Lungs & Heart - Physical Examination

COPD (Blank) [4 words] is an umbrella term used to describe progressive lung diseases including emphysema, chronic bronchitis, refractory (non-reversible) asthma, and some forms of bronchiectasis. This disease is characterized by increasing breathlessness.

Respiratory Examination 

• Observation, inspection

• Palpation

• Tapping

• Percussion

• Auscultation

Wasting of small muscles of hand in (Blank) [2 words].

Place you hands on chest- at the point of lower ribs--ask to do a deep breath in and out– look for the distance between big thumbs. The distance should be no more then 5 cm and expansion should be symmetrical Then place hand on the anterior chest and ask to breath in and out—look for anterior and posterior expansion of the chest– it should be symmetrical Find the apex beat of the heart in the (blank) intercostal space. It can be shifted to the side in patient with pneumothorax.  

A pneumothorax is...

• An abnormal collection of air in the pleural space // the lung and chest wall.

• Symptoms: Typically include a sudden onset of sharp, one-sided chest pain and shortness of breath.

• Symptoms: Typically include a sudden onset of sharp, one-sided chest pain and sneezing.

• Symptoms: Typically include a sudden onset of dull, one-sided chest pain and shortness of breath.

Place you hands on chest- at the point of lower ribs--ask to do a deep breath in and out– look for the distance between big thumbs. The distance should be no more then 5 cm and expansion should be symmetrical Then place hand on the (blank) [2 words] and ask to breath in and out—look for anterior and posterior expansion of the chest– it should be symmetrical.

Right ventricular heave (blank) [2 words].

Palpation-posterior positionAssess (Blank) [2 words] — "ninety-nine" Normal lung transmits a palpable vibratory sensation to the chest wall. 

Important Hand signs in Respiration.

• Cyanosis of the nails

• Nail Bed Fluctuation (the first sign in clubbing)

• Hair on fingers

• Clubbing Nails

• CO2 Retention Flap Sign of Hypercapnia (due to abnormally elevated Carbon Dioxide levels)

• Yellow hands

• Salbutamol induced tremor (Side effects of using Salbutamol as a treatment)

Emphysema is...

• Caused by damage to bronchial root.

• Chronic Lung disease

• Caused by damage to the alveoli

• Damage to Alveoli results in fluid becoming trapped, causing them to expand and rupture.

• Damage to Alveoli results in air becoming trapped, causing them to expand and rupture.

Accentuating normal chest excursion: Place your hands on the patient's back with thumbs pointed towards the spine. Remember to first rub your hands together so that they are not too cold prior to touching the patient. Your hands should lift symmetrically outward when the patient takes a deep breath. Processes that lead to asymmetric lung expansion, as might occur when anything fills the (Blank) [2 words] (e.g. air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree. There has to be a lot of plerual fluid before this asymmetry can be identified on exam.

Pneumonia stages:    

• Congestion within first 24 hours; characterized by vascular engorgement, intra-alveolar fluid, small numbers of neutrophils, often numerous bacteria. Grossly, the lung is heavy and hyperaemic.

• Red hepatization or consolidation; vascular congestion persists, with intravasation of red cells into alveolar spaces, along with increased #s of neutrophils and fibrin. The filling of airspaces by the exudate leads to a gross appearance of solidification, or consolidation of the alveolar parenchyma. This appearance has been likened to that of the liver, hence the term "hepatization".

• Red hepatization or consolidation; vascular congestion persists, with extravasation of red cells into alveolar spaces, along with increased #s of neutrophils and fibrin. The filling of airspaces by the exudate leads to a gross appearance of solidification, or consolidation of the alveolar parenchyma. This appearance has been likened to that of the liver, hence the term "hepatization".

• Grey Hepatization: Red cells disintegrate, with persistence of the neutrophils and fibrin. The alveoli still appear consolidated, but grossly the colour is paler and the cut surface is drier.

• Resolution (complete recovery): The exudate is doubled by enzymatic activity, and cleared by macrophages or by cough mechanism. Enzymes produced by neutrophils will liquify exudates, and this will either be coughed up in sputum or be drained via lymph.

• Resolution (complete recovery): The exudate is digested by enzymatic activity, and cleared by macrophages or by cough mechanism. Enzymes produced by neutrophils will liquify exudates, and this will either be coughed up in sputum or be drained via lymph.

A (Blank) is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath.

