Subject: Physical Diagnosis Topic: Chest and Lungs 1 Lecturer: Dr.

Feliciano Date of Lecture: August 31, 2011 Transcriptionist: PortalTriad Editor: Diordan De Lemos Pages: 5

CHEST AND LUNGS 1 CASE: 57 year old, male, 50 pack year smoking HPI: 1 year PTA = intermittent cough 2 months PTA = persistent cough, whitish phlegm, anorexia, weight loss Few days PTA = symptoms progressed, (+) dyspnea, pleuritic chest pain Next step: GET A COMPLETE HISTORY! For an accurate diagnosis, explore the history more What do we need to know/ask further? - Make differential diagnosis/etiologies - Aggravating factors, etc - If patient is a foreigner, consider other diseases - Further elucidate dyspnea and chest pain - Localize the chest pain: what relieves it? - Occupation of patient PACK YEARS - Implicate smoking as cause of particular diseases - Chronic illnesses due to smoking = 10 pack years - Consider cancer/cardiac diseases if patient has 10 pack years or more - # of sticks per day / 20 x years smoked - Less than 10 pack years = other illnesses REVIEW - Most prominent portion of chest is the suprasternal notch (palpable; reference where clavicle will meet sternum) - Another prominent area: Angle of Louis/sternal angle (2nd rib connects in this area) - Pneumothorax (air within pleura)/ Tension Pneumothorax = hypotension, decreased cardiac output, bradycardia

Point of palpation where you can insert large bore needle to relieve tension pneumothorax Palpate 2nd intercostal space then in midclavicular line -> poke needle to relieve pneumothorax Actual connection of sternum, 1st-7th rib Label the intercostal space below the rib 1st intercostal space = covered by clavicle Tip of sternum = xyphoid, connected to 7th rib 8th- 10th ribS = fused and connected to 7th rib 11th and 12th ribs = floating ribs Visceral pleura covers lung parenchyma Potential space in between visceral and parietal pleura; potential site for pleural effusion Posteriorly, point of reference is spine C7 = most prominent Tip of scapula = refers to 7th rib Use sternal angle as point of reference, count 2 ribs below, you have 4th rib 4th rib = marker where trachea will bifurcate into right and left main bronchus Above clavicle = supraclavicular fossa; significant in chronic lung disease

RIBS -

Landmarks of the Chest

SY 2011-2012

LUNGS - RIGHT LUNG = 3 lobes - Right upper lobe (3 segmentS) = apical, anterior, posterior - Right middle lobeS (2 segments) = medial, lateral - Right lower lobe (5 segments) = superior basal, lateral basal, posterior basal, etc (segments are nice to know only) _____________________________ - LEFT LUNG = 2 lobes - Upper (2 segments) = fusion of apical and posterior segment = APICOPOSTERIOR - Lingular division = superior and inferior portion - Lower (4 segments) = superior, anterior, lateral, postbasal segment - It is important to examine the lateral side of chest; some diseases manifest here

If patient is moribund/weak, examine patient in the supine position/lateral position For female patients, drape them properly Do not auscultate the chest with patients clothing on

INSPECTION - Rate and pattern of breathing - Normal rate of breathing = 16-20 cpm - Resting tidal volume = 500 (if youre 50 kilos); 10-15ml/kilo - Pattern: regular, symmetrical movement of chest - Abnormality: increase/decrease in respiratory rate - Hyperpnea = fast, deep breathing - Polypnea = Kussmauls breathing (metabolic acidosis due to renal disease) - Cheyne-Stokes: regularly irregular pattern = period of apnea, hypopnea, hyperpnea, hypopnea, hyperpnea, etc. - Cheyne-Stokes = seen in pediatric patients, brain damage, stroke patients, patients with tumors - Cheyne-Stokes occurs in congestive heart failure and uremia = problem in feedback mechanism; brain has difficulty perceiving increase in PCO2 or decrease in PO2 - Apnea = 10 seconds (> 10 = significant apnea) - Biots Respiration: regularly irregular, not periodic, sometimes slow, sometimes rapid, sometimes superficial, no pattern at all; with pauses following irregular interval; preceded or followed by a sigh more or less prolonged - Biots Respiration: cranial problems, meningitis - The more irregular it gets, it is ataxic; seen in dying patients

Properly position your patient before physical examination Position yourself (as examiner) well Ideally, patient should be seated or standing Examiner should stand beside or at the back of patient = for examiners own protection from patients possible infectious disease If you should stay in front of the patient, stand obliquely/slightly away from patient Expose area you want to examine properly Ask patients preference/permission to undress For pediatric patient, supine position is acceptable

*NOTE: chronic obstructive pulmonary diseases are Emphysema and Bronchitis (others include Asthma) *NOTE: AP Transverse diameter Ratio: 1:2 or 1:3 (adults) 1:1 (infant)

