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Transcript of DPx Paru.pdf
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Examination of the posteriorchest
By
dr.H.R.Handojo Padmosoeparto, SpP, Msc
Inspection Shape of the chest
The way in which it moves
Deformities / asymmetry
Inspiration:
Normal retraction of the interspaces
Lower interspaces : most apparent
Retraction : often present
Eg : Severe astma
COPD
Upper airway obstruction
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Impaired respiratory movement :
One / both sides / unilateral lag
Suggests : disease of the underlyinglung / pleura
Palpation
Focus:
Tenderness
Abnormalities in the overlying skin
Respiratory expansion
Fremitus
Tender areas: Palpate carefully : pain / lesions / bruises
Eg : fractured rib
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…..palpation Abnormalities :
Masses
Sinus tracts ( infection of underlying pleura and lung )
Chest expansion :
Thumbs - level ribs X
Finger - loosely grasping
Unilateral decrease in chest expantion:
- chronic fibrotic disease of lung / pleura
- pleural effusion
- lobar pneumonia
- bronchial obstruction
…..palpationFremitus :
patient speaks palpable vibrationsbronchopulmonary tree chest wall
ball words : 99 / 1-1-1
ulnar surface words : 99 / 1-1-1
both hands : detection of differences tocompare differences
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location for feeling fremitus :
interscapular area > lowerlung fields
right side > left
below the diafragma -
…..palpation
Vibration : larynx chest wall is impeded:
Obstructed broncus
COPD
Pleural effusion
Fibrosis ( pleural thickening )
Pneumothorax Infiltrating tumor
Very thick chest wall
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Percussion
Underlying tissue : air / fluid filled / solid ( ± 5-7cm deep-seated )
Technique :
Middle finger of left hand = pleximeter
Distal interphangeal joint firmly on the surfaceto be percussed
Thumb, fingers 2nd, 4th, 5th. free, nottouching the chest
Right forearm quite close to the surface
trying to transmit vibrations throug the bones ofthis joint to the underlying chest wall
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…..percussion
Characteristics:
Flatness : (thigh) : large pleural effusion
Dullness: (liver) : lobar pneumonia
Resonance normal lung : simple chronic bronchitis
Hyperresonance : none normally : emphysema,pneumothorax
Tympany :
gastric airbubble : large pneumothorax Puffed-out check
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Auscultation
= assessing air flow through thetracheobronchial tree
Listening :
to the sounds generated by breathing
for any adventitions ( added ) sounds
to the sounds of the patient`s spoken /
whispered voice ( if abnormalities aresuspected)
…..auscultation
Normal breath sounds :
Vesicular : inspiration expiration without pause fade away
Bronchovesicular : inspiration expiration :
equal in length
seperated by a silent interval
Bronchial : inspiration expiration : a short silence
expiratory sounds last longer than inspiration
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…..auscultation
Normal breath sounds :
Tracheal breath sounds, heart by listeningover the trachea in the neck:
Vesicular-over most of both lungs
Bronchovesicular : in the 1st and 2nd
interspaces anteriorly
Bronchial : over the manubrium
…..auscultation
Added breath sounds :
Crackles / Rales :
Pneumonia
Fibrosis
Wheezes / ronchi :
Wheezes ( narrowed airways ) : astma,COPD, bronchitis
Ronchi : = secretions in large airways
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…..auscultation
Listening the breath sounds :
The patient breathes deeply through anopen mouth
Listen to at least one full breath in eachlocation
Allow the patient to rest as needed (discomfort due to hyperventilation )
Examination on theanterior chest
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Inspection
Position : supine / sitting
Inspection : observe
The shape
The movement of the chest wall
Note :
Deformities / asymmetry
Inspiration : abnormal retraction of the lower
interspaces Local impairment in respiratory movement
Palpation
Identification of tenderness : chest pain has amusculoskeletal origin
Assessment of
Observed abnormalities
Chest expansion:
how far your thumbs diverge as the thoraxexpands
feel for the extend & symetry of respiratorymovement
Tactile fremitus over the precordium : or –(decreased or absent)
