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References: recording, 2010 ppt, Bates, google Sorry medyo mahaba sya ang dami kasi sinabi ni Dr. Feliciano.. Hi Mico haha! Yung iba jan peechures naman lang so kering keri! Go!
OUTLINE I. CASE PRESENTATION II. REVIEW OF ANATOMY -Anterior -Posterior -Landmarks -Lungs III. PROPERLY POSITION THE PATIENT IV. UNDRESS THE PATIENT PROPERLY :> V. INSPECTION
-rate of breathing -pattern of breathing -position of the patient - antero-posterior and lateral diameter of the chest -chest and spine deformities -Lung expansion -extrapulmonary findings
VI. PALPATION -lymph node -trachea -chest -palpate for mass and tenderness -assessing for asymmetry of lung expansion -tactile fremitus -unilateral diminished fremitus -bilateral diminished fremitus VII. PERCUSSION -level of diaphragm -differentiation of notes in percussion VIII. CERTAIN DISEASES WITH USUAL FINDINGS
Case: 57 y/o, 50 pack year smoking HPI: 1 year PTA- cough intermittent 2 mos PTA- persistent cough, whitish phlegm, anorexia, weight loss Few days PTA- symptoms progressed, (+) dyspnea, (+) pleuritic chest pain Next thing to do: AUSCULTATE, BP, general survey. Above case is a very incomplete history. Your physical examination will depend on the history youll be able to get from the patient. Remember your title as a clinician when you are taking the history: You are the HISTORIAN that means.. Whatever you write down is YOUR story. It is the analysis of the case with the facts coming from the patient. Do not just write down what the patient would tell you. You have to give some of your inputs there and see what is important/relevant to the assessment you are making. Going back to the case, you would want to ask more.. characterize cough MORE! What aggravates it? What relieves it? When is the time predilection that the patient would cough? Is it associated w/ hemoptysis? Fever? Dyspnea.. How severe? Any medications? In pleuritic chest pain.. is it localized? Ask for more information.. sometimes the patient wouldnt volunteer, then YOU WILL BE THE ONE TO ASK!
Ask for Past Medical History. The case above can manifest a pulmonary disease as well as systemic disease (cardiac).
Family History. Ask if the patient smokes. Is he a smoker w/ chronic cough? One of the differentials would be LUNG CANCER. Ask for history of cancer or other pulmonary disorder like asthma which can be genetically predisposed to the patient. Ask Personal/Social History in terms of occupation history as well.
Review of Anatomy
ANTERIOR
Suprasternal notch- point of reference where trachea will pass through; where clavicle would attach to the sternum.. the point where manubrium would start. Angle of Louis -most prominent area next to
Suprasternal notch; where 2 rib would attach. In tension pneumothorax (air in pleural space), if its too large causing compression of cardiac structurebradycarcardia, hypotension, cardiac arrest Thats a medical emergency so you should Immediately insert large core needle to release the air and tension. Insert it at the 2nd INTERCOSTAL SPACE midclavicular line. Or count 2 intercostals space below.. PHYSICAL DIAGNOSIS : Chest and Lungs | 1
nd
at the level of 4 rib/ nipple area(bifurcation of trachea to R and L main bronchus). From Bates Note special landmarks: 2nd intercostal space for needle insertion for tension pneumothorax; 4th intercostal space for chest tube insertion; T4 for lower margin of endotracheal tube on chest x-ray. the clavicle would block the 1 intercostals space. nd st 2 intercostal space-1 soft area that you will palpate. th th th th In midclavicular line you could palpate up to 6 intercostals space. Go obliquely on the lateral for 7 , 8 , 9 intercostals spaces. Palpate Xiphoid-where the sternum would end and youll be able to delineate your lung during inhalation.
st
th
POSTERIOR -Spine -Spinous Process(C7-the most prominent) -Thoracic vertebrae -Tip of Scapula(7th rib)
From Bates Note T7-8 interspace as landmark for thoracentesis. When the neck is flexed forward, the most protruding process is usually the vertebra of C7. If two processes are equally prominent, they are C7 and T1.
