1 / 27

physical diagnosis - the pulmonary exam

salena
Download Presentation

physical diagnosis - the pulmonary exam

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. PHYSICAL DIAGNOSIS - THE PULMONARY EXAM R MICHAEL RODRIGUEZ M.D. ASSOCIATE PROFESSOR OF MEDICINE VANDERBILT UNIVERSITY SCHOOL OF MEDICINE

    5. THE HISTORY FAMILY HISTORY EMPHYSEMA AT AN EARLY AGE - CONSIDER ALPHA – 1 ANTITRYPSIN RECURRENT RESPIRATORY INFECTIONS AND STERILITY IN A YOUNG ADULT MALE – CONSIDER CYSTIC FIBROSIS, IMMOTILE CILIA OR YOUNG’S SYNDROME PULMONARY NODULE AND HYPOXEMIA – CONSIDER OSLER WEBER RENDU

    6. THE HISTORY OCCUPATIONAL - CHRONOLOGIC ORDER EXPOSURE : BRAKE SHOES, PIPE FITTERS (ASBESTOS) SANDBLASTING, QUARRY (SILICOSIS) FARMING – (FARMERS LUNG) MILITARY – (BERYLLIOSIS) TRAVEL- FAR EAST (PARAGONIMIASES) SOUTH AMERICA (BRUCELLOSIS) SOUTHWEST USA (COCCIDIOMYCOSIS) DRUGS – INTERSTITIAL LUNG DISEASE (NITROFURANTOIN) HABITS – TOBACCO, NOSE DROPS, ILLICIT DRUGS

    8. MAIN SYMPTOMS OF PULMONARY DISEASE COUGH DYSPNEA HEMOPTYSIS CHEST PAIN – PLEURITIC WHEEZING CYANOSIS SPUTUM PRODUCTION SNORING

    10. DESCRIBE THE COUGH PRODUCTIVE – NONPRODUCTIVE ACUTE – CHRONIC TIME OF DAY PRECIPITANTS – RELIEF BLOODY – NON BLOODY BARKING – HACKY

    11. COUGH SYMPTOM MORNING NON-PRODUCTIVE RECUMBENT BARKING NOCTURNAL PRODUCTIVE BLOODY ETIOLOGY CHRONIC BRONCHITIS VIRAL, ILD,TUMOR SINUSITUS, CHF,REFLUX CROUP,LARYNGEAL ASTHMA, CHF INFECTIOUS TUMOR,CHF, GPS

    12. THE PNEA’S DYSPNEA – SOB : ACUTE – (PULMONARY EMBOLISM, PNTX, ASTHMA) CHRONIC – (COPD, CHF, ILD) TACHYPNEA – RR>20 BR/MIN BRADYPNEA - RR< 8 BR/MIN (DRUGS, AGONAL) PND - PAROXYSMAL NOCTURNAL DYSPNEA SUDDEN ONSET OF SOB DURING SLEEP (CHF) ORTHOPNEA – SOB LYING FLAT (CHF) PLATYPNEA – SOB SITTING UP AND BETTER LYING FLAT (R TO L SHUNT) TREPOPNEA – SHORTNESS OF BREATH IN ONE LATERAL DECUBITUS POSITION WHICH IS IMPROVED BY TURNING ON THE OPPOSITE SIDE

    13. DYSPNEA MY CHEST FEELS TIGHT I CANNOT TAKE A DEEP BREATH I FEEL LIKE I HAVE A PILLOW OVER MY MOUTH I AM SMOTHERING

    14. THE NUMEROUS ETIOLOGIES OF CHEST PAIN PLEURITIC – PARIETAL PLEURA – SHARP STABBING – INSPIRATION ESOPHAGEAL – REFLUX CARDIAC – MYOCARDIAL INFARCTION GALL BLADDER – CHOLECYSTITIS CHEST WALL – COSTOCHONDRITIS GREAT VESSELS – DISSECTION PULMONARY - PNEUMOTHORAX

    15. SPUTUM - WHAT ARE ITS CHARACTERISTICS ? YELLOW – GREEN (PNEUMONIA, BRONCHIECSTAIS) RUSTY (PNEUMOCCOAL PNEUMONIA) ANCHOVY PASTE (AMEBIASIS) PINK – BLOOD TINGED (EPISTAXIS, BRONCHITIS) FROTHY (CHF) BLOODY (MALIGNANCY, BRONCHIECSTASIS, PULMONARY RENAL SYNDROME) SMELL – FOUL? (ANAEROBIC LUNG ABCESS) SANDLIKE (BRONCHOLITHIASIS) BLACK – COAL DUST INHALATION

    16. HEMOPTYSIS - REQUIRES CAREFUL QUESTIONING THIS SYMPTOM USUALLY DENOTES A SERIOUS ILLNESS. TB, TUMOR, BRONCHIECSTASIS, PE, CARDIAC DISEASE THE PATIENT SHOULD BE QUESTIONED CAREFULLY REGARDING HOW MUCH, FREQUENCY WEIGHT LOSS ETC.