DEFECTS and DEFORMITIES

1.) Pectus Excavatum a.k.a. Funnel Chest -abnormal depression of sternal area at the lower portion of the sternum developed at a younger age (during bone growth)

epiphyses closure:

male-21 y/o; female-18 y/o

*Most common pathologic problem: a. Rickets disease (Vit. D deficiency) -common in patient with malnutrition or dietary restrictions. Other chest findings: rachitic rosary or beading of the ribs (bulging lesions in the costosternal junction- it will appear only in the 1st 2 years of the illness. 4 Manifestations common in patients with COPD (with predominance of emphysema): a. Pursed lip breathing- is the patient aware? It is a learned response to a problem within the respiration. It would relieve patients with dyspnea. It would allow increase in positive pressure while exhaling; therefore, it would open up the alveoli during the phase of expiration allowing the air to exit. b. Tripod position-another way for the patient to adapt to the difficulty of breathing b. Marfans disease- arachnodactyly 2.) Pectus Carinatum a.k.a. Chicken Breast, Pigeons Breast -abnormal bulging of sternum seen in patients with congenital heart disease may also be seen as post effect in patients with Rickets, Marfans and Pagets disease and any other bone abnormality. It can be also seen in patients with kyphosis (exaggeration of thoracic curvature) 3. Kyphosis - exaggeration of thoracic curvature 4. Scoliosis - ask patient to bend over to asses symmetry (Adams forward bending test) -scoliosis implies less expansion of lungs -if COPD, will cause restrictive lung disease, cardiac structure may as well be affected because of compression. 5. Masses - (nipple area) midclavicular and anterior axillary line 4th/6th rib. 5.a. Dermatochondrosarcoma 5.b. Chondrosarcoma-indicate if there are lesions 6. Empyema necessitans - if there is pus draining out of patients lesion on chest (complication of TB)

patient whos sitting in a tripod position c. prominence supraclavicular fossa d. intercostal retractions

- draining sinus of pus caused by tuberculosis that might reflect in your skin chest wall. 7. Flail Chest -higher chest on left, lower chest on right, usually due to rib fracture -inward movement of chest during inhalation, in exhalation there is protrusion of chest due to the pressure caused by fractured rib (normal would be the other way around) -would only occur in patient with multiple fractured rib/ both sides rib fracture, not in patient with only one rib fracture

-palpate chest anteriorly and posteriorly (check for mass or tenderness) -press intercostal with pain felt indicates: pleural, lung or parenchymal problem -check symmetry (10th rib at the back) -check for tactile fremitus by instructing the patient to say: tres, tres ninety-nine (99) one, two, three one, one, one -> Place baller surface/ulnar surface of arm and compare both sides (right from left) -> Feel the vibration, the sound would create. -> ABNORMALITIES -increased tactile fremitus: caused by consolidation (caused by pneumonia) -decreased tactile fremitus: Unilaterally (+) pleural effusion (+)obstruction of bronchus (via mass) (+)atelectasis (+)pneumothorax

EXTRA-PULMONARY FINDINGS
1. Superior Vena Cava Syndrome -puffy face -prominence of superficial veins and arteries -can be caused by diseases with mass, tumors; that would compress Superior Vena Cava 2. Cyanosis -sign of decreased oxygen/hypoxia -look at periphery and centrally (mouth) -only at periphery: Reynauds phenomenon -circumoral cyanosis (true cyanosis that you would probably have hypoxia) 3. Clubbing of Fingers -sign of chronic illness

PHYSICAL EXAMINATION
A. INSPECTION Respiratory rate Rhythm Abnormalities Deformities/ defects Lesions/ Hyperpigmentation Extrapulmonary findings

Bilaterally - if patient is obese (excess fat tissue) -air trapping (COPD, asthma, obstructive lung disease) C. PERCUSSION -perform at intercostal spaces -use index finger PLEXOR-dominant hand PLEXIMETER-non-dominant hand -place index finger at intercostal space (plexor should be flexed at wrist) tap 3 times

B. PALPATION -first to palpate is the CERVICAL LYMPH NODES -certain points: start with Pre-auricular, then Postauricular, Submandibular, Submental, Cervical (anterior/posterior), Supraclavicular (*NOTE: Can be done from bottom, up) -palpate trachea (check if at midline and if its deviated, there would be a problem) (+) Mass- would push trachea contralaterally (+) Atlectasis- would push trachea ipsilaterally

-Should be reported as : resonant on all lung fields except the area of cardiac dullness and the liver -----------------------------------------------------------END OF TRANSCRIPTION-Note: naka- underline na po and naka-bold yung important things that you should know.. HAPPY ARAL BTW, Some of the pictures are in the last part of the tranx. CHAO!

CONDITION Asthma

INSPECTION Dyspnea; use of accessory muscles; poss. cyanosis; hyperinflation Increased AP diameter; use of accessory muscles; thin Poss. cyanosis; short; stacky Often normal; lag on affected side Poss. cyanosis and splinting on affected side Often normal; lag on affected side

PALPATION Often normal, decreased fremitus

PERCUSSION Often normal; hyperresonant; low diaphragm

Emphysema

Decreased fremitus

Chronic Bronchitis Pneumothorax

Often normal Absent fremitus; trachea shifted to contralateral side Increased fremitus

Increased resonance; decreased excursion of diaphragm Often normal Often normal

AUSCULTATION Prolonged expirations; wheezes; decreased lung sounds Decreased lung sounds and vocal fremitus

Early crackles; rhonchi Absent breath sounds Late crackles; bronchial breath sounds Absent breath sounds

Pneumonia

Dull

Pleural Effusion

Atelectasis

Often normal; lag on affected side

ARDS

Use of accessory muscles, cyanosis

Decreased fremitus; trachea shifted to contralateral Decreased fremitus; trachea shifted to ipsilateral Usually normal

Dull

Dull

Absent breath sounds

Often normal

Pulmonary Embolism Pulmonary Edema

Often normal Often normal

Usually normal Often normal

Usually normal Often normal

Normal initially, crackles and decreased lung sounds Usually normal Early crackles or wheezes

Diaphragmatic excursion is the movement of the thoracic diaphragm during breathing.