LANDMARKS- these are vertical lines used to locate findings around the circumference of the chest. The midsternal
and vertebral lines are precise; the others are estimated.
Anteriorly: Get the midpoint of your sternum, draw a perpendicular line, to refer to your MIDSTERNAL LINE.
Approximate the midline of clavicle, draw a perpendicular line: MIDCLAVICULAR LINE.
Posteriorly: In your Spinous process, draw perpendicular line to refer to your MIDVERTEBRAL or SPINAL
LINE. In the lateral surface of scapula, you can have your MIDSCAPULAR LINE. In between your scapula, you have your INTRASCAPULAR AREA. Below the scapula, is INFRASCAPULAR AREA. Posteriorly, the vertebral line overlies the spinous processes of the vertebrae. The scapular line drops from the inferior angle of the scapula.
Each lung is divided roughly in half by an oblique (major) fissure. This fissure may be approximated by a string that runs from the T3 spinous process obliquely down and around the chest to the 6th rib at the midclavicular line. The right lung is further divided by the horizontal (minor) fissure. Anteriorly, this fissure runs close to the 4th rib and meets the oblique fissure in the midaxillary line near the 5th rib. The right lung is thus divided into upper, middle, and lower lobes. The left lung has only two lobes, upper and lower. See left figure
RIGHT LUNG(3 lobes) Right Upper Lobe: Apical, Anterior, Posterior Middle Lobe: Medial, Lateral Posterior Lobe: Superior basal, Antero-lateral basal, Posterior basal, Medial basal
LEFT LUNG Upper Lobe: Apicoposterior, Anterior, Superior and Inferior Lingula Lower lobe: Superior basal, anteromedial basal, lateral basal, posterior basal
You can identify problems on RIGHT UPPER LUNG(RUL) and RIGHT MIDDLE LOBE(RML), partly RIGHT LOWER LOBE(RLL) ; LEFT UPPER LUNG and partly LEFT LOWER LUNG
Figure 2. Posterior view: Partly Left Upper Lung and Right Upper Lung; Better appreciation of Left Lower Lung and Right Lower Lung
Figure 3. Right Lateral view: Right Upper Lung, Right Middle Lung, Right Lower Lung divided by OBLIQUE and HORIZONTAL fissure
Figure 4. Left lateral view: Left Upper lung and Left Lower lung, divided by OBLIQUE FISSURE
PROPERLY POSITION THE PATIENT: might affect your findings so be cautious about it Patient: SITTING OR STANDING - so you can examine the anterior and the back(posterior) of the patient Babies: supine position Doctors: do not stand in front of your patient! FOR YOUR OWN PROTECTION and HYGIENE PURPOSES. Also if the patient is female, awkward if guy yung doctor tapos nasa harap dibuh (KINKY!) UNDRESS THE PATIENT PROPERLY (KINKIER!) narinig ko si Rayson at Mico nag-ohhhh For Male patient, its not a problem For some who do not want that, allow them to undress themselves and examine the chest directly WITHOUT their clothes on. (DO NOT AUSCULTATE WITH THE PATIENTS CLOTHES ON.. Remove all obstructions) In females, ask them to retract their breast (ask permission first) so you can auscultate the chest. If patient is really that sick, examine them in SUPINE POSITION. I. INSPECTION 1. Checking Respiratory rate Dont stare at the patients chest (might be anxious and change his/her manner of breathing). You can talk to the patient or get the pulse while counting the RR
RR Adults Normal RR - 16-20 breaths/min (Tachypnea-higher; Bradypnea-lower) RR on Normal Pediatric patients - higher RR
PHYSICAL DIAGNOSIS : Chest and Lungs | 4
2.