    17. CLUES TO DIFFERENTIATING HEMOPTYSIS FROM HEMATEMESIS HEMOPTYSIS COUGH FROTHY COLOR- BRIGHT RED PUS DYSPNEA CARDIAC DISEASE HEMATEMESIS NAUSEA – VOMITING NOT FROTHY COFFEE GROUNDS FOOD NAUSEA GI DISEASE

    19. WHAT SHOULD WE KNOW ABOUT THE EXAMINATION OF THE CHEST? HISTORY SYMPTOMS LANDMARKS PERTINENT VOCABULARY SIGNS HOW TO PERFORM AN EXAM HOW TO FORMULATE A DIFFERENTIAL DIAGNOSIS HOW TO PRESENT THE INFORMATION

    22. WHAT IS A BARRELL CHEST? THORACIC INDEX – RATIO OF THE ANTERIORPOSTERIOR TO LATERAL DIAMETER NORMAL 0.70 – 0.75 IN ADULTS - >0.9 IS CONSIDERED ABNORMAL NORMALS - ILLUSION COPD

    24. PALPATION FEELING WITH THE HAND – FINGERTIPS TEXTURES DIMENSIONS CONSISTENCY TEMPERATURE EVENTS

    25. PERCUSSION TWO TECHNIQUES DIRECT – BLOW LANDS DIRECTLY ON THE CHEST INDIRECT – PLESSIMETER - USUALLY THE MIDDLE FINGER THREE TYPES COMPARATIVE TOPOGRAPHIC AUSCULATORY

    26. METHODS OF PERCUSSION

    27. PERCUSSION SOUNDS TYMPANY – HEARD OVER THE ABDOMEN RESONANCE – HEARD OVER NORMAL LUNG DULLNESS – HEARD OVER LIVER OR THIGH

    28. AUSCULTATORY PERCUSSION METHOD THE STETHOSCOPE IS PLACED OVER THE POSTERIOR CHEST WALL, THE CLINICIAN THEN TAPS LIGHTLY OVER THE MANUBRIUM, EQUIVALENT SOUNDS SHOULD BE HEARD OVER CORRESPONDING AREAS OF THE LUNG. ASYMETRY SUGGESTS DISEASE.

    31. LONG FORGOTTEN PERCUSSION TERMS SKODAIC RESONANCE – HYPERRESONANT SOUND GENERATED BY PERCUSSION OF THE CHEST ABOVE A PLEURAL EFFUSION GROCCO’S TRIANGLE – RIGHT - ANGLED TRIANGLE OF DULLNESS FOUND OVER THE POSTERIOR REGION OF THE CHEST OPPOSITE A LARGE PLEURAL EFFUSION

    34. TACTILE FREMITUS A THRILL OR VIBRATION WHICH IS FELT ON THE CLINICIANS HAND WHILE RESTING IT ON THE PATIENTS CHEST WALL AT T HE SAME TIME THE PATIENT SPEAKS. 99 – 1-2-3 SYMETRY MAY BE SEEN IN NORMALS ASYMETRY – IS ABNORMAL

    36. TACTILE FREMITUS PNEUMONIA PNEUMOTHORAX PLEURAL EFFUSION COPD FAT

    37. VOCAL FREMITUS THE PATIENTS VOICE IS HEARD THROUGH A STETHOSCOPE PLACED ON THE PATIENTS CHEST – NORMALLY THE SOUNDS ARE INDISTINCT ABNORMALITIES – BRONCHOPHONY, PECTORILOQUY, EGOPHONY CONSOLIDATION

    38. VOCAL FREMITUS BRONCHOPHONY – SOUND OF THE BRONCHI – SOUND MUCH LOUDER THAN NORMAL - WORDS INDISTINCT PECTORILOQUY – VOICE OF THE CHEST – WHISPER – WORDS INDISTINCT EGOPHONY – VOICE OF THE GOAT – BLEATING - E – A CHANGES – COMPARE SIDE TO SIDE REMEMBER - ALL SUGGEST CONSOLIDATION OF THE LUNG

    39. THORACIC EXPANSION ASYMETRY IN EXPANSION OF THE THORAX CAN BE DETECTED DURING INSPECTION OF THE CHEST DURING PROMPTED INHALATION OBSERVE THE MOVEMENT OF THE THORAX PLEURAL EFFUSION, PNEUMOTHORAX

