1. © 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.htm http://medicine.ucsd.edu/clinicalmed/lung.htm 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.htm http://medicine.ucsd.edu/clinicalmed/lung.htm

2. © Continuing Medical Implementation ® …...bridging the care gap Inspection 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

3. © Continuing Medical Implementation ® …...bridging the care gap Cyanosis

4. © Continuing Medical Implementation ® …...bridging the care gap

5. Differential Diagnosis of Clubbing Cyanotic congenital heart disease Lung disease –Cystic fibrosis –Interstitial fibrosis –Malignancy –Sarcoidosis –Bronchiectasis Hyperthyroidism

6. © Continuing Medical Implementation ® …...bridging the care gap Emphysema

7. © Continuing Medical Implementation ® …...bridging the care gap Pectus excavatum

8. © Continuing Medical Implementation ® …...bridging the care gap Barrel chest

9. © Continuing Medical Implementation ® …...bridging the care gap Kyphosis

10. © Continuing Medical Implementation ® …...bridging the care gap Scoliosis

11. © Continuing Medical Implementation ® …...bridging the care gap Lobar surface markers anterior chest

12. © Continuing Medical Implementation ® …...bridging the care gap Lobar surface markers posterior chest

13. © Continuing Medical Implementation ® …...bridging the care gap Lobar surface markers Right lateral view

14. © Continuing Medical Implementation ® …...bridging the care gap Lobar surface markers Left lateral view

15. © Continuing Medical Implementation ® …...bridging the care gap Inspection Rate rhythm depth effort 14-20/min Supraclavicular retraction and SC mastoid retraction Posterior shape, symmetry, deformities

16. © Continuing Medical Implementation ® …...bridging the care gap Palpation 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

17. © Continuing Medical Implementation ® …...bridging the care gap Tracheal Deviation Ipsilateral –Atelectasis –Fibrosis –Lung collapse –Pneumothorax Contralateral –Pleural effusion –Hemothorax –Tension pneumothorax

18. © Continuing Medical Implementation ® …...bridging the care gap Percussion 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

19. © Continuing Medical Implementation ® …...bridging the care gap Ohio State University Interactive Guide to Physical Exam http://familymedicine.osu.edu/products/physicalexam/exam/ Click on image and scroll down page

20. © Continuing Medical Implementation ® …...bridging the care gap Auscultation Breath sounds –Bronchial over sternum –Bronchovesicular 1-2 interspace anteriorly interscapular –Vesicular Most of lung fields Duration Pitch Intensity

21. © Continuing Medical Implementation ® …...bridging the care gap Ohio State University Interactive Guide to Physical Exam http://familymedicine.osu.edu/products/physicalexam/exam/ Click on image and scroll down page

22. © Continuing Medical Implementation ® …...bridging the care gap Adventitial sounds Wheezes - continuous –Rhonchi Crackles- intermittent –Fine –Course –Rales

23. © Continuing Medical Implementation ® …...bridging the care gap Changes 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

24. © Continuing Medical Implementation ® …...bridging the care gap Review of Lung Sounds http://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htm http://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htm Review of Lung Sounds http://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htm http://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htm Click on image

25. © Continuing Medical Implementation ® …...bridging the care gap Conditions Consolidation Collapse Pleural effusion Pneumothorax

26. © Continuing Medical Implementation ® …...bridging the care gap Describe the Physical Signs of LLL Pneumonia Inspection Palpation –Trachea –Expansion –Fremitus Percussion Auscultation –Broncophony –Egophony

27. © Continuing Medical Implementation ® …...bridging the care gap Describe the Physical Signs of LLL Collapse Inspection Palpation –Trachea –Expansion –Fremitus Percussion Auscultation

28. © Continuing Medical Implementation ® …...bridging the care gap Describe the Physical Signs of Right Pleural Effusion Inspection Palpation –Trachea –Expansion –Fremitus Percussion Auscultation Whispering pectorliloquay

29. © Continuing Medical Implementation ® …...bridging the care gap Describe the Physical Signs of Right Pneumothorax Inspection Palpation –Trachea –Expansion –Fremitus Percussion Auscultation

30. © Continuing Medical Implementation ® …...bridging the care gap Describe the Physical Signs of Right Tension Pneumothorax Inspection Palpation –Trachea –Expansion –Fremitus Percussion Auscultation

31. © Continuing Medical Implementation ® …...bridging the care gap Signs in Respiratory Disease AbnormalityChest wall movement Percussion note Breath soundsVocal Resonance Added sounds Consolida- tion Decreased on affected side DullBronchialIncreasedCrepitations CollapseDecreased on affected side DullDecreased or absent None EffusionDecreased on affected side Stoney dullDecreased or absent May be pleural rub Pneumo- thorax Decreased on affected side Normal or hyper-resonant Decreased or absent None EmphysemaDecreased on both sides Normal or hyper-resonant DecreasedNormal or decreased None AsthmaDecreased on both sides Normal or hyper-resonant Prolonged expiration NormalRhonchi

32. © Continuing Medical Implementation ® …...bridging the care gap COPD 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)

33. © Continuing Medical Implementation ® …...bridging the care gap Pulmonary Fibrosis Clinical Features Dyspnea on exertion Non-productive cough Clubbing (50% in idiopathic fibrosis) Fine bibasilar inspiratory crackles (Velcro)