History Taking & Chest Examination Dr. Waseem HAJJAR, MD. FRCS. Assistant professor & Consultant...
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Transcript of History Taking & Chest Examination Dr. Waseem HAJJAR, MD. FRCS. Assistant professor & Consultant...
History Taking & Chest Examination
Dr. Waseem HAJJAR, MD. FRCS.
Assistant professor &
Consultant Thoracic Surgeon
Rules:
1. Patient should be allowed to tell his history in his own words.
2. Leading questions must be avoided unless the information can’t be obtained by other means
Questions:
1. Complete the immediate description.
2. Elucidate the vague points.
3. Fill in the gaps the history not mentioned by patient.
4. Emphasize the important points.
Types of questions:
1. Neutral questions.
2. Simple direct questions (yes/No).
3. Leading questions.
WHAT SHOULD WE KNOW ABOUT THE EXAMINATION OF THE CHEST?
• HISTORY• SYMPTOMS • LANDMARKS• PERTINENT VOCABULARY • SIGNS• HOW TO PERFORM AN EXAM• HOW TO PRESENT THE INFORMATION • HOW TO FORMULATE A DIFFERENTIAL DIAGNOSIS
Personal data:
Name. Age. Sex. Occupation. Residence.
The patients complaint:
A simple statement in the patients own words and its duration.
Present History:
This means detailed history of the patients present illness which must provide answer for the following questions:
1. Duration
2. Mode of onset (acute, sub acute, chronic).
3. Sequence of events:I. Course (progressive, regressive or recurrent).
II. Appearance of new additional symptoms or disappearance of others.
III. Treatment received during the course & response.
4. Analysis of each particular symptom.
History
Acute/chronic disorder Preceding systemic disturbance Past medical history Drug history Social history Family history Occupational history
THE HISTORY
FAMILY HISTORY EMPHYSEMA AT AN EARLY AGE - CONSIDER
ALPHA – 1 ANTITRYPSIN RECURRENT RESPIRATORY INFECTIONS AND
STERILITY IN A YOUNG ADULT MALE – CONSIDER CYSTIC FIBROSIS, IMMOTILE CILIA OR YOUNG’S SYNDROME
PULMONARY NODULE AND HYPOXEMIA – CONSIDER OSLER WEBER RENDU
THE HISTORY
OCCUPATIONAL - CHRONOLOGIC ORDER EXPOSURE : BRAKE SHOES, PIPE FITTERS (ASBESTOS) SANDBLASTING, QUARRY (SILICOSIS) FARMING – (FARMERS LUNG) MILITARY – (BERYLLIOSIS) TRAVEL- FAR EAST (PARAGONIMIASES) SOUTH AMERICA (BRUCELLOSIS) SOUTHWEST USA (COCCIDIOMYCOSIS) DRUGS – INTERSTITIAL LUNG DISEASE
(NITROFURANTOIN) HABITS – TOBACCO, NOSE DROPS, ILLICIT DRUGS
MAIN SYMPTOMS OF PULMONARY DISEASE
COUGH DYSPNEA HEMOPTYSIS CHEST PAIN – PLEURITIC WHEEZING CYANOSIS SPUTUM PRODUCTION SNORING
DESCRIBE THE COUGH
PRODUCTIVE – NONPRODUCTIVE ACUTE – CHRONIC TIME OF DAY PRECIPITANTS – RELIEF BLOODY – NON BLOODY BARKING – HACKY
COUGH
SYMPTOM
MORNING
NON-PRODUCTIVE
RECUMBENT
BARKING
NOCTURNAL
PRODUCTIVE
BLOODY
ETIOLOGY
CHRONIC BRONCHITIS
VIRAL, ILD,TUMOR
SINUSITUS, CHF,REFLUX
CROUP,LARYNGEAL
ASTHMA, CHF
INFECTIOUS
TUMOR,CHF
THE PNEA’S
DYSPNEA – SOB : ACUTE – (PULMONARY EMBOLISM, PNTX, ASTHMA) CHRONIC – (COPD, CHF, ILD) TACHYPNEA – RR>20 BR/MIN BRADYPNEA - RR< 8 BR/MIN (DRUGS, AGONAL) PND - PAROXYSMAL NOCTURNAL DYSPNEA SUDDEN
ONSET OF SOB DURING SLEEP (CHF) ORTHOPNEA – SOB LYING FLAT (CHF) PLATYPNEA – SOB SITTING UP AND BETTER LYING FLAT
(R TO L SHUNT) TREPOPNEA – SHORTNESS OF BREATH IN ONE LATERAL
DECUBITUS POSITION WHICH IS IMPROVED BY TURNING ON THE OPPOSITE SIDE
DYSPNEA
MY CHEST FEELS TIGHT I CANNOT TAKE A DEEP BREATH I FEEL LIKE I HAVE A PILLOW OVER MY
MOUTH I AM SMOTHERING
THE NUMEROUS ETIOLOGIES OF CHEST PAIN PLEURITIC – PARIETAL PLEURA – SHARP
STABBING – INSPIRATION ESOPHAGEAL – REFLUX CARDIAC – MYOCARDIAL INFARCTION GALL BLADDER – CHOLECYSTITIS CHEST WALL – COSTOCHONDRITIS GREAT VESSELS – DISSECTION PULMONARY - PNEUMOTHORAX
SPUTUM - WHAT ARE ITS CHARACTERISTICS ?
