[os 213] lec 09 physical diagnosis of the respiratory system (b)-2

7/17/2019 [OS 213] LEC 09 Physical Diagnosis of the Respiratory System (B)-2

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OS 213: Circulation and RespirationLEC 09: PHYSICAL DIAGNOSIS O !H" R"SPIRA!ORY

SYS!"#

O$!LIN" "ntroduction

A. #e$ie% o& #es'irator( Anatom(B. #e$ie% o& #es'iration P)(sio*og(

+istor(,-aingPresenting /(m'toms

A. Coug)

B. D(s'neaC. +emo't(sisD. Abnorma* Laborator(

P)(sica* ExaminationA. "nitia* /ur$e(B. "ns'ectionC. Pa*'ationD. PercussionE. Auscu*tation

I% IN!ROD$C!ION

A% Re&ie' o( Respirator) Anato*)

Conductin+ S)ste*

•ade out o& tubes

•asa* ca$it( and ')ar(nx u''er air%a(s3 *ar(nx trac)ea main bronc)i dista* bronc)io*es *o%erair%a(s3

•Bu* o& res'irator( s(stem

•Disturbance %ou*d resu*t in a ')(sica* com'*aint

Gas ",c-an+e S)ste*

•Ensures (ou get enoug) 42 and get rid o& C42

•ain structures in t)e 'eri')er(

•"nterru'tion in t)is structures %it) t)e circu*ator( s(stecan resu*t in d(s'nea and c(anosis

• -ermina* bronc)io*es a*$eo*ar ducts a*$eo*i sacso -)e termina* bronc)io*es di$ide into 2,5 a*$eo*ar

ducts! eac) o& %)ic) consists o& 10,16 a*$eo*io -)e adu*t res'irator( s(stem contains 7800

a*$eo*io -)e sur&ace area o& t)e a*$eo*o,ca'i**ar( membrane

a$ai*ab*e &or 42,C42 exc)ange is a''roximate*( 0,5m2

!a.le 1% Cells (ound in t-e al&eolar le&el o( t-elun+s%Ale&eoli Cell!)pe IPneu*oc)tes

Lining ce** %)ic) accounts &or 95;o& t)e a*$eo*ar sur&ace area

Al&eoli Cell!)pe IIPneu*oc)tes

Produces sur&actant! a mixture o&')os')o*i'ids! %)ic) maintainsa*$eo*ar stabi*it(

#acrop-a+es Acts as ')agoc(tic de&ense againstin&ection

Lun+ Anato*)

Ri+-t Lun+ /3 lo.es0o <''er Lobe not accessib*e &rom 'osterior3o idd*e Lobeo Lo%er Lobe direct access &rom t)e bac3

Le(t Lun+ /2 lo.es0

o <''er Lobe = Lingu*ar segment Lingu*ar is obser$ed on t)e *e&t o& t)e )emit)orax

ot accessib*e &rom 'osterior exce't i& (ou domaneu$er %it) res'ect to t)e sca'u*a

o Lo%er Lobe

•>)en 'atients are su'ine! no access o& t)e 'osteriorsegments

•Patients need to ?)ug t)emse*$es@ to %ing t)e sca'u*ato access t)e *e&t and rig)t u''er *obes 'osterior*(

•De'endent area o& t)e 'atient %)en *(ing su'ine is t)erig)t *obe

•ood tends to *odge at t)e 'osterior rig)t u''er *obe!and t)is is a*so t)e common site &or as'iration

•Latera* $ie% reuires t)at t)e 'atient raise )is )ands

"n anterior $ie%! t)e axis 'oint o& t)e #L is near t)exi')oid

"t is im'ortant to do PE on bot) u''er and *o%er)emit)orax due to dierences in accessibi*it(

!a.le 2% Areas to t-at allo' access to t-e lo.es

o( t-e lun+s%Anterior #<L! #L! L<L most*( t)e *ingua*3! LLLip-oid #L! LLLPosterior

• ?>ing out to examine t)e u''er *obes!but (ou %i** main*( examine t)e *o%er*obes &rom t)is 'osition@

• #<L 'osterior segment! L<La'ico'osterior segment

Ri+-tLateral

A** *obes o& t)e rig)t *ung! but in *imitedamounts

Le(tLateral

L<L! LLL

i+ure 1% Anterior &ie' o( t-e lun+s and itslo.es%

i+ure 2% Posterior &ie' o( t-e lun+s and itslo.es%

i+ure 3% Ri+-t and le(t lateral &ie's o( t-e lun+sand its lo.es%

% Re&ie' o( Respirator) P-)siolo+)

#aria)4 5a*es4 Allie $PC# 2617 : "! >a*angFa'anta(G

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SYS!"#

Gas ",c-an+e

•Primar( &unction o& t)e res'irator( s(stem

•Exc)ange o& ox(gen 423 and carbon dioxide C423bet%een t)e a*$eo*i and 'u*monar( circu*ation

