Advanced Physical Assessment
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| Putrid sputum | suggests the presence of a lung abscess.
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| Rusty sputum | indicates the presence of blood.
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| GERD and cough | chronic- epigastric pain, heartburn, bad taste, hoarseness, sleep patterns
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| Hemoptysis is defined as | expectoration of bright red blood from lower respiratory tract-scant is blood streaking sputum. Gross <600 ml&Massive hemoptysis > 600 ml of blood in a 24 hr period-cancer Acute bronchitis
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| Chest pain changes with breathing | pleuritic may be sharp or dull- may radiate to the ipsilateral shoulder or neck-
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| Chest pain changes with position | pericardial
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| Cardiac chest pain- ischemic | exertion—bad when at rest- acute coronary syndrome
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| Chest pain with tenderness- superficial | costochondritis- give NSAIDS only one with tenderness
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| GERD and chest pain in the epigastrium | heartburn- epigastric
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| Stomach pain | gastritis
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| Gallbladder pain | biliary colic
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| Signs of respiratory distress | tachypnea >25 breaths per minute, cyanosis, pallor, nasal flaring, tripod, foggy/anxious, audible whistling over neck/lungs, use of accessory muscles
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| Tachypnea may be the first sign of | pneumonia and CHF—bradypnea <8 BPM can be hypothyroidism
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| Kussmaul breathing is | regular, deep respirations with ↑ tidal volume and alveolar ventilation-can be fast or slow- compensation for metabolic acidosis, direct effect of salicylates, DKA, hypoxemia or anemia
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| Cheyne-Stokes Respirations | A pattern of cyclic respirations- Periods of hyperventilation followed by periods of apnea-brain injury- stroke, hypoxia, trauma, hemorrhage- opiates, barbiturates, etoh also low cardia output
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| What stimulates us to breath? Why can’t we commit suicide by holding our breath? | 1) Level of CO2 stimulates central chemoreceptors 2) next acidosis- PH gets lower- pH in CHF gets ↓ and stimulates central chemoreceptors- 3) hypoxia- peripheral chemoreceptors to start breathing- this is why Cheyne-stokes start breathing deep and fast.
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| Inspection of the chest | diaphragm descends during inspiration- active process, and exhalation is a passive process
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| In emphysema the diaphragm is | flattened- air trapping and over inflation of the lungs- flattens the diaphragm- they will try to use other accessory muscles to help- scalene and SCM- expirationbecomes active
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| Respiratory paradox | the chest wall moves outward during inspiration while the abdominal wall is moving inward. This indicates bilateral diaphragmatic weakness or paralysis
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| Normal Adult chest shape | The AP diameter is smaller than the transverse diameter- The ratio (Thoracic ratio) is 0.7 and it increases with age up to 0.9
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| Barrel Chest | The AP diameter increases and the thoracic ratio exceeds 0.9 in emphysema and during severe bouts of asthma- almost the same
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| Traumatic Flail Chest | A condition where one or both sides of the chest move paradoxically inward in inspiration and outward in expiration. It develops following multiple rib fractures in one or both sides of the chest wall
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| Thoracic Skeleton | Tenderness (costochondritis, Tx NSAIDs), Bulges, Depressions, Masses, Unusual movements, Unusual positions, Pulsations
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| Subcutaneous crepitus | bubbles of air under the skin from- from external wound or the lung- tracheostomy- trauma or rib frax- Palpable feeling of gas bubble in the SQ tissue. Light pressure of the fingers produces a feeling of “bursting” or “crackling” bubbles in the skin XR
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| Patients with subcutaneous crepitus should all be assumed to have | a PNEUMOTHORAX unless it has been excluded
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| Thoracic expansion is decreased in patients who have | moderate to severe chronic obstructive lung dz(emphysema > chronic bronchitis), restrictive lung dz (pulmonary fibrosis), pneumothorax, atelectasis, chest wall or spinal deformities
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| Thoracic expansion- normal findings | Normally, the thumbs move apart with breathing- symmetrically - 4-6 cm
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| most accurate involving the lungs | chest xr (pneumonia) or CT (PE)
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| tactile fremitus | u feel vibrations when pt talks- say 99- looking 4 asymmetric vocal tactile fremitus VTF- normally when lungs are filled w/air, they have lt density- u should not feel vibration- if u feel it, it’s something other than air- density= fluid, pneumonia
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| consolidation | a certain area of the lung more fluid than air- more tissue than air-inflammation- PNEUMONIA- fluid—higher densityalveolar edema, and alveolar fibrosis
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| weak tactile fremitus pt | emphysema—filled with air- not fluid obvious would be pneumonia
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| another sample of weak tactile fremitus | barrier between lungs and the hand- air such a pneumothorax or fluid as in pleural effusion
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| if the fluid is inside the lung, is tactile fremitus felt more or less? | more= consolidation if it’s outside the lung, it’s a barrier
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| tracheal deviation, pushed or pulled- what can cause this | pneumothorax or pleural effusion, or left sided atelectasis- airway collapse- more room- lung tumors- mass
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| a resonant percussion does not | rule out lung pathology- dullness (consolidation, pneumothorax, pleural effusion, atelectasis) hyperresonance (pneumothorax (unilateral) emphysema (bilateral)
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| Diaphragmatic Excursion | vertical distance of diaphragm movement between end of full inspiration/expiration3-6 cm.decreases/reduced in chronic LD2-3 cm caused by↓expiratory airflow (emphysema) or caused by ↓inspiratory airflow-pulmonary fibrosis- 95% specificity
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| Anterior auscultation | lung sounds from the upper lobes and the right middle lobe dominate the auscultatory findings.