YELLOW – GREEN (PNEUMONIA, BRONCHIECSTAIS) RUSTY (PNEUMOCCOAL PNEUMONIA) ANCHOVY PASTE (AMEBIASIS) PINK – BLOOD TINGED (EPISTAXIS, BRONCHITIS) FROTHY (CHF) BLOODY (MALIGNANCY, BRONCHIECSTASIS,
PULMONARY RENAL SYNDROME) SMELL – FOUL? (ANAEROBIC LUNG ABCESS) SANDLIKE (BRONCHOLITHIASIS) BLACK – COAL DUST INHALATION
HEMOPTYSIS - REQUIRES CAREFUL QUESTIONING THIS SYMPTOM USUALLY DENOTES A
SERIOUS ILLNESS. TB, TUMOR, BRONCHIECSTASIS, PE, CARDIAC DISEASE
THE PATIENT SHOULD BE QUESTIONED CAREFULLY REGARDING HOW MUCH, FREQUENCY WEIGHT LOSS ETC.
CLUES TO DIFFERENTIATING HEMOPTYSIS FROM HEMATEMESIS
HEMOPTYSIS
COUGH
FROTHY
COLOR- BRIGHT RED
PUS
DYSPNEA
CARDIAC DISEASE
HEMATEMESIS
NAUSEA – VOMITING
NOT FROTHY
COFFEE GROUNDS
FOOD
NAUSEA
GI DISEASE
WHAT SHOULD WE KNOW ABOUT THE EXAMINATION OF THE CHEST?
HISTORY SYMPTOMS LANDMARKS PERTINENT VOCABULARY SIGNS HOW TO PERFORM AN EXAM HOW TO FORMULATE A DIFFERENTIAL DIAGNOSIS HOW TO PRESENT THE INFORMATION
Inspection of the chest
Important:
- SHAPE
- MOVEMENT
- VISIBLE PULSATIONS!
SHAPE of the chest:
Deformities: - kyphosis
- scoliosis
- depressed sternum (pectus excavatum)
- bulges in left parasternal area
(congenital malformation)
e.g. VSD
of the thorax
Inspection
Shape Scars Lesions Resp rate Resp depth Mode of breathing Abnormal inspiratory movements Abnormal expiratory movements Asymmetry of movement
Percussion
Impaired(dull)resonance obtained – Aerated lung tissue is separated from the
chest wall e.g. fluid, pleural thickening Lung tissue is airless e.g. consolidation,
collapse, fibrosis
“stony dullness”- pleural effusion
Hyperresonance - pneumothorax
Percussion technique
Place left hand on chest wall, palm downwards with fingers separated
2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx
producing hammer effect Entire movement comes from wrist
PERCUSSION SOUNDS
TYMPANY – HEARD OVER THE ABDOMEN RESONANCE – HEARD OVER NORMAL
LUNG DULLNESS – HEARD OVER LIVER OR
THIGH
AUSCULTATORY PERCUSSION
METHOD THE STETHOSCOPE IS PLACED OVER
THE POSTERIOR CHEST WALL, THE CLINICIAN THEN TAPS LIGHTLY OVER THE MANUBRIUM, EQUIVALENT SOUNDS SHOULD BE HEARD OVER CORRESPONDING AREAS OF THE LUNG. ASYMETRY SUGGESTS DISEASE.