    41. CYANOSIS PERIPHERAL – HANDS, FEET – WARMING DECREASES CYANOSIS – DECREASED CARDIAC OUTPUT CENTRAL- LIPS, TONGUE,SUBLINGUAL - RIGHT TO LEFT SHUNTS PSEUDOCYANOSIS – BLUE PIGMENTS IN SKIN - AMIODARONE

    43. CLUBBING PAINLESS – FINGERNAILS CURVED AND WARM ENLARGEMENT OF THE CONNECTIVE TISSUES IN THE TERMINAL PHALANGES OF THE FINGERS >TOES

    47. DO NOT FORGET THE TRACHEA TRACHEAL DEVIATION AUSCULTATE - STRIDOR TRACHEAL TUG (OLIVERS SIGN) – DOWNWARD DISPLACEMENT OF THE CRICOID CARTILAGE WITH VENTRICULAR CONTRACTION – OBSERVED IN PATIENTS WITH AN AORTIC ARCH ANEURYSM TRACHEAL TUG (CAMPBELL’S SIGN) – DOWNWARD DISPACEMENT OF THE THYROID CARTILAGE DURING INSPIRATION – SEEN IN PATIENTS WITH COPD

    49. WHITE NOISE (NOISY BREATHING) THIS NOISE CAN BE HEARD AT THE BEDSIDE WITHOUT THE STETHOSCOPE LACKS A MUSICAL PITCH AIR TURBULENCE CAUSED BY NARROWED AIRWAYS CHRONIC BRONCHITIS

    52. BREATH SOUNDS VESICULAR – NORMAL BREATH SOUNDS - SITE OF PRODUCTION THE ALVEOLI TRACHEAL – TUBULAR – LIKE BLOWING AIR THROUGH A HOLLOW TUBE – PHYSIOLOGIC BRONCHIAL – TUBULAR - ALWAYS PATHOLOGIC WHEN THEY OCCUR OVER POSTERIOR OR LATERAL CHEST WALL BRONCHOVESICULAR – CHARACTERISTICS OF BOTH VESICULAR AND TUBULAR – DO THEY EXIST? ADVENTITOUS – EXTRA SOUNDS

    54. ADVENTITIOUS SOUNDS THESE ARE SOUNDS HEARD DURING AUSCULTATION OTHER THAN BREATH SOUNDS OR VOCAL RESONANCE NOMENCLATURE – HAS BEEN CONFUSING CRACKLES – DISCONTINUOUS SOUNDS WHEEZES AND RHONCHI – CONTINUOUS SOUNDS

    55. ADVENTITIOUS LUNG SOUNDS (BRUITS ETRANGERS – FOREIGN SOUNDS) WHEEZE – HIGH PITCHED RHONCHI – LOW PITCHED CRACKLE RALES - HAIR VELCRO (FINE – COARSE) PLEURAL RUBS – CREAKING LEATHER STRIDOR SQUEAK – HIGH PITCHED WHEEZE HEARD AT THE END OF INSPIRATION

    57. SIGNIFICANCE OF LATE AND EARLY CRACKLES EARLY – CENTRAL AIRWAYS (BRONCHITIS) LATE – PERIPHERAL AIRWAYS (FIBROSIS,EDEMA)

    58. WHEEZING ASTHMA BRONCHITIS VOCAL CORD DYSFUNCTION FOREIGN BODY ASPIRATION INFECTIONS – CROUP LARYNGITIS CONGESTIVE HEART FAILURE COPD FORCED EXPIRATION IN NORMAL SUBJECTS CYSTIC FIBROSIS

    62. PURSED – LIPS BREATHING COPD – DECREASES DYSPNEA DECREASES RR INCREASES TIDAL VOLUME DECREASES WORK OF BREATHING

    63. HOOVERS SIGN COPD IN COPD THE DIAPHRAGM MAY BE FLATTENED, DURING THE INSPIRATORY PHASE OF A BREATH THE RIBS ARE PULLED INWARD AND MEDIALLY RATHER THAN OUTWARD AND LATERALLY

    64. RESPIRATORY ALTERNANS NORMALLY BOTH CHEST AND ABDOMEN RISE DURING INSPIRATION PARADOXICAL RESPIRATION IMPLIES THAT DURING INSPIRATION THE CHEST RISES AND THE ABDOMEN COLLAPSES IMPENDING MUSCLE FATIGUE

    65. PUTTING IT ALL TOGETHER PNEUMONIA PNEUMOTHORAX PLEURAL EFFUSION ASTHMA

More Related