Pattern of Breathing While the patient is standing/lying/seated upright at the end of the examing table or bed. Usual pattern: diaphragm goes down, chest goes anteriorly and upward (inspiratory movement) Normal Tidal volume(during resting respiration) on average is 500 mL(if patients 50 kg). Depends on the weight. [TV= 10-15 ml/kg] If the patient is smaller, smaller tidal volume
rapid, deeper breathing metabolic hypoxia acidosis, anxiety, excercise,
Hyperpnea
Hypopnea Tachypnea
Bradypnea
coma,
morphine
and
Kussmaul respiration
hyperpneic breathing/polypnea; deep, regular, sighing respiration can be fast, normal or slow -Regulary irregular: apnea(absence of breathing for more than 10 secs), hypopnea, hyperpnea, hypopnea, apnea in cycle;
**Trivia: Why Cheyne-Stokes? Best described by Cheyne a kind of breathing pattern cease of 10 secs, became perceptible though very low, and became hyperpnea, and gradually ceases again(apnea)
Cheyne-Stokes
-UREMIA -Congestive heart failure(failing heart so blood flow to brain is slower, then feedback mechanism is affected and delayed kaya may hypopnea, hyperpnea, hypopnea, hyperpnea - brain injuries, metabolic encephalopathy - common in children
Biots Breathing
-Irregularly regular; Not periodic. -Sometimes slow, sometimes rapid. Sometimes superficial. Sometimes deep; without any constant relation of succession between the two types; with pauses following irregular interval preceeded and often following by a sigh, more or less prolonged; -very irregular: hypopnea, hyperpnea, hypopnea, hypopnea, hypopnea, hyperpnea, apnea -group of quick, shallow inspiration followed by regular or iregular period of apnea
MENINGITIS Cerbro vascular disease Cranial tumors generally indicates poor prognosis
Normal ratioAP diameter: Lateral Diameter1:2 to 1:3(adults, bawal ang barrel chest); 1:1(pediatrics, ang barrel chest okay lang sa baby) Dont just say the patient is obese!!! Take note of the history! A patient with Bronchitis, AP diameter is 1:1 due to bronchitis (not just due to obesity). Check for defects or deformities Pectus Excavatum funnel chest- Depression of lower aspect of the sternum; common in shoemakers in olden times, they press the shoes in their chest; abnormal in patients who had Rachitic Rosary and Marfan Syndrome(congenital) Rachitic Rosary: manifestaion of Vit D deficiency or problem with the receptors of Vit D; nutritional in origin; prominence of costosternal notch; bulging ear like beads thats why it is called Rachitic rosary); seen in patient 1 to 2 years with Rickets **Complication: Pectus Excavatum funnel chest Marfan Syndrome(termed as arachnodactyly but not all patients manifest) long bones, long skull with Pectus Excavatum; autosomal dominant genetic predisposition
Pectus Carinatum birds chest/pigeons breast/chicken breastsoftened upper ribs bend inward, forcing the sternum forward complication of Rickets, Pagets Disease, congenital Heart Diseases. Can develop if epiphysis is still open, up to age 18(females) and 21(males) Kyphosis exaggeration of the posterior curvature of the back. Most common: osteoporosis causes the patient to bend forward Scoliosis di pantay ang shoulders at fat fold. Ask the patient to bend forward to really see (Adams Forward Test) if you have Chronic Obstructive Lung Disease, this will cause Restrictive Lung Diseases - lower Tidal Volume, lower reserve volume, lower total lung capacity, all inspiratory capacities will be low difficulty of breathing it can also compress cardiac structure cardiac abnormalities. Chondrosarcoma malignancy of the rib or bone more severe form describe the lesion, measure the circumference if it has ulceration(typical of malignancy) Empyema necessitans - pus draining out of the chest wall; complication of tuberculosis TB lymphadenitis Scrofula- TB of lymph node
Extra pulmonary findings- cyanosis, clubbing, increase vascularity of superficial veins, puffy face