Place you hands on chest- at the point of lower ribs--ask to do a deep breath in and out– look for the distance between big thumbs. The distance should be no more then (blank) [2 words - distance] and expansion should be symmetrical.

Accessory Muscle Use / Intercostal RetractionNeck and shoulder muscles used to assist breathing.  Muscles between ribs (Blank) [2 words] during inspiration.

Bronchiectasis is a disease in which...

• Permanent enlargement of parts of the airways of the lung.

• Typical symptoms: Chronic Cough with mucous production

• Other Symptoms: Shortness of breath, coughing up blood and chest pain.

• Typical symptoms: Chronic Cough with mucous production; coughing up blood.

Chest Deformities

• Funnel Chest

• Pigeon Chest

• Canary Chest

• Harrison's Sulcus

Ausculation - how to:

• Requesting that the patient exhale forcibly will occasionally help to accentuate abnormal breath sounds (in particular, wheezing) that might not be heard when they are breathing at normal flow rates.

• Ask patient to take slow, deep breaths (increases duration, intensity-thus detestability of abnormal breath sounds)

• Have patient cough DURING auscultation (clears airway secretions and opens small atelactatic areas at lung bases).

• Have patient cough BEFORE beginning auscultation (clears airway secretions and opens small atelactatic areas at lung bases).

• If patient cannot sit up - auscultation can be performed while patient is lying on their side.

• Request patient exhale forcibly - can sometimes help to accentuate abnormal breath sounds (esp.wheezing)

• If patient needs to remain supine - a minimal examination can be performed by listening laterally/posteriorly.

Which muscles to look for when checking to see if patient is using accessory muscle to breathe.

• Sternocleidomast

• Scalene Trapezius

• Brachials

• Pectorialis Major

• Internal Inter-costals

• Abdominal Muscles

Recognizing inadequate breathing.

• Yellow or Cyanotic skin

• Fast or slow rate; Irregular Rhythm

• Abnormal Lung Sounds

• Reduced Tidal Volumes

• Use of Accessory Muscles

• Canary shaped ribs

• Cool, damp, pale or cyanotic skin

Possible Etiology for Accessory Muscle Use while breathing.

• COPD

• Asthma in exacerbation

• Secretion Retention

• Indicates Severe Respiratory distress and Hypoxemia

Change in pattern of Respiration

• Laboured Respiration (Assess for the use of Accessory muscles f)

• Belly breathing

• Retraction of intercostal spaces during inspiration

• Long expiratory phase of respiration

• Laughing while exhaling

• Use of abdominal muscles to aid in expiration

Areas of the lungs for percussion

• Anterior Wall - Upper Lobe

• Anterior Wall - Lower Lobe

• Posterior Wall - Upper Lobe

• Posterior Wall - Lower Lobe

• Right Lateral Wall - Middle Lobe

• Left Lateral Wall - Lingula

Chronic Obstructive Pulmonary Disease (COPD)  is characterized by increasing breathlessness. COPD is an umbrella term used to describe progressive lung diseases including.

• Some forms of Bronchiectasis

• Emphysema

• Chronic Bronchitis

• Refractory (non-reversible) asthma

• All forms of Bronchiectasis

Respiration Examination - Observation 

• Well or unwell

• Altertness and conscious level

• Body Habitus

• Absconcess

• Signs of Respiratory Distress: Trachea, Tripod position, Use of Accessory Muscles, Pursed Lips, Flared Nostrils

• Ability to whistle

• Breathing Pattern

• Added Breathing Sounds

• Cough: Dry or Productive

A healthy individual breathing through their mouth at normal tidal volumes produces a soft inspiratory sound as air rushes into the lungs, with little noise produced on expiration. These are referred to as (Blank) [3 words]. 

(Blank) [2 words] refers to an increased loudness of whispering. Usually spoken sounds of a whispered volume by the patient would not be heard by the clinician auscultating a lung field with a stethoscope EXCEPT in areas of the lung where there is lung consolidation, these whispered spoken sounds by the patient (such as saying 'ninety-nine') will be clearly heard through the stethoscope. This increase in sound exists because sound travels faster and thus with lower loss of intensity through liquid or solid ("fluid mass" or "solid mass," respectively, in the lung) versus gaseous (air in the lung) media. Whispered pectoriloquy is a clinical test typically performed during a medical physical examination to evaluate for the presence of lung consolidation, which could be caused by cancer (solid mass) or pneumonia (fluid mass).