•An(t)ing t)at disru'ts t)is &unction *eads to 'u*monar(s(m'toms

reat-in+

•Large*( an automatic act contro**ed in t)e brainstemand mediated b( t)e musc*es o& res'irationo "n a s'ina* cord inHur( t)ere ma( be a 'rob*em in

breat)ing e$en t)oug) anatom( o& res'irator(s(stem is norma*

•Dome,s)a'ed dia')ragm is t)e 'rimar( musc*e o&res'iration

•"ns'iration is an acti$e 'rocess %)i*e ex'iration is a'assi$e 'rocess

o During ins'iration! as t)ese musc*es contract! t)et)orax ex'ands intrat)oracic 'ressure decreases dra%s air into t)e trac)eobronc)ia* tree into t)ea*$eo*i *ungs ex'and gas exc)ange taes'*ace in t)e a*$eo*i

o

o During ins'iration! air enters t)e u''er air%a(!tra$e*s t)roug) t)e *o%er air%a(s unti* it reac)est)e a*$eo*i

•A&ter ins'irator( eort sto's! t)e ex'irator( ')asebeginso -)e c)est %a** and t)e *ungs recoi*o -)e dia')ragm re*axes and rises 'assi$e*(! air

Io%s out%ard and t)e c)est and abdomen return

to t)eir resting 'ositions•An( disru'tion at t)e *e$e* o& C8,C C53 o& t)e s'ina*

cord *eads to disru'tion o& 'u*monar( &unctionremember: C85 ee's t)e dia')ragm a*i$eG3

II% HIS!ORY !A9ING

S)ste*atic in$estigation surrounding patients c-ie( co*plaint bacbone o& )o% (ou %i** assubseuent uestions3

•ain tas: to *and on a $a*id diagnosis

•Basica**( asing a series o& uestions in a *ogica* orderso as to 'a( more attention to t)e re*e$ant'ertinentKndingso #e*e$ance o& gi$en data is determined based on

ex'erienceo eed to 'robe dee'er %it) &o**o%,u' uestions to

c*ari&( t)e $a*idit( o& in&ormation obtained

• C*assi&( unco$ered data to 'ertinent 'ositi$es andnegati$es! and re*ate a** retrie$ed data to c)ie& com'*aint

•A good )istor( and PE c*inc)es t)e diagnosis in 0,90;o& cases so added *abs and maneu$ers %i** on*( add10,20;3

•Past *edical -istor)! (a*il) -istor)!personal;social -istor)! occupational -istor)

•A*%a(s as >+A-! >+E! +4> in t)e )istor( o& 'resent i**ness

Ai*s o( Histor) !ain+• Designed to integrate t)e 'ertinent 'ositi$es and

negati$es

• Estab*is) c)rono*og( o& e$ents! and *in a** &actorst)at ma( be 'ertinent

• "so*ate 'reci'itating and re*ie$ing &actors most o& t)etime

• Estab*is) se$erit(

• -reatmentconsu*tation done! *ab tests! and 'ossib*eres'onse or ot)er Kndings

• -)e most im'ortant goa* is to )a$e a directedness int)e *ab tests t)at (ou %i** reuest i& needed3: dontassume t)e ?+ouse@ menta*it( %)erein ordering a**

t)e tests %i** come Krst be&ore ru*ing in or ru*ing outcertain diagnoses.

C-ie( Co*plaint

• Common C)ie& Com'*aints:o Coug) most common3o D(s'neao +emo't(siso C)est Paino #adiogra')ic Abnorma*it(

•"t is im'ortant t)at t)e maHor c)ie& com'*aint beiso*ated es'ecia**( t)at i*i'inos usua**( )a$e a *ot o& com'*aints

• -)e c)ie& com'*aint %i** direct t)e next ste's in t)e

)istor(

Past #edical Histor)

•/imi*ar s)*pto*s in t-e past t)at cou*d )a$e beenbecoming %orse or more 'ersistent3 and )o% t)e'atient res'onded:o ?Dati po ba meron na kayong paubo-ubo?@o Mou ma( o&ten times gi$e t)em cues because

'atients ma( usua**( &orget suc) instances ?Kumusta po ba kayo noong bagong taon? Noong

nagputukan sa inyo?@

•An( pre&ious operation e.g. bio's( or surger(3%ou*d gi$e us an in*ing o& t)e 'u*monar( reser$eca'acit( o& t)e 'atient

o Due to t)e &act t)at use o& gas anet)etics %i**concern t)e 'u*monar( s(stem and an( signiKcante$ent during t)e surger( %ou*d be $a*uab*e

•4t)er diseases and 'ossib*e treatment

•Consu*tation &or ot)er com'*aints

•Pre$ious )os'ita*iNation

a*il) Histor)

•+ereditar( &ami*ia* diseases e.g. ast-*a3o ?May na sabihan na ba na may hika katulad niyo?@o ote t)at a**ergies s)ared b( &ami*( members

cou*d be a contributing &actor to ast)ma

•/imi*ar s(m'toms in t)e &ami*( signiKcant ex'osure)istor(3o ?Sa pamilya niyo ba meron ring may ubo katulad

ng sa inyo?@

•4t)er diseases *ie in&ectious diseases s'ecia**( aboutc*ose contact3! conKrmed or sus'ected e.g. P-B3

Personal Histor)

• /moing )istor(o Document %)et)er acti$e or 'assi$eo +o% man( in t)e &ami*( are smoing

• ices i.e. Drug )istor(3

• Drining )istor(

•/exua* )istor( +" can )a$e dierent mani&estationso& common 'u*monar( diseases3

• !ra&el )istor(o Es'ecia**( i& 'atient came &rom an area endemic &or

a disease

Occupational Histor)

•<or -istor)

o Current and 'ast occu'ations e$en amongunem'*o(ed


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SYS!"#

o Constant annua* c)ec,u's t)at %ou*d be t)ereason %)( t)e 'atient is reHected &rom a Hob canbe a c*ue3

o Mou ma( as )is)er s'eciKc Hob descri'tion #eca**! t)e ?construction %orer@ assumed to be

ex'osed to certain agents but actua**( on*( doingc*erica* %or time ee'ing on*(3

•",posure to dust! &umes! and ot)er )aNards!'rotecti$e eui'ment used! *ie mass! g*o$es etc.

