IVMS -ICM Lung Examination- Abnormal

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IVMS -ICM Lung Examination- Abnormal

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IVMS -ICM Lung Examination- Abnormal

  1. 1. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Lung Examination: Abnormal 1 Marc Imhotep Cray, M.D.
  2. 2. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Respiratory System • Lungs • Airways • Pleura • Mediastinum • Chest Wall • Respiratory Centers 2
  3. 3. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Physical Exam Steps • General examination • Mediastinal position • Chest expansion • Lung resonance • Breath sounds • Adventitious sounds • Voice transmission 3
  4. 4. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. General Examination • Respiratory rate • Pattern of breathing • Cyanosis • Clubbing • Weight • Cough • Hospital setting • Effort of ventilation • Shape of thorax 4
  5. 5. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Respiratory Rate • Bradypnea: rate less than 8 per minute • Tachypnea: rate greater than 25 per minute 5
  6. 6. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Pattern of Breathing • Kussmals • Sleep apnea • Cheyne strokes • Pursed lip breathing • Orthopnoea: Short of breath in supine position, gets some relief by sitting or standing up 6
  7. 7. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Sleep apnea syndrome 7
  8. 8. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. 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. 8
  9. 9. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Central Cyanosis 9
  10. 10. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Cor pulmonale 10
  11. 11. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Clubbing 11
  12. 12. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Clubbing • In clubbing, there is widening of the AP and lateral diameter of terminal portion of fingers and toes giving the appearance of clubbing. • The angle between the nail and skin is greater than 180. • The periungual skin is stretched and shiny. • There is fluctuation of the nail bed. • One can feel the posterior edge of the nail. 12
  13. 13. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. 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 13
  14. 14. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Gibbus 14
  15. 15. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Weight • Emaciation cachectic – Malignancy – Tuberculosis 15
  16. 16. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. 320 lbs Obese: Sleep apnea syndrome Weight 16
  17. 17. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Cough • Productive • Dry • Whooping • Bovine 17
  18. 18. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. 18 1.the upper for bubble-like, frothy, foamy (partly from saliva) 2.middle-level for thin sero-mucus liquid 3.the underlying base = pus, necrotic tissue , cell debris Bronchiectasis three layers phlegm
  19. 19. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. 2 liters of O2 Nasal Cannula 19
  20. 20. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Hospital Setting • Isolation room • Oxygen set up 20
  21. 21. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Effort of Ventilation • Patient appears uncomfortable. Breathing seems voluntary. • Accessory muscles are in use, expiratory muscles are active and expiration is not passive any more. • The degree of negative pleural pressure is high. • The respiratory rate is increased. 21
  22. 22. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Resting Size and Shape of Thorax • Barrel chest • Kyphosis • Scoliosis • Pectus excavatum • Gibbus 22
  23. 23. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Barrel Chest AP Diameter = Transverse Diameter 23
  24. 24. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Tracheal Position: Mediastinum • Any deviation of the mediastinum is abnormal • Lateral shift: The mediastinum can be either pulled or pushed away from the lesion – Pull: Loss of lung volume (Atelectasis, fibrosis, agenesis, surgical resection, pleural fibrosis) – Push: Space occupying lesions (pleural effusion, pneumothorax, large mass lesions) – Mediastinal masses and thyroid tumors 24
  25. 25. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Tracheal shift to right 25
  26. 26. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. 26
  27. 27. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Chest Expansion • Asymmetrical chest expansion is abnormal – The abnormal side expands less and lags behind the normal side – Any form of unilateral lung or pleural disease can cause asymmetry of chest expansion • Global expansion decrease 27
  28. 28. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Percussion: Decreased or Increased Resonance is Abnormal • Dullness – Decreased resonance is noted with pleural effusion and all other lung diseases – The dullness is flat and the finger is painful to percussion with pleural effusion • Hyper resonance: Increased resonance can be noted either due to lung distention as seen in asthma, emphysema, bullous disease or due to Pneumothorax • Traube's space 28
