOUS SOUND  Crackles, Wheeze, Rhonchi, and Pleural friction rub  “Extra” sounds other than breath sounds.  These are superimposed on the usual breath sounds.  Always ask yourself is the sound: - Inspiratory or expiratory or both? - Continuous or discontinuous? - High-pitched or low-pitched? CRACKLES Figure X. Categories of respiratory sounds  See appendix for the clear view of the picture  Previously termed rales  Discontinuous sounds  Loud and low pitched = coarse crackles G. ABNORMAL VOICE SOUND  Less intense, higher pitch and short duration = fine crackles 🖊 Another maneuver that we can do is ask the patient to speak and find  Short, explosive, non-musical sounds out how the sound is transmitted.  Voice sounds are produced by vibrations of vocal cords as air from lungs pass over them COARSE CRACKLES  Normally, vowel tones contain high frequency sounds are filtered  “Extra” sounds other than breath sounds. and diminished  louder, low-pitched, and longer.  Over consolidation (solid lungs because of inflammatory cells) or  From airway secretions atelectatic lung tissue, less filtering takes pace, thus, enhancing transmission FINE CRACKLES  Ask the patient to say “tres-tres”, “ee” and whisper “tres-tres” or “ee”  Soft, less intense, high pitched, and very brief (short duration) and often accompany CHF  Softer, shorter, higher in pitch BRONCHOPHONY  Opening of small airways  clear, distinct & intelligible voice sound over airless lung tissue  Much more common during inspiration WHISPERED PECTORILOQUY WHEEZE  clear, distinct, intelligible whispered voice sound heard over airless,  Continuous sounds that are high-pitched with a hissing sound. consolidated/atelectatic lung tissue  Continuous, musical sounds 🖊 Kapag dinig na dinig yung whisper ng patient.  Wheeze-sibilant rhonchus - High pitched hissing sound EGOPHONY  Rhonchi – sonorous rhonchus  voice sound with nasal or bleating quality heard over chest wall - Low pitched snoring sound over consolidated/atelectatic lung tissue, also seen in the upper  “RHONCHI” or LOW-PITCHED WHEEZES: low pitched, border of a large pleural effusion continuous sounds heard primarily during expiration and caused by fluids/secretions partially blocking large airways (narrowing of the airways) * STRIDOR  Loud musical sound that is heard at a distance without a stethoscope. PLEURAL FRICTION RUB  It is a wheeze that is predominantly inspiratory and louder in the  Due to inflammation of visceral and parietal pleura. neck than in the chest. It indicates a partial obstruction of the 🖊Parang crackling sound elicited by deep inhalation and expiration trachea or larynx and is an emergent problem.  Caused by laryngeal spasm and mucosal swelling  Typically heard during inspiration, but maybe heard throughout the respiratory cycle. [PD] Arcinue, Bermundo, Cuevas TH Cantos Page 8 of 10  MODULE 4. TRANS 01 LE 2 PHYSICAL EXAMINATION OF THE RESPIRATORY SYSTEM 10/01/23 🖊 This is a medical emergency kasi sign ito ng upper airway obstruction pwede life-threatening. Refer immediately for upper airway evaluation. Padala na agad sa ER for management. # Figure X. Categories of respiratory sounds 🖊 This how you put together all your PE findings and hopefully come up with a specific abnormality. * NORMAL (NI CONSOLIDATION OR ATELECTASIS PATENT AIRNA) · CONSOLDATION OR ATELECTASIS (WI BLOCKED AIRNAY) ASTHMA INTERStIIAL Luny DiseSE EMPHYSEMA & PneumotHORAY * PLEUNAL EFFusion Figure X. Categories of respiratory sounds 🖊Ganito yung makikita niyo meron kayong mga PE findings kailangan malaman niyo kung ano yung condition based on the combination of PE findings. Of course, hindi palaging perfect yan, hindi naman palagi present or absent yan but that could give you a clue kung ano yung medical condition that is causing the pathology sa patient. [PD] Arcinue, Bermundo, Cuevas TH Cantos Page 9 of 10  PHYSICAL DIAGNOSIS MODULE 4. TRANS 01 PHYSICAL EXAMINATION OF LE 2 10/01/23 THE RESPIRATORY SYSTEM NORMAN MAGHUYOP, M.D. APPENDIX [PD] Arcinue, Bermundo, Cuevas TH Cantos Page 10 of 10