TACTILE FREMITUS
A THRILL OR VIBRATION WHICH IS FELT ON THE CLINICIANS HAND WHILE RESTING IT ON THE PATIENTS CHEST WALL AT T HE SAME TIME THE PATIENT SPEAKS. 99 – 1-2-3
SYMETRY MAY BE SEEN IN NORMALS ASYMETRY – IS ABNORMAL
VOCAL FREMITUS
THE PATIENTS VOICE IS HEARD THROUGH A STETHOSCOPE PLACED ON THE PATIENTS CHEST – NORMALLY THE SOUNDS ARE INDISTINCT
ABNORMALITIES – BRONCHOPHONY, PECTORILOQUY, EGOPHONY
CONSOLIDATION
VOCAL FREMITUS
BRONCHOPHONY – SOUND OF THE BRONCHI – SOUND MUCH LOUDER THAN NORMAL - WORDS INDISTINCT
PECTORILOQUY – VOICE OF THE CHEST – WHISPER – WORDS INDISTINCT
EGOPHONY – VOICE OF THE GOAT – BLEATING - E – A CHANGES – COMPARE SIDE TO SIDE
REMEMBER - ALL SUGGEST CONSOLIDATION OF THE LUNG
THORACIC EXPANSION
ASYMETRY IN EXPANSION OF THE THORAX CAN BE DETECTED DURING INSPECTION OF THE CHEST
DURING PROMPTED INHALATION OBSERVE THE MOVEMENT OF THE THORAX
PLEURAL EFFUSION, PNEUMOTHORAX
CYANOSIS
PERIPHERAL – HANDS, FEET – WARMING DECREASES CYANOSIS – DECREASED CARDIAC OUTPUT
CENTRAL- LIPS, TONGUE,SUBLINGUAL - RIGHT TO LEFT
SHUNTS
PSEUDOCYANOSIS – BLUE PIGMENTS IN SKIN - AMIODARONE
Central Cyanosis
Results from pulmonary dysfunction, the mucous membrane of conjunctiva and tongue are bluish.
If there was chronic hypoxemia and secondary erythrocytosis, you can detect the conjunctival and scleral vessels to be full, tortuous and bluish.
Significance: Clubbing Observed In:
Intrathoracic malignancy: Primary or secondary (lung, pleural, mediastinal)
Suppurative lung disease: (lung abscess, bronchiectasis, empyema)
Diffuse interstitial fibrosis: Alveolar capillary block syndrome
In association with other systemic disorders
CLUBBING
PAINLESS – FINGERNAILS CURVED AND WARM
ENLARGEMENT OF THE CONNECTIVE TISSUES IN THE TERMINAL PHALANGES OF THE FINGERS >TOES
LOVIBOND’S ANGLE – THE ANGLE BETWEEN THE BASE OF THE NAIL AND SURROUNDING
SKIN.
CLIN CHEST MED 8:287-298,1987
CLUBBING
DO NOT FORGET THE TRACHEA
TRACHEAL DEVIATION
AUSCULTATE - STRIDOR
TRACHEAL TUG (OLIVERS SIGN) – DOWNWARD DISPLACEMENT OF THE CRICOID CARTILAGE WITH VENTRICULAR CONTRACTION – OBSERVED IN PATIENTS WITH AN AORTIC ARCH ANEURYSM
TRACHEAL TUG (CAMPBELL’S SIGN) – DOWNWARD DISPACEMENT OF THE THYROID CARTILAGE DURING INSPIRATION – SEEN IN PATIENTS WITH COPD
ABNORMAL BREATHING PATTERNS
APNEA - CARDIAC ARREST
BIOTS – INCREASED INTRACRANIAL PRESSURE – DRUGS- MEDULLA
CHEYNE STOKES – CONGESTIVE HEART FAILURE – DRUGS – CEREBRAL
KUSSMAULS – METABOLIC ACIDOSIS
WHITE NOISE (NOISY BREATHING) THIS NOISE CAN BE HEARD AT THE BEDSIDE
WITHOUT THE STETHOSCOPE LACKS A MUSICAL PITCH AIR TURBULENCE CAUSED BY NARROWED
AIRWAYS CHRONIC BRONCHITIS
LUNG SOUNDS
BREATH SOUNDS ADVENTITIOUS
TRACHEALBRONCHIALVESICULAR
WHEEZERHONCHICRACKLE
PLEURAL RUBSTRIDORSQUEAK
BREATH SOUNDS VESICULAR – NORMAL BREATH SOUNDS - SITE OF PRODUCTION THE
ALVEOLI TRACHEAL – TUBULAR – LIKE BLOWING AIR THROUGH A HOLLOW
TUBE – PHYSIOLOGIC
BRONCHIAL – TUBULAR - ALWAYS PATHOLOGIC WHEN THEY OCCUR OVER POSTERIOR OR LATERAL CHEST WALL
BRONCHOVESICULAR – CHARACTERISTICS OF BOTH VESICULAR AND TUBULAR – DO THEY EXIST?