•/imi*ar s(m'toms in co,%orers

•/(m'toms %)en a%a( &rom Hobo ?Yung bang nararamdaman mo sa trabaho

bumubuti kapag nasa bahay ka?@

III% PR"S"N!ING SY#P!O#S

A% Cou+-

• Duration: 2 'ees as cut=o>

o Acute O2 %3 usua**( in&ectiousQ can be ast)ma

as %e** coug) can be seen in 80,0; o& ast)macases3

o C)ronic R2%3 P-B! C4PDo -4P -+#EE dierentia* diagnoses:

Post=nasal drip /*ost co**on cause0

Ast-*a /2nd *ost co**on0

P! /3rd *ost co**on cause

o Ast)ma 're$a*ence in t)e P)i*i''ines: 22;o "n t)e P)i*i''ines! c)ronic coug) %o an( ob$ious

cause s)ou*d ru*e out P-B

Precipitatin+;relie&in+ (actors;ti*in+o Precipitatin+ (actors ex'osure to a 'articu*ar

agent Anong nag'a'a*a*aS e.g. ast)ma usua**( 'atient is a%are o& t)e trigger3 in

t)e P)i*i''ines! )ouse dust mite c*eaning t)e )ouse3remains t)e T1 trigger o& ast)maQ c)ange o& %eat)ercan a*so trigger

o Relie&in+ (actors i*i'inos *o$e to se*&,medicateQ t)us! beta,adrenergics

e.g. sa*butamo*3 and *agundi are usua**( used "& re*ie$ed b( in)a*er and nebu*iNer 'inausuan3 U AM

%eig) to%ards ast)ma as one o& t)e 'otentia* causes

But in genera*! t)ese in&ormation on non,s'eciKcmedication %i** not gi$e 'ertinent data

o !i*in+ %)en t)e s(m'toms are &e*t Postnasal drip: s(m'toms %orsen during morning or

%)en t)e 'atient assumes a recumbent 'osition! due to'oo*ing o& secretions t)at cou*d trigger coug) but not(et 100; 'ro$en3

"t is no%n t)at %)en %e s*ee' e$en &or norma*'eo'*e3! t)e ca*iber o& our air%a(s decrease U one o&t)e reason %)( 'eo'*e %it) obstructi$e s*ee' a'neasnore

• An) acco*pan)in+ s)*pto*so He*opt)sis

An( 'at)o*og( t)at )as connection to t)e air%a( *esioncan *ead to )emo't(sis

Does not %arrant a diagnosis o& *o%er res'irator( tractdisease suc) as P-B

rom b*ood,tinged s'utum to dar b*ood coug)ed u'

o P-le+*"& t)e ')*egm is (e**o% or 'uru*ent! it ma( signi&( anin&ection! 'articu*ar*( bacteria* rat)er t)an $ira*

o e&er

"n P-B! &e$er is intermittentQ a*so %it) %astingcac)exia "& accom'anied b( ')*egm or &e$er im'*ies in&ection.

• An) pre&ious *edications and response

o ost medications non,s'eciKc and &ocus on*( ons(m'tomatic re*ie&

4-C drugs suc) as muco*(tics e.g.! carbocisteine3 arecommon*( used b( i*i'inos

-useran! #obitussin on,s'eciKc medication suc) as *agundi is a*so used

o /ome ma( be taing bronc)odi*ators suc) as a V2agonist /a*butamo* i& a 'atient res'onds to t)isdrug )es)e ma( not necessari*( ast)matic3

o "n)a*ants BL<EW#EE rescue drugs suc) as sa*butamo* #EDB#4>4#AWE , steroid

o "n&ormation on anti,-B drugs ma( not be $o*untari*(gi$en b( t)e 'atient so (ou mig)t )a$e to 'robe

/o as %)o ga$e it to t)em i& &rom )ea*t) center t)eni& anti,-B meds! t)e( are in a ?banig@ and not on*( onet('e3

C)ange in co*or in urine since taing ri&am'icin

o Dont &orget to as &or t)e 'atients res'onse to t)edrug

• La.s doneo Diagnosis o& t)e 're$ious doctor

ost remarab*e i& 'arenc)(ma* disease "n a *ot o& instances! 'atients remember doctors ad$ice

and 'ertinent Kndings

o C)est ,ra( C#3

As i& t)ere %as an(t)ing &ound in t)e C#

Cou+-in+ Sounds

•Etio*og( cannot be determined b( t)e sound o& t)ecoug)o A*t)oug)! in 'ediatric cases etio*og( ma( be

determined b( t)e sound

•/ound does not dictate se$erit(

•C)aracter and timing o& coug) are not )e*'&u* in'redicting its cause in adu*ts

•AC-""-M: Are (ou going to use a mucoacti$e agentSo on,s'eciKco >it) e)ec e)ec e)eco +ig) 'itc) e)eco >aa)eeeec: ma)a*a (ung uboo >it) %)eeNing: ma)uni na uboo "t %ou*d seem t)at *ast t%o are %orse! but

actua**( a** came &rom cancer 'atients

% D)spnea

• /ubHecti$e com'*aint so main*( determined b('atients t)res)o*d

• Duration

o i*i'inos tend to underestimate d(s'nea! %)ic) is%)( it is im'ortant &or 'atients to uanti&( t)eird(s'nea

o ost o& t)e time d(s'nea is secondar( to c)ronicdisease

o Acute d(s'nea ma( be more *i&e t)reatening t)anc)ronic t('e

o Mou mig)t )a$e to c)a**enge t)e 'atient becausei*i'inos tend to den( t)eir s(m'toms

