Refined Lung Exam:Review of Breath Sounds andCase Exercises :Refined Lung Exam:Review of Breath Sounds andCase Exercises


Review of Breath Sounds :Review of Breath Sounds http://www.stethographics.com/main/physiology_ls_introduction.html Go to this link and work through each of the sound bites and explanations Bronchial Vesicular Fine crackles Coarse crackles Wheezes Rhonchi


Stridor :Stridor Upper airway turbulent flow Go to: http://www.rale.ca/Stridor.htm for an example of stridor recorded in a 15 month old with croup


Case 1 :Case 1 78 year old man presents to the Emergency Department with 5 days of progressively worsening shortness of breath with severe shortness of breath the last 8 hours. The physical examination of the lungs shows the following.


Slide 5:C = Crackles = Decreased breath sounds and dullness to percussion = Tactile Fremitus CCCCCCCCCCCC CCCCCCCCCCC CCCCCCCCCCCC CCCCCCCCCCC CCCCCCCCCCCC CCCCCCCCCCC CCCCCCCCCCCC CCCCCCCCCCC CCCCCCCCCCCC CCCCCCCCCCC


Slide 6:What is your differential diagnosis?


: What is your differential diagnosis? Congestive heart failure with bilateral pleural effusions Usual interstitial pneumonia/Idiopathic pulmonary fibrosis with low lung volumes


: What additional physical examination findings would you like to narrow your DDx?


Additional Information :Additional Information VS: T 37.1 P 101 R 24 BP 175/80 JVP 15 cm Heart: regular, S1 and S2 are normal, no S3 or S4, no murmur, no hepatojugular reflux Abdomen: normal Extremities: 1+ edema


: This is a case of congestive heart failure Both CHF and pulmonary fibrosis have bilateral, dependent crackles CHF from interstitial edema Fibrosis from interstitial fibrosis Both may have bibasilar dullness and decreased fremitus CHF from pleural effusions Fibrosis from low lung volumes from the restrictive lung disease. In this case, the hemidiaphragms are elevated


: The elevated JVP differentiates this as CHF The absence of a gallop or murmur does not exclude CHF. Gallops are not common Murmurs signify valvular heart disease, but there are many other causes of CHF


Case #2 :Case #2 45 year old man presents to the Emergency Department with 5 days of shortness of breath.


: Interpret the physical exam findings


Slide 15:C = Crackles = Decreased breath sounds and dullness to percussion = Tactile Fremitus Patient A CCCCCCCCCCCCC


: What is your differential diagnosis?


: What if the physical findings are as follows? How does this change your differential diagnosis?


Slide 18:C = Crackles = Decrease breath sounds and dullness to percussion = Tactile Fremitus CCCCCCCCCCCCC Patient B


Slide 19:What are your diagnoses?


: Lobar pneumonia (Patient A) Pleural effusion (Patient B)


Slide 21:Note that the difference between the two patterns is that tactile fremitus is increased in consolidation and decreased in pleural effusion Vibratory sounds from the central airways are transmitted by solid (consolidated lung) Pleural effusion (fluid) does not transmit these vibrations efficiently


: What additional physical examination findings may help differentiate consolidation from effusion?


: Consolidation may be characterized by tubular breath sounds in an area that you would expect vesicular breath sounds Consolidation may also be characterized by egophany


: In either case, there may be crackles adjacent (on top of) the consolidation or the effusion Consolidation- Adjacent to the consolidation, there is a transition zone where the lung is not fully consolidated. In these areas, there is excess fluid in the alveoli and interstitium that produce crackles. Effusion- There may be compressive atelectasis adjacent to the effusion that may produce crackles.


Slide 25:C= Crackles V= Vesicular breath sounds T = Tubular breath sounds CCCCCCCCCCCCC TTTTTTTTTTTTTT TTTTTTTTTTTTTT TTTTTTTTTTTTTT Patient A


Slide 26:Patient A- LLL pneumonia


Slide 27:Patient A- LLL pneumonia


Slide 28:Patient B- Pleural effusion


Case #3 :Case #3 52 year old man with 10 year history of chronic dyspnea on exertion presents to the Emergency Department with 7 days of worsening shortness of breath.


Slide 30:PMI


Slide 31:W= Wheezing = Decrease breath sound intensity WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW WWWWWWW


: What is your differential diagnosis?


: What is your differential diagnosis? Asthma exacerbation Emphysema with bronchitic exacerbation (COPD exacerbation)


: What additional physical examination findings would you like to narrow your DDx?


Additional Information :Additional Information VS: T 36.8 P 110 R 28 BP 135/70 Thin, dyspneic, ill-appearing, pursed lip breathing JVP 6 cm Increased anterior-posterior diameter of the chest Heart: regular, S1 and S2 are almost inaudible, no S3 or S4, no murmur Abdomen: normal Extremities: no edema


: This is a case of emphysema with bronchitic exacerbation (COPD exacerbation) Asthma and COPD exacerbation are both characterized by diffuse wheezing, but can be difficult to distinguish when the emphysema is not severe Emphysema causes chronic, hyperinflation of the lungs Hyperinflation may cause the PMI to become subxyphoid as the diaphragm flattens and pulls the heart inferiorly


: Emphysema is characterized by the destruction of alveoli and the supporting structures distal to the respiratory bronchioles resulting in a loss of the elastic recoil that prevents airway collapse during inspiration This causes chronic airway obstruction and hyperinflation Asthma is caused by chronic airway inflammation and bronchoconstriction which may cause hyperinflation acutely, but not chronically


: Emphysema results in loss of lung parenchyma and alveoli causing a general decrease in the intensity of breath sounds Asthma exacerbation does not typically cause a diffuse decrease in breath sound intensity, unless the exacerbation is so severe that respiratory failure is imminent


Slide 40:Findings: Hyperlucent- upper > lower lungs Large lung volumes


Slide 41:Findings: Flattened hemidiaphragms Increased retrosternal airspace Consistent with hyperinflation


The End :The End