ADVENTITOUS – EXTRA SOUNDS
BREATH SOUNDS
TIMING
CHARACTERISTIC
TRACHEAL BRONCHIAL BV VESICULAR
INTENSITY VERY LOUD LOUD MODERATE LOW
I:E RATIO 1:1 1:3 1:1 3:1
Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea, bronchi to chest wall
Rustling quality Inspiration continuous with expiration Intensity increases during inspiration & fades
during first 1/3rd expiration
Diminished breath sounds
Conduction limited by Airflow limitation
e.g. diffusely – asthma, emphysema
localised – tumour, collapse
Something separating chest wall from lung
e.g. effusion, fibrosis
Bronchial breathing
“blowing” inspiratory & expiratory sounds Expiratory phase as long as inspiration Distinct pause between phases High-pitched e.g. consolidation Low-pitched e.g. fibrosis
Rhonchi
Due to passage of air through narrowed bronchus e.g. bronchospasm, mucosal oedema
Musical quality High or low pitched Usually expiratory Expiration prolonged
Crepitations
Inspiratory noises, usually 2nd half Non-musical Due to explosive reopening of peripheral
small airways during inspiration which have become occluded during expiration
Pleural Rub
Creaking noise Movement of visceral pleura over parietal
pleura Surfaces roughened by exudate 2 separate phases at end inspiration and
early expiration
ADVENTITIOUS SOUNDS
THESE ARE SOUNDS HEARD DURING AUSCULTATION OTHER THAN BREATH SOUNDS OR VOCAL RESONANCE
NOMENCLATURE – HAS BEEN CONFUSING
CRACKLES – DISCONTINUOUS SOUNDS WHEEZES AND RHONCHI – CONTINUOUS
SOUNDS
ADVENTITIOUS LUNG SOUNDS (BRUITS ETRANGERS – FOREIGN SOUNDS)
WHEEZE – HIGH PITCHED RHONCHI – LOW PITCHED CRACKLE RALES - HAIR VELCRO
(FINE – COARSE) PLEURAL RUBS – CREAKING LEATHER STRIDOR SQUEAK – HIGH PITCHED WHEEZE
HEARD AT THE END OF INSPIRATION
EARLY AND MID INSPIRATORY LATE INSPIRATORY
COARSE FINE
LOW PITCHED HIGH PITCHED
CLEAR WITH COUGHING DO NOT CLEAR WITH COUGHING
SCANTY PROFUSE
GRAVITY IN DEPENDENT GRAVITY DEPENDENT
TRANSMITTED TO THE MOUTH POORLY TRANSMITTED TO THE MOUTH
ASSOCIATED WITH OBSTRUCTION
ASSOCIATED WITH RESTRICTION
CRACKLES
BRONCHITIS- BRONCHIECSTASIS
INTERSTITIAL FIBROSIS - INTERSTITIAL EDEMA
SIGNIFICANCE OF LATE AND EARLY CRACKLES
EARLY – CENTRAL AIRWAYS (BRONCHITIS)
LATE – PERIPHERAL AIRWAYS (FIBROSIS,EDEMA)
WHEEZING
ASTHMA BRONCHITIS VOCAL CORD
DYSFUNCTION FOREIGN BODY
ASPIRATION INFECTIONS – CROUP
LARYNGITIS
CONGESTIVE HEART FAILURE
COPD FORCED EXPIRATION IN
NORMAL SUBJECTS CYSTIC FIBROSIS
NOT ALL THAT WHEEZES IS ASTHMA
PURSED – LIPS BREATHING
COPD – DECREASES DYSPNEA DECREASES RR INCREASES TIDAL VOLUME DECREASES WORK OF BREATHING
CHEST 101:75-78, 1992
HOOVERS SIGN
COPD IN COPD THE DIAPHRAGM MAY BE
FLATTENED, DURING THE INSPIRATORY PHASE OF A BREATH THE RIBS ARE PULLED INWARD AND MEDIALLY RATHER THAN OUTWARD AND LATERALLY
RESPIRATORY ALTERNANS
NORMALLY BOTH CHEST AND ABDOMEN RISE DURING INSPIRATION
PARADOXICAL RESPIRATION IMPLIES THAT DURING INSPIRATION THE CHEST RISES AND THE ABDOMEN COLLAPSES
IMPENDING MUSCLE FATIGUE
PNEUMONIA
INSPECTION – SPLINTING