?Talaga kahapon lang? Kamusta kayo last month?@

• Precipitatin+;relie&in+ (actors;ti*in+o Princi'a**( im'ortant in association %it) ot)er

s(m'toms! suc) as c)est 'aino -)e degree o& acti$it( t)at 'reci'itates ito Com'ensator( acti$ities s)ou*d be ased

rom -a&t to PW+! usua**( (ou %a*! but 'atient used a'edicab

<sing o& e*e$ators e$en i& c*imbing t)e stairs is more'ractica* *ie going u' to t)e L#- station3

agtago sa ban(o da)i* sa 'utuan during e% Mearo Di>erentiate pul*onar) and cardiac etiolo+)

D(s'nea %it) coug) is usua**( 'u*monar( inorigin

!a.le 3% Pul*onar) &s% Cardiac "tiolo+)%Pul*onar) Cardiac

#e*ie& u'onex'ectoration<sua**( associated %it)

#e*ie$ed %it) certainmeds nitrates3 and rest4t)er associated


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SYS!"#

s'utum s(m'toms

A%aens a&ter on*( a&e% )ours o& s*ee'

'oo*ing o& secretions3

A%aens a&ter se$era*)ours since 'ressure

c)anges Krst be&ore *osso& breat)34rt)o'nea! PD

Circadian $ariationsdramatic during ear*(mornings3

>orsens at t)e end o&t)e da(

• An) acco*pan)in+ s)*pto*s

o Cou+- ma( be a sign o& c)ronic bronc)itis orem')(sema3

ote t)at in C+ cardiac rat)er t)an'u*monar(3! some ma( com'*ain o& ex'oration o& &rot)( sa*i$a

o C-est Pain occurs bot) in cardiac and 'u*monar(in originQ i& 'u*monar( in origin! it is %orsened b(dee' breat)ing3

o "de*a in )eart &ai*ureQ i& cardiac in etio*og(!ca**ed cor 'u*monare3

• An) pre&ious *edications and response

o itrates gi$en in 're$ious "o "& 'u*monar( in origin! beta,2 agonists mae

'atients &ee* better because o& bronc)odi*ation Uobstructi$e *ung dieases C4PD! ast)ma!e')(sema! c)ronic bronc)itis3

o ote t)at 're$ious )os'ita*iNation due to d(s'neais common! so 'ertinent to inuire

• La.s doneo C#o /'irometr(o ECW to c)ec i& cardiac in etio*og(3

C% He*opt)sis

• B*ood,tinged s'utum

• /igna*s an( 'at)o*og( connected %it) t)e air%a( mig)ts*oug) o 'arenc)(ma causing b*ood re*ease! so canbe:

o /inusitis: "n)a*ed nasa* secretionso Bronc)itis: %)en (ou tr( to 'roduce ex'ectorate on

inIamed air%a(! &riction %i** occur

• A*ount tentati$e cut,o: 766 *l

o R600 m* massi$e )emo't(sis most critica* &actoris )emato*ogica**( unstab*e since nobod( rea**(

measures! so matter o& estimation3o O600 m* non,massi$e )emo't(siso ost o& t)e time! t)is amount is not signiKcant

ocus on t)e accom'an(ing s(m'toms Patients dont tend to exaggerate since t)e( no% t)at

doctors mig)t resu*t to in$asi$e tec)niues

• Duration maHorit( o& bacteria* in&ections )a$e s)ortduration O1 %3 o& )emo't(siso Acute a**erg(! bacteria* in&ectiono C)ronic *ung ma*ignanc(! -B

• Acco*pan)in+ s)*pto*s

o Coug) most common accom'an(ing s(m'tom3and i& 'ersistent! &e$er and e$ents 'rior to)emo't(sis

"& ?&rot)(@ U congestion "& ?'in(@ U secretions in congesti$e )eart &ai*ure3

o >eig)t *oss! *oss o& a''etite -B3

• Precipitatin+;relie&in+ (actors;ti*in+o <sua**( in)a*ed &oreign bod( *oca*iNed %)eeNe U

*oca*iNed obstruction3 t)at 'reci'itated ito Ate tuna sand%)ic) t)en started coug)ing t)en on

,ra( t)ere %as a Ks))oo &rom t)e tuna3

• Causes ma( be -B or an( ma*ignanc(

• La.s acid &ast baci**i AB3 smear! C#

D% A.nor*al La.orator)

• <sua**( ?as)*pto*atic@ according to 'atients3 butt)ere are ?incidenta*@ Kndings on tests

