practical skills in chest Exam. : practical skills in chest Exam. Dr. Rabie zahran.
Tropical M. specialist .
Damietta Fever Hospital. Slide 2: Dr: Rabie Zahran Clinical Skills
These are skills needed for a successful doctor patient relationship.
These skills are :
1) history taking skills,
2) physical examination skills 3)communication skills. Slide 3: Dr: Rabie Zahran the American Board of Internal Medicine
Recognizing that skilled history-taking is in danger of becoming a lost art . Slide 4: Chest Examination
The 4 major components of chest exam are :
*Auscultation. Dr: Rabie Zahran Slide 5: Inspection Dr: Rabie Zahran Slide 6: Dr: Rabie Zahran Slide 7: A great deal of information can be gathered from simply watching a patient breath. Pay particular attention to:
(1) General comfort and breathing pattern of the patient. Do they appear :
* Are the breaths regular and deep? Dr: Rabie Zahran Slide 8: (2) Use of accessory muscles of breathing (e.g. scalenes, sterno-cleidomastoids). Their use signifies some element of respiratory difficulty.
(3) Color of the patient, in particular around the lips and nail beds. Obviously, blue is bad! Dr: Rabie Zahran Slide 9: Cyanosis of Nails Dr: Rabie Zahran Slide 10: Nail clubbing=when view fingernail from side, angle of base of nail is >160°. Dr: Rabie Zahran Slide 11: Dr: Rabie Zahran Slide 12: Dr: Rabie Zahran CLUBBING:
• Cyanotic heart diseases .• Lung ds: hypoxia, lung CA, bronchiectasis, CF• U Colitis, Crohn's• Biliary cirrhosis• Birth defect [harmless]• Infective Endocarditis .• Neoplasm [esp. Hodgkin]• GI mal-absorption Slide 13: (4)-The position of the patient. Those with extreme pulmonary dysfunction will often sit up-right. In cases of real distress, they will lean forward, resting their hands on their knees in what is known as the tri-pod position. Dr: Rabie Zahran Slide 14: Patient with emphysema bending over in Tri-Pod Position Dr: Rabie Zahran Slide 15: (5) Breathing through pursed lips, often seen in cases of emphysema.
(6) Ability to speak.
the fewer words per breath, the worse the problem.
(7) Any audible noises associated with breathing as wheezing or gurgling caused by secretions in large airways are audible to the "naked" ear. Dr: Rabie Zahran Slide 16: (8) Note any chest or spine deformities. These may arise as a result of:
*chronic lung disease (e.g. emphysema), *congenitally, or
In any case, they can impair patient's ability to breath normally.
A few common variants include: Dr: Rabie Zahran Slide 17: Chest Shape:
Pectus Excavatum (Funnel chest): Congenital posterior displacement of lower aspect of sternum. This gives the chest a somewhat "hollowed-out" appearance. The x-ray shows a subtle concave appearance of the lower sternum. Dr: Rabie Zahran Slide 18: Pectus Excavatum Dr: Rabie Zahran Slide 19: Pectus Carinatum (pigeon shaped chest): where the sternum and the costal cartilages project outwards. It can occur secondary to childhood asthma. Dr: Rabie Zahran Slide 20: Barrel chest: Associated with emphysema and lung hyperinflation.
x-ray chest shows :increased anterior-posterior diameter as well as diaphragmatic flattening. Dr: Rabie Zahran Slide 21: Harrison's sulcus Rickety Rosary Harrison's sulcus [depression above costal margin]
(rickets, childhood asthma) Or Rickety Rosary in Rickets. Dr: Rabie Zahran Slide 22: Spine abnormalities:
Kyphosis : Causes the patient to be bent forward. X-Ray chest clearly demonstrates extreme curvature of the spine. Dr: Rabie Zahran Slide 23: Scoliosis: Condition where the spine is curved to either the left or right.
Curvature is more pronounced on x-ray. Dr: Rabie Zahran Slide 24: (9) The direction of abdominal wall movement during inspiration. Normally, the descent of the diaphragm pushes intra-abdominal contents down and the wall outward.
In cases of severe diaphragmatic flattening (e.g. emphysema) or paralysis, the abdominal wall may move inward during inspiration, referred to as paradoxical breathing. Dr: Rabie Zahran Slide 25: If you suspect this to be the case, place your hand on the patient's abdomen as they breathe, which should accentuate its movement.
In respiratory distress, some of the following may occur:
* accessory muscle use,
* nasal flaring,
* inter-costal retractions,
* abdominal paradox. Dr: Rabie Zahran Slide 26: (10) Look for prominent chest veins, especially if the patient also had a raised JVP, as it can occur due to SVC obstruction. SVC. obstruction IVC. obstruction Dr: Rabie Zahran Slide 27: (11) see any scars? This may give an indication of previous operations or procedures.