PALPATION – INCREASED FREMITUS
PERCUSSION – DULL
AUSCULTATION – BRONCHIAL BREATH SOUNDS, CRACKLES, EGOPHONY, PECTORILOQUY, RHONCHI
ENDOBRONCHIAL OBSTRUCTION MAY MASK THE USUAL PHYSICAL FINDINGS OF PNEUMONIA
PNEUMONIA
PLEURAL EFFUSION
INSPECTION – LAG AFFECTED SIDE
PALPATION – ABSENT FREMITUS
PERCUSSION – FLAT, DULL
AUSCULTATION – ABSENT OVER EFFUSION, BRONCHIAL IMMEDIATELY ABOVE EFFUSION, RUB OCCASIONALLY
PLEURAL EFFUSION
PNEUMOTHORAX
INSPECTION – LAG AFFECTED SIDE
PALPATION – ABSENT FREMITUS
PERCUSSION – TYMPANIC
AUSCULTATION – ABSENT BREATH SOUNDS
PNEUMOTHORAX
Interpretation of findings
Pleural effusion reduced tactile vocal
fremitus reduced chest expansion stony dull reduced air entry no added sounds reduced vocal resonance
Consolidation increased tactile vocal
fremitus reduced expansion dull percussion bronchial breathing coarse creps increased vocal resonance whispering pectoriloquy
Interpretation of findings
Pneumothorax deviated trachea reduced tactile vocal
fremitus hyper-resonance reduced air entry reduced vocal
resonance
Collapse deviated trachea reduced tactile vocal
fremitus dull percussion reduced air entry +/- creps
1. Symptoms due to lung congestion:
Dyspnea. Acute pulmonary edema. Cough, hemoptysis. Recurrent chest infections.
2. Symptoms due to lung congestion:
Pain in the right hypochondrium. Dyspepsia. Swelling of lower limb. Swelling of the abdomen. Oliguria.
3. Symptoms due to low cardiac output:(tissue hypoxia →brain, muscles, kidneys) Exertional fatigue. Blurring of vision. Dizziness / Syncope. Oliguria, Angina.
4. Chest pain:
1. Of Cardiac Origin:
Ischemia, pericarditis, Dissecting aorta, Aortic Aneurysm.
2. Other Causes: Chest wall Neurological Mediastinum Diaphragm Abdominal. ( esophagus, stomach, gall bladder,
pancreas).
Analysis:
1. Site & radiation.
2. Provocation & relief.
3. Duration.
4. Character.
5. Associated features.
5. Symptoms due to changes in rate, Rhythm, or force → palpitation.
( time, mode of onset & offset, relation to exertion, duration, irregularity).
General Examination
1. General appearance.
2. Vital signs: pulse, temp. Blood pressure, respiration.
3. Hands: (cold, warm, clubbing, cyanosis, sweating)
4. Eyes
5. Neck:I. Neck veins.
II. Pulsations (arterial vs. venous).
III. Carotid arteries.
IV. Trachea, thyroid gland.
1. Combined Inspection and palpation:
1. Shape.
2. Cardiac impulses (apex beat, parasternal pulsations, epigastric, to the right of sternum, suprasternal notch, 2nd left space)
3. Thrills.4. Palpable heart sounds.5. Position of the mediastinum6. Tactile vocal fremitus7. Chest movements8. Local tenderness,pulsations,wheezes.
2. Percussion
Types of percussion notes Apices of the lungs Anterior chest wall Lateral chest wall Posterior chest wall Cardiac and hepatic dullness
3. Auscultation:
Apex, lower end of sternum (tricuspid area), aortic area and pulmonary area .
Murmurs:1. Timing 2. Character3. Point of maximum intensity and propagation4. Relation to respiration5. Intensity6. ± Thrill.