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Pulmonary examination – (El) examen pulmonar

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PULMONARY EXAMINATION
Physical Examination of the ChestI. THE PHYSICAL EXAMINATION IS FOCUSED BY THE HISTORY.The following six symptoms are of such specific importance in pulmonary disease diagnosisthat they warrant special discussion:1. Cough2. Sputum production3. Hemoptysis4. Chest pain5. Dyspnea6. Wheezing1. Coughs should be characterized: time of day, is it productive or non productive of sputum.Cough should be related to any exacerbating factors e.g. running in cold weather.2. Sputum production should be described: e.g. 1 cup a day of foul smelling sputum.3. Hemoptysis (coughing up blood) must be distinguished from hematemesis (vomitingblood).4. Chest pain should be well characterized: pleuropulmonary, cardiovascular orneuromuscular.5. Dyspnea requires quantifying. A patient who usually runs 5 miles a day who then noticesdyspnea after running one mile a day may have new disease. A patient who usually canrun up two flights of stairs who then notices dyspnea after walking up one flight of stairsmay have new disease.6. Wheezing. Know the importance of inspiratory stridor and unilateral wheezing.Inspiratory stridor should be recognized immediately since the obstruction is situated inthe larynx or trachea and the relief of the obstruction may be a matter of great urgency.For unilateral wheezing, in most instances, the lesion will be bronchogenic carcinoma,although other tumors, foreign bodies or inflammatory stenosing lesions may occasionallybe the cause of unilateral wheezing.II. FOUR COMPONENTS OF THE EXAMINATIONA. InspectionB. PalpationC. PercussionD. Auscultation
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Pocket Medical Spanish
A. INSPECTION1. FIRST AND MOST IMPORTANT IS THE RESPIRATORY RATE. TO BEACCURATE RESPIRATORY RATE SHOULD BE COUNTED FOR 30 SECONDS. Isthe respiratory rate increased or decreased? (NORMAL RATE VARIES BETWEEN 8AND 14). What is the length of inspiration and expiration?INSPIRATION LASTS TWICE TO THREE TIMES LONGER THAN EXPIRATION.Is the patient in respiratory distress?2. CHEST WALL STRUCTUREContourSymmetryHyperinflationSternal deformity: Pectus CarinatumPectus ExcavatumSpinial deformity: KyphosisGibbusLordosisScoliosis3. INSPECTION MEANS MORE THAN OBSERVING THE CHEST:USE OF ACCESSORY RESPIRATORY MUSCLES such as sternocleidomastoid retraction –Signifies increased work of breathing and respiratory distress.CLUBBING is associated with lung cancer, is commonly associated with diffuse fibrosis ofthe lung and is almost always seen in patients with cystic fibrosis. It is NOT a manifestationof asthma, chronic bronchitis or emphysema.SKIN – cyanosis, rashesB. PALPATION1. Examine for adenopathy2. Examine the neckTracheal position – is it the midline admitting almost an index finger on either side ofthe episternal notch when palpated from behind the patient. The lower palpable tracheamay deviate slightly to the right in older patients.Thyroid gland3. Chest wall tenderness4. PrecordiumPMIVentricular heavePalpable P2
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5. Chest wall expansion. Place hands at the base of the rib cage with thumbs equidistant fromspinous processes. Ask patient to take slow, deep breaths and observe for any asymmetricmotion of your hands.6. Palpable breath sounds. With the palmar aspect of the fingers or the ulnar aspect of thehand, appreciate tactile fremitus by asking the patient to phonate (“blue moon,” “99”,“one-two-three”).Fremitus n.pl. (L.fremere, to murmur). A palpable vibration.Fremitus is enhanced by consolidation and decreased by pleural fluid or trapped air(pneumothorax = air in the pleural space).Palpation is the best method for evaluation of the degree and symmetry of expansion withrespiration, as well as for appreciation of the transmitted vibrations of the spoken voice.C. PERCUSSIONA method of evaluating the consistency of tissues below the skin by the quality of reflectedsound and palpable vibrations generated by tapping on the body surface. “A poor man’sultrasound”.Method – Place the volar surface of one middle finger firmly against the area to be examined(PLEXIMETER) and tap with the middle finger of the other hand (PLEXOR). Listen and feelthe vibrations.Resonance – the clear long low pitched sound elicited over the normal lung.Hyperresonance – a more vibrant, lower pitched, louder and longer sound heard normally overthe lungs during maximum inspiration.Dullness – short, high pitched, soft and thudding sound which lacks the vibratory quality of aresonant sound. Dullness occurs when the air content of the underlying tissue is decreased andits solidity is increased.Flatness – very short, and high pitched (absolute dullness). Flatness occurs when there is noair present in the underlying tissue. For example, flatness is found over the muscle of the armor thigh.Note: Variations in resonance may be perceived to a greater degree by the pleximeter fingerthan by the ear. SO AS YOU ARE LEARNING PERCUSSION LISTEN AND FEEL THEVIBRATIONS.D. AUSCULTATION