• <-) 'as la.;in&esti+ation done in t-e ?rst

place@o >as it because t)e 'atient soug)t &or consu*t

because )es)e is not &ee*ing %e**So >as it because t)e ')(sician )as a*read(

sus'ected an abnorma*it(So or t)e 'ur'ose o& 're,em'*o(ment or abroad

c*earanceS

• Duration o( s)*pto*s

• Pre&ious la.s or *edical ad&iceo Com'arison o& C# ,6 mo inter$a*3o >it)out c)ange in *esion %it)in t)e said inter$a*

can be a stab*e *esion t)at )as 'rogressed a*read(to Kbrosis and ca*ciKcation

I% PHYSICAL "A#INA!IONote t)at t)ese are &rom Bates in 're'aration &or4/CE so %e no% )o% to 'osition t)e 'atient3

• or men! arrange t)e go%n so t)at (ou can see t)ec)est &u**(

•or %omen! co$er t)e anterior c)est %)en (ouexamine t)e bac and &or t)e anterior examination!dra'e t)e go%n o$er eac) )a*& o& t)e c)est as (ouexamine t)e ot)er )a*&

•>it) t)e 'atient sittin+! examine t)e 'osterior t)oraxand *ungso -)e 'atientXs arms s)ou*d be &o*ded across t)e

c)est %it) )ands resting! i& 'ossib*e! on t)eo''osite s)ou*ders

-)is 'osition mo$es t)e sca'u*ae 'art*( out o& t)e %a(and increases (our access to t)e *ung Ke*ds

•>it) t)e 'atient supine! examine t)e anterior t)oraxand *ungso -)e su'ine 'osition maes it easier to examine

%omen because t)e breasts can be gent*(dis'*aced

o >)eeNes! i& 'resent! are more *ie*( to be )eard

•or 'atients %)o cannot sit up %it)out aid!o Wet )e*' so (ou can examine in t)e sitting 'ositiono "& t)is is im'ossib*e! ro** t)e 'atient to one sideo Percuss u''er *ung! and auscu*tate bot) *ungs in

eac) 'osition Because $enti*ation is re*ati$e*( greater in t)e

de'endent *ung! (our c)ances o& )earing abnorma*%)eeNes or crac*es are greater on t)e de'endent side

A% Initial Sur&e) O( Respiration And !-ora,

• Can be done %)i*e uestioninginter$ie%ing t)e'atient

• 4bser$e res'iration:o #ate orma* ##U1,20min. adu*t3o #)(t)mo De't) and eort o& breat)ingo ote %)et)er ex'iration *asts *onger t)an usua*

• An( signs o& res'irator( distresso Coug)o A*ar Iaringo

As o'en,ended uestions so 'atient %i** oerans%ers in sentences to assess i& 'atient s'eas insentences')rases or %ords

o Contraction o& t)e accessor( musc*es in t)e necsternoc*eidomastoid! sca*ene3! or su'rac*a$icu*arretraction

o Abnorma* retraction o& t)e inters'aces duringins'iration ost a''arent in t)e *o%er inters'aces


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SYS!"#

• Assess 'atients co*or &or c(anosis

• Listen to 'atients breat)ing e.g. *aboredS audib*e%)eeNeS3

• 4bser$e s)a'e o& t)e c)est i.e. AP diameter3

% Inspection• Examine sin o$er t)e c)est &or *esions t)at restrict

res'irator( excursion

• C)est %a** structura* de&ormities. e.g. barre* c)est!'igeon breast3

i+ure B% ro* le(t to ri+-t: Pi+eon c-est t)picalc-est o( COPD patient )p-oscoliosis /spinal

de(or*it)0

!a.le B% C-est s-apes%

• "ns'ect %)i*e in &ront o& orat t)e side o& t)e 'atient.

• 4bser$e retraction o& inters'aces and ot)er signso& *abored breat)inges'ecia**( during

con$ersation i.e. use o& sternoc*eidomastoids3

• rom a mid*ine 'ositionbe)ind t)e 'atient ex'oset)e 'atient %e** and as'ermission3! note t)es)a'e o& t)e c)est and t)e%a( it mo$es! inc*uding:o Abnorma* retraction o&

inters'aces duringins'iration notesu'rac*a$icu*ar retraction3

o "m'aired res'irator( mo$ement on one or bot)sides or uni*atera* *ag or de*a( in mo$ement

"'si*atera* dis'*acement to%ards t)e aected *ungindicates a $o*ume,*oss 'rob*em

C% Palpation

• Pa*'ate to test res'irator( excursion! es'ecia**(posteriorl)

• Pa*'ate &or trac)ea* 'osition

• Pa*'ate &or an( so&t tissue massestenderness %)ic)students usua**( miss3

• Pa*'ate &or ribcostoc)ondra* tenderness

• Pa*'ate &or tacti*e &remitus! using base o& Kngers oredge o& (our )and! com'aring t)e t%o sides o& t)ec)est

• Pa*'ate &rom 'osterior Pxs bac3 to anterior

!rac-eal Position

• er( im'ortant

• "& trac)ea is dis'*aced i'si*atera**( to t)e aected*ung $o*ume *oss 'rob*em

• <se t)e c*a$icu*ar )ead o& /C as tae,o 'oint

Palpation o( t-e C-est

• ocus on areas o( tenderness! a.nor*alities ino&erl)in+ sin! respirator) e,pansion and(re*itus

• Pa*'ate i& trac)ea is mid*ine! an( *(m') nodeen*argement! costoc)ondra* en*argement! t)(roid

&rom t)e bac• "denti&( tender areaso #ibcostoc)ondra* tendernesso /o&t tissue masses tenderness