  29. 29. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Breath sounds: Diminished or Absent • Intensity of breath sounds, in general, is a good index of ventilation of the underlying lung. • Breath sounds are markedly decreased in emphysema. • Symmetry: If there is asymmetry in intensity, the side where there is decreased intensity is abnormal. • Any form of pleural or pulmonary disease can give rise to decreased intensity. • Harsh or increased: If the intensity increases there is more ventilation and vice versa. 29
  30. 30. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Bronchial • Bronchial breathing anywhere other than over the trachea, right clavicle or right inter-scapular space is abnormal. • In consolidation, the bronchial breathing is low pitched and sticky and is termed tubular type of bronchial breathing. • In cavitary disease, it is high pitched and hollow and is called cavernous breathing. You can simulate this sound by blowing over an empty coke bottle. 30
  31. 31. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Bronchial breathing Expiration as long as inspiration Pause between inspiration and expiration Quality 31
  32. 32. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Rhonchi • Rhonchi are long continuous adventitious sounds, generated by obstruction to airways. • When detected, note whether it is generalized or localized, during inspiration or expiration, and the pitch. • Diffused rhonchi would suggest a disease with generalized airway obstruction like asthma or COPD. 32
  33. 33. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Rhonchi Asthmatic Continuous 33
  34. 34. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Rhonchi • Localized rhonchi suggests obstruction of any etiology e.g., tumor, foreign body or mucous. • Mucous secretions will disappear with coughing, so would the rhonchus. • Expiratory rhonchi implies obstruction to intrathoracic airways. • Asthmatics can also have inspiratory rhonchi while it is uncommon in COPD. 34
  35. 35. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Pleural Rub • Normal parietal and visceral pleura glide smoothly during respiration. • If the pleura is roughened due to any reason, a scratching, grating sound, related to respiration is heard. • You can hear the sound by compressing harder with the stethoscope and making the patient take deep breaths. • It is localized and can be palpable. 35
  36. 36. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Pleural rub Scratching, Grating Related to respiration 36
  37. 37. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Stridor • Loud audible inspiratory rhonchi is called a stridor. • Inspiratory rhonchi in general, implies large airway obstruction. 37
  38. 38. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Stridor Asthma 38
  39. 39. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Crackles • Interrupted adventitious sounds are called crackles. • Make a notation about timing, intensity, effect with respiration, position, coughing and character. • Timing and Intensity Crackles heard only at the end of inspiration are called fine crackles. – When the surfactant is depleted, the alveoli collapse. Air enters the alveoli at the end of inspiration. – This sound is generated as the alveoli pop open from it's collapsed state. 39
  40. 40. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Crackles • When the crackles are heard at the end of inspiration and the beginning of expiration the fluid or secretions are probably in respiratory bronchioles: medium crackles. • If the crackles are heard throughout it implies the secretions are in bronchi: coarse crackles. 40
  41. 41. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Voice Transmission (tactile fremitus, vocal resonance) • Asymmetrical voice transmission points to disease on one side. • Increased: – Any situation where bronchial breathing is heard the sounds become loud, sharp and distinct: Bronchophony. – In extreme situations, the whispered words come clearly and distinctly: Whispering pectoriloquy. 41
  42. 42. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Voice Transmission (tactile fremitus, vocal resonance) • Decreased: A quantitative decrease in voice transmission could be due to any other form of lung or pleural disease. • Qualitative Alteration: – A qualitative alteration of voice transmission is noted over consolidation and along the upper margin of pleural effusion: Egophony – The sound is like a nasal twang or goat bleating. 42
  43. 43. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Voice Transmission Bronchophony Whispering Pectoroliquy Normal Whisper Egophony 43
  44. 44. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Pathological Correlation • Localized Disease – Consolidation – Cavitation – Mass – Atelectasis • Pleural Disease – Pleural effusion – Pneumothorax • Diffuse Lung Disease – Emphysema – Diffuse airway disease – Diffuse alveolar disease – Diffuse interstitial disease • Mediastinal Disease • Respiratory Centers 44
  45. 45. Introduction to Clinical Medicine Marc Imhotep Cray, M.D. Further Study 45 IVMS-ICM Cloud Folder Bate’s Guide to the Physical Examination and History Taking, Lynn Bickley (with Video) DeGowin’s Diagnostic Examination, Richard DeGowin Textbook of Physical Diagnosis: History and Examination, M Schwartz (with Video) A Practical Guide to Clinical Medicine, Charlie Goldberg and Jan Thompson (Online Book) Practical Guide Links Page (Links to useful exam / clinical sites.)

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