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Chest pain
Pulmonary :
Tracheobronchitis :
Process : inflamation of trachea & largebronchi
Location : upper sternal or on either sideof sternum
Quality : burning, mild to moderate
Factor that aggravate : coughingFactor that relieve : lying on the
involved side
Associated symptoms : cough
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……chest pain
Pulmonary :
Pleural pain:
Process : inflamation of the parietal pleura(pleurisy, pneumonia, pulmonary infarction orCa)
Location : chest wall overlying the process
Quality : sharp, knifelike, often severe
Factor that aggravate : breathing, coughing,movement of the trunk
PercussionChest : anterior & lateral ( comparing both sides )
The heart : left of the sternum ( 3rd - 5th interspaces )= area of dullness percuss the left lung lateral to it
COPD :
hyperresonance may totally replace cardiacdullness
often displaces the upper border of the liverborder lowers the level of diafragmaticdullness
Pleural effusion ; replaces resonance of the air
containing lung Right middle lobe pneumonia (woman : behind
the right breast
displace the breast)
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Auscultation
The patient breathes with mouth open.Compare symetric areas of the lungs
Vesicular breathing : the upper anteriorlung fields are usually louder
Bronchovesicular breath sounds : heardover the large airways, especially on theright
Adventitions sounds……….
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….auscultation
Adventitions sounds
Crackles :
late inspiratory crackles :
intertitial lung disease (fibrosis)
early congestive heart failure
Midinspiratory & expiratory cracles :
bronchiectasis ( not specific )
Early inspiratory cracles (relativelyfew in number)
chronic bronchitis astma
….auscultation Adventitions sounds:
Wheezes (air flow rapidly throughbronchi) :
astma ( may be heard only inexpiration or in both phases ofrespiratory cycle
Chronic bronchitis
COPD
cardiac asthma a persistent localized wheeze = partial
obstruction of a bronchus ( Ca / foreignbody, inspiratory / expiratory or both )
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….auscultation
Adventitions sounds:
Ronchi : secretions in the airways
chronic bronchitis ( wheezes & ronchioften clear with coughing )
Stridor : a wheeze that is entirely orpredominantly inspiratory. Louder in theneck than over the chest wall demands
immediate attention:
a partial obstruction of thelarynx/trachea
….auscultation
Adventitions sounds:
Pleural rub : inflamed & roughenedpleural surfaces grate against each other
Mediastinal crunch : a series ofprecordial crackles. Synchronous withthe heart beat, not with respiration (mediastinal emphysema /pneumomediastinum )
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Condition :
NORMAL :
Percussion :
resonant
Breath sounds :
vesicular
over the large bronchi = bronchovesicular,
trachea = bronchial
Adventitions sounds :
none
at the bases of the lungs : transientinspiratory crackles
Tactile fremitus :
normal
Chronic bronchitis
P: resonant
B: vesicular ( normal )
A: - none
-crackles
-wheezes / ronchiT: normal
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Consolidation
Pneumonia
Pulmonary edema
Pulmonaryhemorrhage
P: dull over theairless area
B: bronchial over theinvoled area
A: crackles over theinvoled area
T: increased over theinvolved area
bronchophony
egophony
whisperedpestoloquy
Atelectasis (lobar obstruction)
P: dull over the airless area
B: absent (usually) when bronchial plugpersists
A: none
T: usually absent
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Pleural effusion
P: dull over the fluid
B: -decreased to absent
-near top of large effusion: bronchial
A: -none
-possible pleural rub
T: -decreased to absent
-increased toward the top of a largeeffusion
Pneumothorax
P: hyperresonant / tympanitic over thepleural air
B: decreased to absent over the pleuralair
A: none, except a possible pleural rub
T: decreased to absent over the pleuralair
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C O P DP: hyperresonant diffusely
B: decreased to absent
A: - none
- crackles
- wheezes & ronchi (+chronicbronchitis)
T: decreased
A S T H M A
P: resonant hyperresonant
B: wheezes
A: wheezes + crackles
T: decreased
ref: BATES`. The Thorax and Lung. Guite to Physical
Examination and history taking: 253-64, 2007
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