• Assess an( obser$ed abnorma*itieso /o&t masseso /inus tracts: b*ind! inIammator(! tube,*ie

structures o'ening onto t)e sino Lesions

• -est c)est ex'ansion

• ee* &or tacti*e &remitus

• Pa*'ate and com'are s(mmetric areas eua*it(3

!estin+ C-est ",pansion

• As t)e 'atient to )ug )imse*& rig)t )and o$er *e&ts)ou*der and *e&t )and o$er rig)t s)ou*der3 to <INGO$! SCAP$LA &or eas( access

• P*ace (our t)umbs at about t)e *e$e* o& t)e 16t-

=11t- ri.s! %it) (our Kngers *oose*( gras'ing and'ara**e* to t)e *atera* rib cage

• As (ou 'osition (our )ands! s*ide t)em media**( Hustenoug) to raise a *oose&o*d o& sin on eac) sidebet%een (our t)umb ands'ine

• As t)e 'atient to ins'ire

• >atc) t)e distancebet%een (our t)umbs ast)e( mo$e a'art and &ee*&or t)e range ands(mmetr( o& t)e rib cageas it ex'ands andcontracts

• An( 'at)o*og( can *eadto c)est *ag somet)inginter&eres %it) air goingout o& t)e *ungso Accumu*ation o& air

'neumot)rorax3! Iuid!mucus and inIammation in 'neumonia3

i+ure % Respirator) e,cursion

!actile re*itus

• Pa*'ab*e $ibration o& t)e c)est %a** &rom soundstransmitted &rom t)e ')onating *ar(nx

•

As t)e 'atient to )ug )imse*& to 'in+ out scapula• P*ace )and diagona**( on an "C/ /ON" le&el at a

ti*eE0 and 'a*'ate &or tacti*e &remiti using t)e baseo& t)e Kngers! 'a*m or u*nar sur&ace o& (our )and i& anterior! a$oid cardiac area3

• As t)e 'atient to sa( ?ninet(,nine@ or ?tres,tres@creates t)e greatest $ibration in t)e *ar(nx

• Com'are s(mmetr( and 'er&orm at dierent *e$e*s


o( 8

Nor*al • >ider t)an it is dee' *atera*RAP

diameter3Pectus",ca&atu*/unnelC-est0

• De'ression on *o%er 'ortion o& sternum

• Com'ression o& )eart great $esse*s ma(

cause murmurs

arrelC-est

• "ncreased AP diameter

• orma* during in&anc(! o&ten

accom'anies C4PD! c)ronic bronc)itis

PectusCarinatu*/Pi+eonC-est0

• /ternum is dis'*aced anterior*(!

increasing t)e AP diameter

• Costa* carti*ages adHacent to t)e

'rotrudingsternum are de'ressed

• ost o&ten secondar( to trauma




SYS!"#

• 4&ten more 'rominent on t)e rig)t side t)an on t)e*e&t

• Disa''ears be*o% t)e dia')ragm

• "& norma* and no im'ediment! t)e $ibration %i** betransmitted eua**(

• indings: ma( be decreased or increased i& abnorma*o "ncreased -: Kbrot)orax %it) co**a'sed air%a(!

inter$ening tissue! a&ter surgica* 'rocedures!conso*idation secondar( to 'nemonia

o Decreased -: '*eura* eusion! *obar conso*idation!Iuid eusion! so*id mass

i+ure 7% Points to (eel (or tactile (re*itus% A&oidt-e cardiac area '-en (eelin+ (or t-e (re*itus

o&er t-e anterior aspect o( t-e c-est%

D% Percussion

• DeKnes densit( o& under*(ing structures b(dierences in sound %a$e conduction

• Again i& (ou 'ercuss in t)e 'osterior as'ect! >"W4<- /CAP<LA

• A$oid bon( structures *ie t)e sca'u*a and t)e$ertebra

!a.le % Percussion Notes and t-eirC-aracteristics /#$S! 9NO<E0Sound Intensi

t)Pitc- Durati

on",a*ple

latness /o&t +ig) /)ort -)ig)musc*e

Dullness edium

edium

edium

Li$er

Resonance

Loud Lo% Long orma**ung! o$errig)t'ectora*is

H)per=resonance

er(*oud

Lo%er Longer one!norma**(QPneumot)or

axaccumu*ation o& air3

!)*pan) Loud +ig) Longer Wastric airbubb*e

i+ure F% Areas o( Percussion

i+ure 8% Ladder=lie pattern (or percussion andauscultation o&er t-e anterior /le(t0 and

posterior /ri+-t0 t-ora,%

!ec-niue

• A$oid inHur( b( cutting (our Kngernai*s

• +('erextend t)e midd*e Knger o& (our *e&t )and!no%n as t)e ple,i*eter ?n+er. Press its dista*inter')a*angea* Hoint Krm*( on t)e sur&ace to be'ercussed

• A$oid sur&ace contact b( an( ot)er 'art o& t)e )andas t)is dam'ens our $ibration on*( one Knger s)ou*dbe ta''edQ 2nd and t) Knger are on*( used tostabi*iNe t)e 8rd Knger3

• Position (our rig)t &orearm uite c*ose to t)e sur&ace%it) t)e )and coced u'%ard. -)e midd*e Kngers)ou*d be 'artia**( Iexed! re*axed and 'oised tostrie

• >it) a uic4 s-arp .ut rela,ed %rist motion!strie t)e '*eximeter Knger %it) t)e rig)t midd*eKnger or '*exor Knger

• ae sure t)at (ou:o Aim at (our dista* inter')a*angea* Hointo /trie using t)e ti' o& t)e '*exormidd*e Knger! not

t)e Knger 'ado Mour Knger s)ou*d be a*most at rig)t ang*es to t)e

'*eximetero >it)dra% (our striing Knger uic*( to a$oid

dam'ening t)e $ibrations (ou )a$e created

• "n summar(! t-e *o&e*ent is at t-e 'rist. "t isdirected! bris (et re*axed and a bit bounc(.