II. PALPATION Lymph node One at a time only! You can kill the patient if theres a problem in carotid artery and you compress it Guide: start with pre-auricular, post-auricular, submandibular, submental, anterior and posterior cervical, supraclavicular area or the other way around. Trachea palpate the sides It should be goind down straight. If theres deviation, either contralaterally if theres mass, effussion, or even pneumothorax. Most common is goiter pushing the trachea on the other side. In Atelectasis, the trachea will deviate ipsilaterally. Chest palpate anteriorly and posteriorly. Check if theres a mass and tenderness. Palpate the ribs and intercostal space if you have any pleural involvement like in pleurisy/pleuritis (inflammation of the pleura), you can only elicit a pain whenever you try to palpate the intercostal spaces If you palpate on the rib and there is a pain on the rib, then that would be due to a rib problem and not necessarily a pulmonary problem. Do this in front or at the back of your patient. Assessing for Asymmetry of Lung Expansion by checking respiratory excursion: best done at the BACK of the patient. th place your hands at 10 intercostal space (3 intercostal spaces below the tip of the scapula as your reference) your thumb should be positioned in the paravertebral area You have to be on fold and ask the patient to inhale, exhale(This is not the proper way but a better way of doing it) Let the patient move your hand. If there is symmetry, then that is symmetrical chest expansion. You can also do that in the anterior chest th usually at the level of 6 intercostal space. You do the same technique. You can also do that on your upper chest but do not press too much on your brachial. For the patient who cannot sit up, you can also do that while your patient is on supine position. Asymmetrical Lung expansion Problems on the side borders pathology There would be a lag if there is a pleural effusion, pneumothorax or large mass in that area If theres no mass, effusion nor pneumothorax, possible cause is
diaphragmatic paralysis (since diaphragm is the major muscle in respiration). Tactile Fremitus The last you have to do with palpation Ask the patient to say ninety-nine, tres, tres, for as long as that the frequency of what you would ask the patient to say is the same frequency as the chest wall and the lungs. For females with high frequency or high pitches, expect that the fremitus might be decreased or not appreciable at all. Ask the female to lower down the pitch or voice to appreciate the lung fremitus. Certain points to consider: Usually the first point of examination is your supraclavicular area then down to your intercostal space and then obliquely downward to these points (zigzag pattern). You can do it one at a time or at the same time depending on your preference. When examining the back, ask the patient to place the hands on the shoulder to retract the scapula so you would have more space to palpate, percuss or auscultate. You have to place the baller surface of palm or ulnar surface of your hands. Best sensed by using the palmar bases of the fingers applied on the chest wall The intensity is dependent on tissue density Feel for vibration. When you ask the patient to say tres tres or ninety-nine, your vocal cords will vibrate and will send vibrations towards your bronchus, to your parenchyma and your chest wall. Remember your hand should be placed in the intercostal space. Normal is equal vocal fremitus. Abnormality in fremitus can be seen in consolidation that can be appreciated in patient with Pneumonia because of increase in secretion III. PERCUSSION use the dominant hand as a plexor if right handed, use the right hand as a plexor the other hand would be your pleximeter. So your pleximeter is usually your nondmoninant hand, you have to press it in the intercostal space, and then you have to tap it with your plexor. the force should come from the wrist and not from you elbow. You should do a 1-3 strikes to appreciate the sounds created by percussion.
in alveoli due to the inflammatory mucus and cells that would increase density of the lungs allowing a better transmission of that vibration from your lung parenchyma toward the chest wall. This is the only one that can increase the fremitus. The rest of the abnormality will diminish the fremitus.
The lung percussion note is resonance. Heart and liver is dull. Stomach is tympanic.
Thigh is flat. Again, you have to do percussion same as earlier (zigzag pattern). Do not forget to percuss the lateral chest. Be sure to cut your nails (long nails can be painful in percussion). You can do it in supine position. But the vibration might be dumped when doing in supine. It is more audible when you do it in a sitting position and there is a better resonance on your apex rather than on the base and it is highly appreciated on the right intercostal area. PHYSICAL DIAGNOSIS : Chest and Lungs | 8
At the back, you have to do that on your vertebra and scapula, again, ask the patient to retract the scapula (by putting his hands on his shoulders).