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| Lateral auscultation | the sounds originating from the right middle lobe are heard well over the lateral chest wall
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| Posterior auscultation | Lower lobes dominate the surface area of the chest wall. Lung sounds from the upper lobes are heard above the level of the mid scapula at about the third thoracic vertebra
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| Vesicular | inspiratory longer than expiratory- over most of the lungs- soft
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| Broncho-vesicular | in and out equal heard over the 1st and 2nd spaces anteriorly and between the scapulae posteriorly- intermediate expiration
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| Bronchial | heard over the manubrium- relatively high sound- Expiratory sounds last longer than inspiratory sounds-Over the manubrium- large proximal airways- loud expiration
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| Tracheal breath sounds | very loud and over the trachea- in and out equal
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| Vesicular breath sounds are most important when they are absent over | the periphery of the lung (normal) Pathologic processes cause normal vesicular sounds to be replaced by other types of sounds
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| Broncho-vesicular | in upper parts- Bronchovesicular breath sounds are transitional sounds that have inspiratory and expiratory components of equal duration- large airways on either side of sternum or scapula
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| Bronchial | tube- have a shorter and softer inspiratory/expiratory component- heard directly over the intrathoracic trachea- expiratory phase is louder and longer than the inspiratory- There is a silent gap between the two components
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| What do you need to dx pneumonia? | hx and XR
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| Bronchovesicular and bronchial breath sounds are abnormal when detected over | the periphery of the lung
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| Abnormal Bronchovesicular and bronchial breath sounds develop whenever there is | a decrease in the air/water ratio of the pulmonary parenchyma- alveolar pneumonia, microatelectasis, pulmonaryedema, pulmonary fibrosis, consolidation- pneumonia
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| Bronchial breath sounds also occur over the middle of a large pleural effusion due to | compression of the underlying alveoli by the effusion
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| Most common breath sound in COPD pt | decreased breath sounds (pneumonia, atelectasis, restrictive lung dz)
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| diseases that separate the stethoscope from the underlying lung parenchyma | obesity, pleural effusion, pneumo/hemothorax, pleural thickening
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| Adventitious lung sounds are extra sounds that are | normally absent in the respiratory cycle but become superimposed on the normal breath sounds whenever lung disease is present.
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| Adventitious sounds are categorized as being either | discontinuous or continuous.
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| The most important discontinuous adventitious sound is the | crackle
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| the most important continuous adventitious sound is the | wheeze
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| the most abnormal commonly described finding on auscultation is | crackles- short, mainly inspiratory, discontinuous, non-musical sounds from the opening of small airways- breaking of small bubbles or mucus films in the med to lg conducting airways
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| airways are smaller during expiration so during expiration airway obstruction occurs then subject to tractive forces of inspiration= obstruction suddenly resolves. This event results in equalization of pressure that produces | a crackle
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| Crackles should be evaluated for | pitch. The higher pitch, the more peripheral the disease process is located- develop when small airways or alveoli that close during expiration suddenly pop back open during inspiration.
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| Fine pitched crackles are characteristic of | alveolar pneumonia, alveolar hemorrhage and alveolar edema.Pulmonary fibrosissounds like velcro being pulled apart (“Velcro crackles”)
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| Low-pitched Crackles (Coarse crackles) | occur when alveoli pops open- air flows through large airways that are coated in secretions- Coarse crackles are typical of acute and chronic bronchitis.