7 o( 8




SYS!"#

/A0 /0

/C0 /D0

i+ure % ",a*ination o( t-e c-est percussion%Note t-ou+- t-at in t-e ?+ure4 onl) one ?n+ers-ould .e in contact 'it- t-e sur(ace since t-e*ore ?n+ers in contact4 t-e *ore t-e sound is

da*pened%

• ?Du**@ , o$er t)ig)• ?*at@ ,o$er &ore)ead

• ?#esonant@ , o$er rig)t 'ectora*is

Notes:

o Prece'tors 'articu*ar*( obser$e t)e mo$ement o& t)e %rist

o ae sure (ou percuss on t-e intercostal

spaces and 4- on t)e ribso Anterior 'ercussion: a$oid t)e cardiac s)ado%o Latera* 'ercussion not reuiredo As 'atient to ins'ire! c)ec t)e descent o& t)e

*ungso Percussion not usua**( done on side o& )emit)orax

"% Auscultation

i+ure 16% Areas o( Auscultation and Percussion/A0 Anterior /0 Posterior /C0 Ri+-t Lateral /D0

Le(t Lateral

Process

•Learn to identi&( 'atterns o& breat) sounds b( intensit(!'itc)! and t)e re*ati$e duration o& ins'irator( and

ex'irator( ')ases•Listen to t)e breat) sounds %it) t)e diap-ra+*

/(ro* ates4 .ut sir said .ell0 o& a stet)osco'e10,12 inc)es3

•"nstruct t)e 'atient to .reat-e deepl) t)roug) anopen *out-

•<se t)e 'attern suggested &or 'ercussion! mo$ing &romone side to t)e ot)er and co*parin+ s)**etricareas o& t)e *ungs

o "& (ou )ear or sus'ect abnorma* sounds! auscu*tateadHacent areas so (ou can &u**( describe t)e extento& an( abnorma*it(

o Listen to at *east one &u** breat) in eac) *ocation

Nor*al reat- Sounds /#$S! 9NO<E0

!rac-eal and ronc-ial reat- Soundso Loud! )ig),'itc)ed tubu*ar sounds )eard o$er t)e

trac)ea and mainstem bronc)i centra*! *argeair%a(s3.

o Produced b( turbu*ent airIo% 'atterns.o Located at t)e 'arasterna* areaso "E ratioU 1:2 to 1:8.o /ound &reuenc( U 200 to 2!000+N.o +eard o$er c)est %a** on eit)er side o& t)e sternum

&rom 2nd to t) "C/ anterior*( and a*ong $ertebra*co*umn &rom 8rd to 6t) "C/ 'osterior*(.

esicular .reat- sounds in 'eri')era* air%a(s3o Air%a( o'ens u'o Peri')era*o Produced b( c)anges in airIo% 'atterns! uieter

t)an bronc)ia*trac)ea* B/o "ns'iration is )eard c*ear*(! immediate*( &o**o%ed

b( ex'iration %)ic) uic*( &ades as airIo% ratesra'id*( dec*ine and turbu*ent airIo% is directedto%ards t)e centra* air%a(s

o "E ratioU8:1 to :1. /ound &reuenc( U 200,600+N

• ronc-o&esicular .reat- sounds at 'osterior3o +eard anterior*( and 'osterior*( o$er *arge centra*

air%a(s 'roxima* air%a(s3o Pitc) Y duration bet%een $esicu*ar and bronc)ia*

breat) soundso "E ratioU1:1

• ronc-ial reat- Sounds at *arge air%a(s!bi&urcations3

o 4ccurs %)en *ung tissue bet%een centra* air%a(sand c)est %a** becomes air*ess because o& conditions t)at increase lun+ densit)! t)usen)ancing transmission o& breat) sounds %)ic)become louder4 *ore tu.ular

o "E ratioU1:1 or 1:2o /een in consolidation4 atelectasis and ?.rosis

%)ic) increase *ung tissue densit( b( Iuidaccumu*ation! *ung co**a'se or Kbrotic scarring3

• +o% Dr. Benedicto described t)e norma* breat) soundsote t)at t)e in&ormation )e su''*ied %ere not consistent%it) t)e in&ormation &rom *iterature! s'ecia**( on duration o&

sounds3o -rac)ae*: tubu*ar and *onger ex'iration and s)orter

ins'iration since stet)osco'e is in t)e neco Parasterna* Bronc)ia*3: Larger air%a(s a*so tubu*aro Bac: tubu*ar Krst as it goes to termina* bronc)io*es!

t)en to t)e a*$eo*i *ie bubb*es3o "n 'eri')era* *ung Ke*ds: &aster ex'iration since

stet)osco'e nearer to t)e a*$eo*i

!a.le 7% C-aracteristics o( .reat- soundsDuration o(sounds

Intensit) o(e,pirator)sounds

Pitc- o(e,pirator)sounds

Nor*allocation

esicular

"ns' REx'