(12) Look at the chest wall movements:
*Are they symmetrical, i.e. the same on both sides, or
*Is there a difference ?
*Is there any lag or impairment of respiratory movement ? Dr: Rabie Zahran Slide 28: Review of Lung Anatomy:
Understanding the pulmonary exam is greatly enhanced by recognizing the relationships between surface structures, the skeleton, and the main lobes of the lung.
Realize that this can be difficult as some surface landmarks (eg nipples) do not always maintain their precise relationship to underlying structures. Dr: Rabie Zahran Slide 29: Also, surface markers will give you:
*a rough guide to what lies beneath the skin.
The multi-colored areas of the lung model identify precise anatomic segments of the various lobes, which cannot be appreciated on examination. Main lobes are outlined in black.
The following abbreviations are used: RUL = Right Upper Lobe;
LUL = Left Upper Lobe;
RML = Right Middle Lobe;
RLL = Right Lower Lobe;
LLL = Left Lower Lobe. Dr: Rabie Zahran Slide 30: Dr: Rabie Zahran Costal
plura Rt. lung
3 lobes Lt. lung
2 lobes Slide 31: Anterior View Dr: Rabie Zahran Slide 32: Dr: Rabie Zahran Slide 33: Dr: Rabie Zahran Slide 34: Posterior View Dr: Rabie Zahran 1/4 3/4 1/4 3/4 Slide 35: Dr: Rabie Zahran Slide 36: Dr: Rabie Zahran Slide 37: Right Lateral View Dr: Rabie Zahran Slide 38: Dr: Rabie Zahran Slide 39: Dr: Rabie Zahran Slide 40: Dr: Rabie Zahran Slide 41: Dr: Rabie Zahran Slide 42: Palpation Dr: Rabie Zahran Slide 43: Palpation plays a relatively minor role in the examination of the normal chest as the structure of interest (the lung) is covered by the ribs and therefore not palpable.
Specific situations where it may be helpful include: Dr: Rabie Zahran Slide 44: 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. Dr: Rabie Zahran Slide 45: 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 pleural space (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 disease before this asymmetry can be identified on exam. Dr: Rabie Zahran Slide 46: Dr: Rabie Zahran Slide 47: 2-Tactile Fremitus:
* Normal lung transmits a palpable vibratory sensation to the chest wall. This is referred to as fremitus.
* This can be detected by placing the ulnar aspects of both hands firmly against either side of the chest while the patient says the words "Ninety-Nine." This maneuver is repeated until the entire posterior thorax is covered.
*The bony aspects of the hands are used as they are particularly sensitive for detecting these vibrations. Dr: Rabie Zahran Slide 48: Dr: Rabie Zahran Slide 49: Dr: Rabie Zahran Slide 50: Front Fremitus Dr: Rabie Zahran Slide 51: Back Fremitus Dr: Rabie Zahran Slide 52: Dr: Rabie Zahran Slide 53: Assessing Fremitus
Pathologic conditions will alter fremitus. In particular:
As in pneumonia. it can alter the transmission of air and sound. So, fremitus becomes more pronounced. Dr: Rabie Zahran Slide 54: Pleural fluid: a pleural effusion, can collect in the pleural space, displacing the lung upwards. Fremitus over an effusion will be decreased. Dr: Rabie Zahran Slide 55: Dr: Rabie Zahran Slide 56: Effusions and infiltrates can perhaps be more easily understood
using a sponge to represent the lung. In this model, an infiltrate is
Depicted by the blue coloration that has invaded the sponge itself
(sponge on left). Dr: Rabie Zahran Slide 57: 3- Investigating painful areas: If the patient complains of pain at a particular site it is important to carefully palpate around that area. for evidence of
* rib fracture,
* subcutaneous air (feels like your pushing on Rice Krispies or bubble paper), etc. Dr: Rabie Zahran Slide 58: 4- Palpate the trachea in the supra- sternal notch by either the index finger or both the index and middle fingers to detect its position, central or shifted to one side.
. Assess deviation If deviated, focus ensuing chest exam to upper lobe problem. Dr: Rabie Zahran Slide 59: Dr: Rabie Zahran Slide 60: Percussion Dr: Rabie Zahran Slide 61: Percussion:
This technique makes use of the fact that striking a surface which covers an air-filled structure (e.g. normal lung) will produce a resonant note while repeating the same maneuver over a fluid or tissue filled cavity generates a relatively dull sound.