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| Crackles occur when and wheezes occur when | inspiratory- (opening/pooping alveoli), expiratory (letting/forcing air out)
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| Inspiratory crackles are further subdivided into | evaluated for timing- Early to mid inspiratory crackles and end by mid-inspiration- chronic airway obstruction- asthma, chronic bronchitis, bronchiectasis or emphysema-in large-to-medsized airways and are produced by the bubbling
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| How do you know if crackles are from the heart or from the lungs | it changes with posture (supine) - listen and ask pt to cough- see if sounds disappear- rhonchi disappear on cough
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| Late inspiratory crackles are audible only during | the latter half of inspiration-in small bronchioles/alveolar ducts pop open-produced when airways being compressed by interstitial edema(heart failure or pneumonia)-scarring (pulmonary fibrosis)
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| Posturally induced crackles | pulmonary edema crackles- orthopnea- when supine- lying flat- disappears when they sit up, pulmonary edema when upright- severely elevated left ventricular, and left atrial
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| All crackles should be evaluated for | repeatability- do they clear after 3-4 coughs or not (not important if they do)
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| Wheezes are | airway obstruction- narrowing- continuous, musical, adventitious sounds that are caused by vibrations of the opposing walls of narrowed airways- absence of sound is worse
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| High pitch wheeze | The pitch and duration of the wheeze are important clues to the degree of airflow obstruction- more severe obstruction and the longer duration the wheezes
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| Mono-phonic wheezes | single note- intrabronchial tumor or foreign body-
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| Polyphonic wheezing | contains several notes that start and stop at the same time, much like a musical chord, results from narrowing of multiple airways at the same time- bronchospasm, airway edema and/or mucous plugging (asthma).
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| Expiratory wheezes | the norm- if pt has both it’s bad- and if there’s no sound it’s really bad-
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| Wheezing timing and location | location must be determined- asthma is usually diffuse-involves both lungs. Wheezing localized to one lung, suggests focal airway obstruction (foreign body aspiration).
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| Inspiratory or expiratory wheezes | airway obstruction, no wheezes= worst airway obstruction
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| Foreign body aspiration goes where | right lung—so place on left lateral position in kids, angle trachea is equal until age 3
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| Rhonchi | snoring quality- caused by fluid in the larger airways- can be cleared by coughing- associated with excess inflammatory secretions or drowning. Mucus plugging can also cause rhonchi
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| Stridor | emergency- loud, long, high-pitched musical inspiratory sound-upper airway obstruction- occurs in tracheal, epiglottic, laryngeal obstruction-Isolated expiratory stridor=obstruction in bronchus secondary to an aspirated foreign body.
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| A pleural friction | continuous adventitious sound-visceral and parietal pleura rub together during breathing- a continuous adventitious sound-visceral and parietal pleura rub together during breathing,
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| The presence of a pleural friction rub points to a diagnosis of | pleural inflammation (pleuritis).
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| Pleural friction rub vs pericardial friction rub | ask pt to hold their breath and if the sound is still there, it’s pericardial b/c the heart still beats- sound the same
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| Bronchophony | describes an increase in the transmission and clarity of the spoken voice as heard through the stethoscope-
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| Egophony | (goat sound) is present when the spoken word heard through the stethoscope has an intensified nasal/bleating qualityask the patient to say “Eeeee” and it is heard through the stethoscope as “Aaaay”, or the “E” to “A’ change
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| Egophony is one of the most sensitive physical findings for detecting | the presence of pulmonary consolidation.
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| Whispered pectoriloquy describes | an ↑ inthe transmission and clarity of high-pitched-whispered sounds-ask pt to say “sixty-six”- periphery and trachea sound the same
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| Soft, low-pitched-any point of auscultation, most clear @ bases, least toward apex, where lung is thinner, Longer inspiratory phase/shorter expiratory phase -when ↑ in intensity, they are caused by lung consolidation | vesicular
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| High-pitched over manubrium of sternum- like a tube- If found elsewhere over the periphery of the lungs, then caused by consolidation of lung =transmission of sound through the bronchial tree to the stethoscope- pneumonia or atelectasis | bronchial
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| Sound like hairs rubbed together wthe fingers, velcro being detached, popcorn popping, milk being sucked up through a straw, air bubbles popping- short -mostly during inspiration- caused by the sound of alveoli and small airways opening during inspiration | crackles
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| Excessive airway secretions or fluid contribute to their presence pneumonia, pulmonary edema, atelectasis, interstitial lung disease, bronchiectasis | crackles
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| High-pitched, “musical” breath sounds heard on expirationcaused by narrowing of airway with turbulent airflow- bronchospasm, such as asthma Fluid overload and edema from CHF-cardiac asthma | wheezes
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| Lower pitched than crackles, more continuous. Not as musical as wheezes.Heard mostly during inspiration-sonorous or gurgling-cleared by coughing-fluid in the large airways | rhonchi
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| High-pitched sound heard on inhalation even without the use of a stethoscope | stridor
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| Sounds like two pieces of leather grating against each other in time with both inspiration and expiration | pericardial or pleural effusion
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| Diaphragmatic paradox or paradoxical diaphragm phenomenon | the diaphragm moves opposite to the normal directions of its movements. The diaphragm normally moves downwards during inspiration and upwards during expiration
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