/o&ter #e*ati$e*( *o%

Bot)*ungKe*ds

ronc-o=&esicular

"ns' UEx'

"ntermediate

"ntermediate

1st and2nd "C/anterior*(Qbet%eensca'u*ae


F o( 8




SYS!"#

ronc-ial

"ns' OEx'

Loud #e*ati$e*( )ig)

4$ermanubrium

!rac-eal

"ns' UEx'

er( *oud #e*ati$e*( )ig)

Atsterna*

notc)

i+ure 11% Nor*al .reat- sounds 'it- +rap-icrepresentation o( duration and ualit) durin+

inspiration and e,piration%

A.nor*al oice Sounds /*ust=no'0

• oice sounds are 'roduced b( $ibrations o& t)e $oca*cords as air &rom t)e *ungs 'asses o$er t)em

• orma**(! $o%e* tones %)ic) contain )ig) &reuenc(sounds are K*tered and diminis)ed. +o%e$er! o$erconso*idated or ate*ectatic *ung tissue! *ess K*teringtaes '*ace! t)us! en)ancing transmission

• -)ese sounds are rare*( )eard

• -)e t)ree t('es o& abnorma* $oice sounds:o ronc-op-on) c*ear! distinct and inte**igib*e

$oice sound )eard o$er air*ess *ung tissueo <-ispered Pectorilou) c*ear! distinct!

inte**igib*e %)is'ered $oice sound )eard o$erair*ess! conso*idatedate*ectatic *ung tissueQ in'*eura* eusion %it) nasa* t%angQscratc)ingras'ing sound

o "+op-on) $oice sound %it) a nasa* or .leatin+ua*it( )eard o$er t)e c)est %a** o$erconso*idatedate*ectatic *ung tissue! a*so seen inu''er border o& a *arge '*eura* eusion

Ad&entitious Sounds /A!S4 1FF0

• Cracles /Rales0 discontinuous sounds and )eardmore in ins'irationo Coarse cracles *oud Y *o% 'itc)ed 'us,K**ed or

')*egm! usua**( due to in&ection! e.g. 'neumonia!

inIammator( condition3o ine cracles *ess intense! )ig)er 'itc) Y s)ortduration )emorr)age! congestion! or Iuid,K**ed3

o /ound 'roduced %)en (ou rub )air strandstoget)er

o ot reuired to be dierentiated during 4/CE!identi&(ing t)e 'resence or absence o& crac*es %i**suZce

o 2015: accdg. to /ir! ?'arang stra% sa so&tdrins'ag ubos na@

o An( Iuid K**ed a*$eo*i %i** )a$e a res'irator( sound%it) crac*es ! %)erein t)e Iuid is ?t)inner@ sosound is Kner

<-eeJes

o Continuous sounds t)at are -i+-=pitc-ed %it))issing sound! due to narro%ing o& air%a(s

o Prob*em in air%a(s so )eard more in ex'irationbut can be a*so ins'iration3

o "ndicates sma** air%a( obstruction

o E.g. ast)mao -ends to be exaggerated during ex'iration since

our air%a(s co**a'se durin+ e,pirationo 2015: ?'arang dinosaur@

KR-onc-i or Lo'=Pitc-ed <-eeJes

o Lo%,'itc)ed continuous soundso +eard 'rimari*( durin+ inspiration but according

to sir! it is again better )eard in ex'iration since a'rob*em o& air%a( *ie %)eeNes3

o Air%a( 'rob*em C4PD! ast)ma3o Caused b( Iuidssecretions 'artia**( b*ocing *arge

air%a(so +ars)! tubu*ar sounds

Pleural riction Ru.

o Due to genera*iNed inIammation o& $iscera* and'arieta* '*eura

o Leat)er( ua*it( *ie crac*es but )eard a**t)roug)out since aects t)e '*eura3

o But rare*( )eard since usua**( accom'anied b('*eura* eusion %)ic) dam'ens sound

Stridor

o Loud musica* sound no more tubu*ar ua*it(3 t)atis )eard at a distance %it)out a stet)osco'e

o arro%ing o& air%a( 'assageo Caused b( lar)n+eal spas* a**ergic3 and

mucosa* s%e**ing 'ro*onged intubation causesinIammation3

o -('ica**( )eard during ins'iration! but ma(be )eard

t)roug)out t)e res'irator( c(c*eo Patient is breat)ing in %)i*e c*osing t)e g*ottiso "ndicates u''er air%a( obstruction *ie t)e

trac-eao Loca*iNed )acing soundQ 2015: ?'arang

*agarisa%@

"ND

#ar): "m so boring na " dont )a$e an( message in'articu*ar. B<<<- #a( Hust ga$e me an idea. " %ou*d*ie to greet ic). " *o$e (ou and " miss (ouG oredrama soon. +ee)eeG -o Lee -an! " *o$e (ou too. -o Eri!

"m sad t)at (ou )ate me

5a*es: a*a'it na mag,sembreaG ag,aa(a ami ni -erence ng sur& tri' t)is %eeend sa L< since *ong%eeend naman. -araG

Allie: ?"t %asnt a dar and storm( nig)t. "t s)ou*d)a$e been but t)ats t)e %eat)er &or (ou.@ Waiman YPratc)ett! 19903


8 o( 8

[os 213] lec 09 physical diagnosis of the respiratory system (b)-2

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