If you have difficulty in hearing the sound of percussion, it is not the force of your plexor that matters. You can actually apply more pressure with your pleximeter before you try to percuss. In summary, in percussion, you will report the normal findings as resonance on all lung field except on the area of cardiac dullness. If you report otherwise, then it indicates some other diseases.
o o
On palpation, there might be absent fremitus and if there is tension pneumothorax, you will appreciate deviation of your trachea to your contralateral side. On percussion, it is hyperresonant.
affected side, decrease in fremitus and shifting of the trachea to the affected side or ipsilaterally. There is dullness on percussion.
Pneumonia Common infection of the lung parenchyma. The patient may present with possible cyanosis, and splinting on the affected side, increased fremitus, dullness on percussion. Theres a special resonance that can be appreciated (also in patient with pneumohydrothorax) skodaic resonance or tympany. o you would have dullness in the area and have consolidation but just above it you would appreciate hyperresonance or almost tympany. o It can also appreciated in pneumohydrothorax where you have both air and fluid in the pleura. In the area where you have fluid, you have dullness. The area where you have air in the pleura, you will have hyperresonance or tympany upon percussion. Pleural Effusion Usually present with lag on affected side or if it is minimal it can have normal lung expansion. On palpation, you would have a decrease in fremitus, and the trachea is shifted to the contralateral side. On percussion, it would be dull. Atelectasis It can be normal if there is only a segmental atelectasis but if it is a lobar atelectasis or atelectasis of the whole lung then you would expect lag on the
Acute Respiratory Distress Syndrome (ARDS) Upon inspection, the patient is using accessory muscles upon breathing and cyanosis, but the percussion and palpation may be normal. Pulmonary Embolism normal physical examination. You would need to have a good clinical eye. Probably look for risk factors. And have a high index of suspicion before you make a diagnosis of pulmonary embolism. Pulmonary edema or congestion It might also have inspection but in severe congestion you might have dyspnea. Upon palpation and percussion it would be normal. There might have fine crackles when you have congestion.
On the left, anterior sequence of percussing the chest while on the right picture shows posterior examination of the chest
Relative intensity Flatness Dullness Resonance Hyperresonance Soft Medium Loud Very loud
Examples Pleural effusion Lobar pneumonia Chronic bronchitis Emphysema, pneumothorax Large pneumothorax
tympany
loud
High
Condition Asthma
Differentiation of Common Pulmonary Conditions Inspection Palpation Percussion Dyspnea; use of accessory muscles; poss. Cyanosis; hyperinflation Increased AP diameter; use of accessory muscles; thin Poss. Cyanosis; short, stocky Often normal; lag on affected side Often normal, decreased fremitus Often normal; hyperresonant; low diaphragm.
Auscultation Prolonged expiration; wheezes; decreased lung sounds Decreased lung sounds and vocal fremitus
Emphysema
Decreased fremitus
Chronic Bronchitis
Often normal
Pneumothorax
Hyperresonant
Pneumonia
Poss. Cyanosis and splinting on affected side Often normal; lag on affected side
Dull
Pleural Effusion
Decreased fremitus; trachea shifted to contralateral Decreased fremitus; trachea shifted to ipsilateral Usually normal
Dull
Atelectasis
Dull
ARDS
Often normal
Often normal
Usually normal
Usually normal
Often normal
Often normal
Often normal
-ENDHi batchmates! Galingan natin! Thank you Jener sa pagtulong sakin sa last 20 mins of recording.. Nakakapagod tranx na to hmp! Pag may tanong kayo guys, or tingin nyo na mali sabihin nyo lang.. or dedma haha! Goodluck satin! Number of noh?: 133