Pulmonary Exam

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Pulmonary Exam

• Jessica Shin, MS4
• December 6, 2006

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Anatomy
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Anatomy
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Vital Signs

• Temperature
• Respiratory rate (14-20/min)
• Heart rate (80-100 bpm)
• BP (120/80)
• SpO2 (95-100 on room air)

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General Survey

• Evidence of respiratory distress, effort of
  breathing
• Use of accessory muscles
• Retractions
• Nasal flaring, pursed lip breathing
• Breathing
• Audible wheezes, stridor (large airway
  obstruction)
• Position of trachea
• Deviation due to pleural effusion, PTX,
  atelectasis

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General Survey

• Color (skin, nails)
• Cyanosis
• Clubbing

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Areas to Examine

• Posterior Chest
• Patient sitting up
• Anterior Chest
• Patient supine

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Pulmonary Exam

• Inspection
• Palpation
• Percussion
• Auscultation

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Inspection of the Chest

• Deformities or asymmetry
• Shape of the chest
• Pectus excavatum/carinatum
• Barrel chest (COPD)
• Flail chest (multiple rib fractures)
• Kyphosis/Scoliosis
• Increased effort of breathing
• Retractions
• Impaired respiratory movement
• Trauma, masses
• Old surgical scars, skin lesions

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Palpation

• Assess tender areas, lesions

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Palpation

• Chest excursion on deep inspiration

• Abnormal chest excursions
• Splinting
• Bronchial obstruction
• Pleural effusion
• Lobar pneumonia

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Palpation

• Tactile fremitus

• Absent or decreased tactile fremitus
• Bronchial obstruction
• COPD
• Pneumothorax
• Tumor
• Pleural effusion

• Increased tactile fremitus
• Consolidation (lobar pneumonia)

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Tactile Fremitus

• Consolidation versus pleural effusion

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Percussion

• Percuss symmetrically, avoiding the scapula
  (12-14 spots)
• Tap out the diaphragm
• Quiet respiration (asymmetry?)
• Full inspiration and expiration (5-6cm at most)

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Percussion
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Auscultation

• Have patient breathe deeply through an open mouth
• Auscultate top to bottom, alternating from side
  to side

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Auscultation

• Vesicular
• Most of lungs
• Soft, low pitched, IgtE
• Bronchovesicular
• 1st, 2nd interspaces, between scapulae
• Medium intensity, medium pitch, IE
• Bronchial
• Manubrium
• Loud, high pitched, EgtI
• Tracheal
• Trachea
• Very loud, high pitched, IE

• Absent or decreased breath sounds
• ARDS
• Asthma
• Atelectasis
• Pneumothorax

• Bronchial breath sounds
• Consolidation

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Adventitious Sounds

• Crackles/rales (sounds like velcro)
• Fine (shorter, higher pitched, softer)
• Coarse (longer, lower pitched, louder)
• Wheezes
• Rhonchi (sounds like snoring)
• Stridor (predominantly inspiratory, louder in the
  neck than over the chest wall -gt large airway
  obstruction)

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Characterizing Adventitious Sounds

• Inspiratory or expiratory?
• Location (where in the lung fields)
• Number (lots or few)
• Do they clear with coughing?

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Transmitted Sounds

• Bronchophony
• Egophony
• Normal eee
• Egophony
• Whispered pectoriloquy

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Pulmonary Exam Normal Lungs

• Vital signs
• General Patient is well-appearing, in no
  apparent distress.
• Skin No cyanosis or clubbing.
• Pulmonary Clear to auscultation and palpation
  bilaterally. No wheezes, rhonchi, or rales.

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Lobar Pneumonia

• Trachea Midline
• Percussion Dullness to percussion over the area
  of consolidation
• Breath sounds Bronchial breath sounds over the
  area of consolidation
• Tactile fremitus Increased over consolidation
• Adventitious sounds Late inspiratory crackles
• Egophony, whispered pectoriloquy, and
  bronchophony

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Emphysema

• Trachea Midline
• Percussion Diffusely hyperresonant
• Breath sounds Decreased to absent
• Tactile fremitus, transmitted voice sounds
  Decreased
• Adventitious sounds None

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Extras - General Survey

• Fingernails
• Clubbing