© continuing medical implementation ® …...bridging the care gap psd thorax and lungs respiratory...
TRANSCRIPT
© Continuing Medical Implementation ® …...bridging the care gap
PSD Thorax and Lungs Respiratory Physical Exam
Joel Niznick MD FRCPC
adapted from
UCSD: A Practical Guide to Clinical Medicine http://medicine.ucsd.edu/clinicalmed/lung.ht
m
PSD Thorax and Lungs Respiratory Physical Exam
Joel Niznick MD FRCPC
adapted from
UCSD: A Practical Guide to Clinical Medicine http://medicine.ucsd.edu/clinicalmed/lung.ht
m
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InspectionInspection
• Cyanosis• Clubbing• Respiratory rate• Respiratory pattern
– Normal– Restricted– Obstructed– Cheynes-Stokes– Painful
• Chest configuration– Pigeon chest (pectus
carinatum)– Barrel chest– Funnel chest (pectus
excavatum)– Harrison’s sulcus– Kyphosis– Scoliosis
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Differential Diagnosis of Clubbing
Differential Diagnosis of Clubbing
• Cyanotic congenital heart disease• Lung disease
– Cystic fibrosis– Interstitial fibrosis– Malignancy– Sarcoidosis– Bronchiectasis
• Hyperthyroidism
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Lobar surface markersanterior chest
Lobar surface markersanterior chest
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Lobar surface markersposterior chest
Lobar surface markersposterior chest
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Lobar surface markersRight lateral view
Lobar surface markersRight lateral view
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Lobar surface markersLeft lateral view
Lobar surface markersLeft lateral view
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InspectionInspection
• Rate rhythm depth effort
• 14-20/min
• Supraclavicular retraction and SC mastoid retraction
• Posterior shape, symmetry, deformities
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PalpationPalpation
• Lymph Nodes
• Tracheal location, shift
• Cutaneous lesions
• Expansion– Upper lobes– Middle lobes– Posterior lobes
• Palpate tactile fremitus– “99,99,99”
– Increased, decreased, absent
– Resonant, dull
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Tracheal DeviationTracheal Deviation
• Ipsilateral– Atelectasis– Fibrosis– Lung collapse– Pneumothorax
• Contralateral– Pleural effusion
– Hemothorax
– Tension pneumothorax
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PercussionPercussion
• Apices to bases– Intensity, pitch duration- resonant or dull
– Diaphragmatic dullness & respiratory excursion ~ 5-6 cm
– Dull: liver, spleen, heart, consolidation/collapse
– Stony dull: Pleural effusion/thickening
– Resonant: air filled lung
– Hyper-resonant: emphysema, pneumothorax
– Tympanitic: Gas filled viscus
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Ohio State UniversityInteractive Guide to Physical Exam
Ohio State UniversityInteractive Guide to Physical Exam
http://familymedicine.osu.edu/products/physicalexam/exam/
Click on image and scroll down page
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AuscultationAuscultation
• Breath sounds– Bronchial
• over sternum
– Bronchovesicular• 1-2 interspace anteriorly
• interscapular
– Vesicular• Most of lung fields
• Duration• Pitch • Intensity
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Ohio State UniversityInteractive Guide to Physical Exam
Ohio State UniversityInteractive Guide to Physical Exam
http://familymedicine.osu.edu/products/physicalexam/exam/
Click on image and scroll down page
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Adventitial soundsAdventitial sounds
• Wheezes - continuous– Rhonchi
• Crackles- intermittent– Fine– Course– Rales
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Changes in voice soundsChanges in voice sounds
Signs of consolidation
• Bronchophony “99,99,99”
• Egophony “e,e,e” sounds like “ay,ay,ay”
• Whispering pectorliloquay
Additional sounds
• Pleural rubs
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ConditionsConditions
• Consolidation
• Collapse
• Pleural effusion
• Pneumothorax
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Describe the Physical Signs ofLLL Pneumonia
Describe the Physical Signs ofLLL Pneumonia
• Inspection
• Palpation– Trachea– Expansion– Fremitus
• Percussion
• Auscultation– Broncophony– Egophony
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Describe the Physical Signs ofLLL Collapse
Describe the Physical Signs ofLLL Collapse
• Inspection
• Palpation– Trachea– Expansion– Fremitus
• Percussion
• Auscultation
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Describe the Physical Signs ofRight Pleural Effusion
Describe the Physical Signs ofRight Pleural Effusion
• Inspection
• Palpation– Trachea– Expansion– Fremitus
• Percussion
• Auscultation• Whispering pectorliloquay
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Describe the Physical Signs ofRight Pneumothorax
Describe the Physical Signs ofRight Pneumothorax
• Inspection
• Palpation– Trachea– Expansion– Fremitus
• Percussion
• Auscultation
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Describe the Physical Signs ofRight Tension Pneumothorax
Describe the Physical Signs ofRight Tension Pneumothorax
• Inspection
• Palpation– Trachea– Expansion– Fremitus
• Percussion
• Auscultation
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Signs in Respiratory DiseaseAbnormality Chest wall
movementPercussion
noteBreath sounds Vocal
ResonanceAdded sounds
Consolida-
tion
Decreased on affected side
Dull Bronchial Increased Crepitations
Collapse Decreased on affected side
Dull Decreased or absent
Decreased or absent
None
Effusion Decreased on affected side
Stoney dull Decreased or absent
Decreased or absent
May be pleural rub
Pneumo-
thorax
Decreased on affected side
Normal or hyper-resonant
Decreased or absent
Decreased or absent
None
Emphysema Decreased on both sides
Normal or hyper-resonant
Decreased Normal or decreased
None
Asthma Decreased on both sides
Normal or hyper-resonant
Prolonged expiration
Normal Rhonchi
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COPDCOPD
Clinical Features• Cough, sputum, dyspnea• Pursed lip respiration (Forced expiratory time > 6
seconds)• Hyperinflation- increased AP diameter/ hyper-
resonance• Barrel chest• Reduced breath sounds• Wheezes and rhonchi• Hoover sign (paradoxical indrawing of the lateral
rib margin seen during inspiration)