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Inspection

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. Chest configuration Pigeon chest (pectus carinatum) Barrel chest Funnel chest (pectus excavatum) Harrison’s sulcus

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Inspection

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  1. PSD Thorax and Lungs Respiratory Physical ExamJoel Niznick MD FRCPCadapted fromUCSD: A Practical Guide to Clinical Medicinehttp://medicine.ucsd.edu/clinicalmed/lung.htm

  2. Chest configuration Pigeon chest (pectus carinatum) Barrel chest Funnel chest (pectus excavatum) Harrison’s sulcus Kyphosis Scoliosis Inspection • Cyanosis • Clubbing • Respiratory rate • Respiratory pattern • Normal • Restricted • Obstructed • Cheynes-Stokes • Painful

  3. Cyanosis

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

  5. Emphysema

  6. Pectus excavatum

  7. Barrel chest

  8. Kyphosis

  9. Scoliosis

  10. Lobar surface markersanterior chest

  11. Lobar surface markersposterior chest

  12. Lobar surface markersRight lateral view

  13. Lobar surface markersLeft lateral view

  14. Inspection • Rate rhythm depth effort • 14-20/min • Supraclavicular retraction and SC mastoid retraction • Posterior shape, symmetry, deformities

  15. Palpate tactile fremitus “99,99,99” Increased, decreased, absent Resonant, dull Palpation • Lymph Nodes • Tracheal location, shift • Cutaneous lesions • Expansion • Upper lobes • Middle lobes • Posterior lobes

  16. Contralateral Pleural effusion Hemothorax Tension pneumothorax Tracheal Deviation • Ipsilateral • Atelectasis • Fibrosis • Lung collapse • Pneumothorax

  17. 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

  18. Ohio State UniversityInteractive Guide to Physical Exam Click on image and scroll down page http://familymedicine.osu.edu/products/physicalexam/exam/

  19. Duration Pitch Intensity Auscultation • Breath sounds • Bronchial • over sternum • Bronchovesicular • 1-2 interspace anteriorly • interscapular • Vesicular • Most of lung fields

  20. Ohio State UniversityInteractive Guide to Physical Exam Click on image and scroll down page http://familymedicine.osu.edu/products/physicalexam/exam/

  21. Adventitial sounds • Wheezes - continuous • Rhonchi • Crackles- intermittent • Fine • Course • Rales

  22. 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

  23. Conditions • Consolidation • Collapse • Pleural effusion • Pneumothorax

  24. Describe the Physical Signs ofLLL Pneumonia • Inspection • Palpation • Trachea • Expansion • Fremitus • Percussion • Auscultation • Broncophony • Egophony

  25. Describe the Physical Signs ofLLL Collapse • Inspection • Palpation • Trachea • Expansion • Fremitus • Percussion • Auscultation

  26. Describe the Physical Signs ofRight Pleural Effusion • Inspection • Palpation • Trachea • Expansion • Fremitus • Percussion • Auscultation • Whispering pectorliloquay

  27. Describe the Physical Signs ofRight Pneumothorax • Inspection • Palpation • Trachea • Expansion • Fremitus • Percussion • Auscultation

  28. Describe the Physical Signs ofRight Tension Pneumothorax • Inspection • Palpation • Trachea • Expansion • Fremitus • Percussion • Auscultation

  29. 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)

  30. PulmonaryFibrosis Clinical Features • Dyspnea on exertion • Non-productive cough • Clubbing (50% in idiopathic fibrosis) • Fine bibasilar inspiratory crackles (Velcro)

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