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Instruct the patient to breathe with his mouth open, a little deeper and faster. Demonstrate itto the patient yourself.1. Evaluation of breath soundsINTENSITYREGIONS – Listen over all lobes/ segmentsQUALITYTracheal – Loud, harsh, turbulent sound heard over the sternal notch.Bronchovesicular – Less harsh, easily, heard sounds of air flow heard in centralairways under sternum.Vesicular – Normal quiet “whishing noise of airflow through small airways.”THE SOUNDS HEARD OVER NORMAL LUNG PARENCHYMA ARECALLED VESICULAR BREATH SOUNDS.Bronchial (Also called Tubular) – Similar to tracheal breath sounds but are abnormalbecause they are heard over the peripheral lung where only vesicular sound should beheard. BRONCHIAL OR TUBULAR SOUNDS ARE CLASSICALLY OBSERVEDOVER THE CONSOLIDATED LOBE OF LOBAR PNEUMONIA.Amphoric – Hollow, metallic sound heard over a large cavity.ADVENTITIOUS SOUNDSADVENTITIOUS (L.Ad to + venire to come) 1. accidental or acquired; not natural or hereditary.ADVENTITIOUS SOUNDS ARE VIBRATIONS ALWAYS RESULTING FROM SOMEPATHOLOGIC PROCESS AND ARE NEVER HEARD OVER HEALTHY LUNG TISSUE.There are four major types of adventitious sounds.1. Crackles or Rales – Crisp, crackling sounds heard primarily at lung bases. Theyindicate fibrosis of lung or fluid in alveoli and terminal airways. They occur duringmid to late inspiration.2. Rhonchi – Rattling, coarse sounds caused by turbulence around mucus in largerairways.3. Wheezes – Diffuse or localized whistling sounds caused by airflow throughnarrowed distal airways or obstructed larger airways.4. Rub – Harsh, scratching sound heard in either inspiration or expiration caused byinflamed pleural surfaces (visceral surface against parietal) sliding over each other.
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MANEUVERS FOR AUSCULTATION OF THE CHEST. As there are maneuvers in thecardiovascular examination which aid the detection and definition of various murmurs thereare maneuvers used in the auscultation of the chest which aid in the detection and definition oflung disease.Forced Expiratory Time (FET). Duration of time it takes a patient to blow out air as quickilyas they are able, from a full breath (total lung capacity) until air flow stops. NORMALLY ITTAKES 3 SECONDS OR LESS. The prolongation of FET (LONGER THAN 4 SECONDS)correlates very well with the severity of obstruction as in chronic bronchitis or asthma. FET ISA VERY SENSITIVE MEASURE OF AIRWAY OBSTRUCTION.Whispered Pectoriloquy – high pitched, intensified speech heard over area of consolidationwhen the patient is asked to whisper low pitched words.Bronchophony – a change in the pitch of spoken word over an area of consolidation.Egophony – The sound of a spoken “E” changes to “A” over an area of consolidation. Thespoken “E” is heard as “A” when listening over the consolidation because the frequencies ofthe vibrations are altered by the consolidation. “E” to “A” changes may also occur in a smallband like area just above a pleural effusion because of compression of lung tissue that occursjust above the effusion. This is called Skodiac resonance in honor of the physician Skoda whofirst described this to warn physicians not to confuse these “E” to “A” changes with that foundin consolidation.PHYSICAL EXAMINATION FINDINGS OFCOMMON PULMONARY CONDITIONSPLEURALPNEUMONIAENDO-PNEUMO-EFFUSIONBRONCHIALTHORAXTUMOR___________________________________________________________________________TRACHEALSHIFTED OR MIDLINE SHIFTED ORSHIFTEDPOSITIONMIDLINEMIDLINEOR MIDLINECHEST WALL REDUCED REDUCED ORREDUCED OR REDUCEDMOVEMENT OR NORMAL NORMAL NORMALFREMITUS DECREASED INCREASED NORMAL OR NONEDECREASEDPRECUSSION DULL DULL NORMAL OR HYPER-DULL RESONANTBREATH DECREASED INCREASED NORMAL OR DECREASED/SOUNDSDECREASEDABSENTCRACKLES NONE USUALLY NONE NONE
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WHEEZENONENONE POSSIBLE NONEEGOPHONY BAND ABOVE PRESENTNONENONEEFFUSION(skodiac)PRACTICE QUESTIONSFOR SELF ASSESSMENTTRUE OR FALSE1. Patients may confuse coughing up blood with vomiting blood.2. The complaint of dyspnea after walking up a flight of stairs is never worrisome.3. Respiratory rate can be accurately assessed by counting for 15 seconds and multiplying byfour.4. In a normal breath, the expiratory phase takes more time.5. A normal respiratory rate is from 16-20 per minute.6. An arterial blood gas is the only way to determine if a patient is in respiratory distress.7. Clubbing is not a manifestation of asthma, chronic bronchitis or emphysema.8. Inspiratory stridor is a common manifestation of asthma.9. Unilateral wheezing is a common manifestation of asthma.10. Fremitus is enhanced by consolidation.11. Fremitus is decreased by pleural fluid.12. Fremitus is decreased by pneumothorax.13. Percussion is best assessed by simply listening.14. Hyperresonance is used to describe the percussion note found in the normal lung.15. Dullness occurs when the air content of the underlying lung tissue is increased.16. The sounds heard over normal lung parenchyma are called bronchial breath sounds.17. Crackles and rhonchi refer to the same type of adventitious sound.
