© Continuing Medical Implementation ® …...bridging the care gap PSD Thorax and Lungs Respiratory Physical Exam Joel Niznick MD FRCPC adapted from UCSD:

© 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


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


CyanosisCyanosis



Differential Diagnosis of Clubbing

Differential Diagnosis of Clubbing

• Cyanotic congenital heart disease• Lung disease

– Cystic fibrosis– Interstitial fibrosis– Malignancy– Sarcoidosis– Bronchiectasis

• Hyperthyroidism


EmphysemaEmphysema


Pectus excavatumPectus excavatum


Barrel chestBarrel chest


KyphosisKyphosis


ScoliosisScoliosis


Lobar surface markersanterior chest

Lobar surface markersanterior chest


Lobar surface markersposterior chest

Lobar surface markersposterior chest


Lobar surface markersRight lateral view

Lobar surface markersRight lateral view


Lobar surface markersLeft lateral view

Lobar surface markersLeft lateral view


InspectionInspection

• Rate rhythm depth effort

• 14-20/min

• Supraclavicular retraction and SC mastoid retraction

• Posterior shape, symmetry, deformities


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


Tracheal DeviationTracheal Deviation

• Ipsilateral– Atelectasis– Fibrosis– Lung collapse– Pneumothorax

• Contralateral– Pleural effusion

– Hemothorax

– Tension pneumothorax


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


Ohio State UniversityInteractive Guide to Physical Exam


http://familymedicine.osu.edu/products/physicalexam/exam/

Click on image and scroll down page


AuscultationAuscultation

• Breath sounds– Bronchial

• over sternum

– Bronchovesicular• 1-2 interspace anteriorly

• interscapular

– Vesicular• Most of lung fields

• Duration• Pitch • Intensity




http://familymedicine.osu.edu/products/physicalexam/exam/

Click on image and scroll down page


Adventitial soundsAdventitial sounds

• Wheezes - continuous– Rhonchi

• Crackles- intermittent– Fine– Course– Rales


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


ConditionsConditions

• Consolidation

• Collapse

• Pleural effusion

• Pneumothorax


Describe the Physical Signs ofLLL Pneumonia

Describe the Physical Signs ofLLL Pneumonia

• Inspection

• Palpation– Trachea– Expansion– Fremitus

• Percussion

• Auscultation– Broncophony– Egophony


Describe the Physical Signs ofLLL Collapse

Describe the Physical Signs ofLLL Collapse

• Inspection


• Percussion

• Auscultation


Describe the Physical Signs ofRight Pleural Effusion

Describe the Physical Signs ofRight Pleural Effusion

• Inspection


• Percussion

• Auscultation• Whispering pectorliloquay


Describe the Physical Signs ofRight Pneumothorax

Describe the Physical Signs ofRight Pneumothorax

• Inspection


• Percussion

• Auscultation


Describe the Physical Signs ofRight Tension Pneumothorax

Describe the Physical Signs ofRight Tension Pneumothorax

• Inspection


• Percussion

• Auscultation


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


Decreased Normal or decreased

None

Asthma Decreased on both sides


Prolonged expiration

Normal Rhonchi


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)


Pulmonary FibrosisPulmonary Fibrosis

Clinical Features

• Dyspnea on exertion

• Non-productive cough

• Clubbing (50% in idiopathic fibrosis)

• Fine bibasilar inspiratory crackles (Velcro)

© Continuing Medical Implementation ® …...bridging the care gap PSD Thorax and Lungs Respiratory Physical Exam Joel Niznick MD FRCPC adapted from UCSD:

Documents

care gap kyphosis slide

care gap scoliosis slide

care gap emphysema slide

care gap barrel chest

care gap cyanosis

dull slide

care gap psd thorax

care gap inspection