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18. A rub may be heard in airway obstruction.19. When ausculating, the patient should be instructed to breath through his nose.20. Bronchial breath sounds are heard on the side of the chest with the pneumothorax.21. Forced expired time (FET) correlates very well with restrictive lung disease.22. A normal FET is between 4 and 5 seconds.23. Whispered pectoriloquy is best elicited by listening over the trachea.24. Egophony is elicited by having the patient say “A”.25. Egophony is heard in the middle of a pleural effusion.CHOOSE THE ONE BEST ANSWER26. Which of the following best characterizes the findings of pneumonia on physicalexamination?A. Decreased fremitus, dullness to percussion and decreased breath sounds.B. Normal fremitus, dullness to percussion and decreased breath sounds.C. Decreased fremitus, hyperresonant to percussion and decreased breath sounds.D. Increased fremitus, dullness to percussion, increased breath sounds and crackles.27. Which of the following best characterizes the findings of pleural effusion on physicalexamination?A. Decreased fremitus, dullness to percussion and decreased breath sounds.B. Normal fremitus, dullness to percussion and decreased breath sounds.C. Decreased fremitus, hyperresonant to percussion and decreased breath sounds.D. Increased fremitus, dullness to percussion, increased breath sounds and crackles.28. Which of the following best characterizes the findings of a pneumothorax (air in thepleural space)?A. Increased fremitus, dullness to percussion and decreased breath sounds.B. Normal fremitus, dullness to percussion and decreased breath sounds.C. Absence of fremitus, hyperresonant to percussion and decreased or absent breathsounds.D. Increased fremitus, dullness to percussion, increased beath sounds and crackles.ANSWERS TO SELF ASSESSMENT1. TRUE. It is often difficult for the patient to distinguish hemoptysis from hematemesis andsometimes the physician must ask several questions to distinguish the two.2. FALSE. A change in exercise tolerance before dyspnea if noticed may be very significantin a previously healthy adult. This is why dyspnea must be quantitated.
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3. FALSE. Respiratory rate should be measured for 30 seconds to insure accuracy.4. FALSE. Take a breath yourself. Inspiration is longer than expiration.5. FALSE. A normal respiratory rate is from 8 to 14.6. FALSE. You can determine if a patient is in respiratory distress by inspection. A rapidrespiratory rate and the use of accessory muscles are examples of signs of respiratorydistress.7. TRUE. Clubbing is not a manifestation of asthma, chronic bronchitis or emphysema.Clubbing is associated with lung cancer, is commonly associated with diffuse fibrosis ofthe lung and is almost airways seen in patients with cystic fibrosis.8. FALSE. Inspiratory stridor is a manifestation of tracheal or laryngeal obstruction.Inspiratory and expiratory wheezing is a common manifestation of asthma.9. FALSE. In asthma there is bilaterally wheezing.10. TRUE. Fremitus is enhanced by consolidation.11. TRUE. Fremitus is markedly decreased by pleural fluid.12. TRUE. Fremitus is decreased by pneumothorax.13. FALSE. Percussion is best assessed by listening and feeling the resonance detected withthe finger used as the pleximeter.14. FALSE. Hyperresonance is used to describe the percussion note found in overexpandedlungs and in pneumothorax.15. FALSE. Dullness occurs when the air content of the underlying lung tissue is decreased.16. FALSE. The sounds heard over normal lung parenchyma are called vesicular. Bronchialor tubular breath sounds are heard in areas of consolidation.17. FALSE. Crackles are crisp sounds heard primarily at lung bases indicating fibrosis of thelung or fluid in alveoli and terminal airways. Rhonchi are rattling, coarse sounds causedby turbulence around mucus in larger airways.18. FALSE. A rub is heard when the pleural surfaces rub against each other.19. FALSE. When auscultating, the patient should be instructed to breath through his mouth.Furthermore, the patient should be shown what to do during the examination by thephysicians.
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English Spanish Medical Dictionary
20. FALSE. Breath sounds are markedly decreased or absent on the side of a pneumothorax.21. FALSE. FET correlates very well with degree of obstruction. FET is normal or decreasedin restrictive lung disease.22. FALSE. A normal FET is 3 seconds or less.23. FALSE. Whispered pectoriloquy is appreciated in areas of consolidation.24. FALSE. Egophony is elicited by having the patient say “E”. Where there is consolidation,“E” changes to “A”.25. FALSE. Egophony is sometimes heard just above a pleural effusion. This is also calledSkodiac resonance.26. Answer is D. Increased fremitus, dullness to percussion, increased breath sounds andcrackles are heard in consolidation (Pneumonia).27. Answer is A. Decreased fremitus, dullness to percussion and decreased breath sounds arefound with plural effusion.28. Answer is C. Absence of fremitus, hyperresonant to percussion and decreased or absentbreath sounds.9/00