If the normal, air-filled tissue has been displaced by fluid (e.g. pleural effusion) or infiltrated with white cells and bacteria (e.g. pneumonia), percussion will generate a deadened tone. Dr: Rabie Zahran Slide 62: Alternatively, processes that lead to
* chronic air trapping in the lung (e.g. emphysema) or
*acute air trapping in the pleural space, (e.g. pneumo-thorax), will produce hyper-resonant (i.e. more drum-like) notes on percussion. Dr: Rabie Zahran Slide 63: Dr: Rabie Zahran Allow your hand to swing freely at the wrist, hammering your finger onto the target at the bottom of the down stroke.
A stiff wrist forces you to push your finger into the target which will not elicit the correct sound.
In addition, it takes a while to develop an ear for what is resonant and what is not. Slide 64: A few things to remember:
If you percuss with your right hand, stand a bit to the left side of the patient's back.
Ask the patient to cross their hands in front of their chest, grasping the opposite shoulder with each hand. This will help to pull the scapulae laterally, away from the percussion field. Dr: Rabie Zahran Slide 65: 3.Work down the "alley" that exists between the scapula and vertebral column, which should help you avoid percussing over bone. 4.Try to focus on striking the distal inter-phalengeal joint (i.e. the last joint) of your left middle finger with the tip of the right middle finger. So you should cut your nails . Dr: Rabie Zahran Slide 66: The last 2 phalanges of your left middle finger should rest firmly on the patient's back.
Try to keep the remainder of your fingers from touching the patient, or rest only the tips on them if this is otherwise too difficult , in order to minimize any dampening of the percussion notes. Dr: Rabie Zahran Slide 67: 6. When percussing any one spot, 2 or 3 sharp taps should suffice, though feel free to do more if you'd like. Then move your hand down several inter-spaces and repeat the maneuver. In general, percussion in 5 or so different locations should cover one hemi-thorax. Dr: Rabie Zahran Slide 68: After you have percussed the left chest, move yours hands across and repeat the same procedure on the right side.
If you detect any abnormality on one side, it's a good idea to slide your hands across to the other for comparison. In this way, one thorax serves as a control for the other. Dr: Rabie Zahran Slide 69: In general,
percussion is limited to the posterior lung fields. However, if auscultation reveals an abnormality in the anterior or lateral fields, percussion over these areas can help identify its cause. Dr: Rabie Zahran Slide 70: Dr: Rabie Zahran Slide 71: Percussion Technique Dr: Rabie Zahran Slide 72: Proper Technique Dr: Rabie Zahran Slide 73: Anterior Chest Posterior Chest Dr: Rabie Zahran Slide 74: 7. The goal of percussion is to recognize the quality of the sound changes. Dr: Rabie Zahran Slide 75: 8. "Speed percussion" may help to accentuate the difference between dull and resonant areas. During this technique, the examiner moves their left (i.e. the non-percussing) hand at a constant rate down the patient's back, tapping on it continuously as it progresses towards the bottom of the thorax. This tends to make the point of inflection (i.e. change from resonant to dull) more pronounced. Dr: Rabie Zahran Slide 76: Interpretation
Percussion Notes and Their Meaning
Flat or Dull : Pleural Effusion or
Normal : Healthy Lung or Bronchitis
Hyper-resonant : Emphysema or
Pneumo-thorax Dr: Rabie Zahran Sites of Anterior percussion : Sites of Anterior percussion Dr: Rabie Zahran Position of Posterior percussion : Position of Posterior percussion Dr: Rabie Zahran Slide 79: Auscultation Dr: Rabie Zahran Slide 80: Auscultation:
Prior to listening over any one area of the chest, remind yourself which lobe of the lung is heard best in that region:
* lower lobes occupy the lower
3/4 of the posterior fields; * right middle lobe heard in right axilla; * lingula in left axilla; * upper lobes in the anterior chest and at the upper 1/4 of the posterior fields. Dr: Rabie Zahran Slide 81: This can be helpful in trying to pin down the location of pathologic processes that may be restricted by anatomic boundaries(e.g. pneumonia).
Many disease processes (e.g. pulmonary edema, broncho-constriction) are diffuse, producing abnormal findings in multiple fields. Dr: Rabie Zahran Slide 82: Put on your stethoscope so that the ear pieces are directed away from you. Adjust the head of the scope so that the diaphragm is engaged. If you're not sure, scratch lightly on the diaphragm, which should produce a noise. If not, twist the head and try again. Gently rub the head of the stethoscope on your shirt so that it is not too cold prior to placing it on the patient's skin. Dr: Rabie Zahran Slide 83: 2. The upper aspect of the posterior fields (i.e. towards the top of the patient's back) are examined first. Listen over one spot and then move the stethoscope to the same position on the opposite side and repeat.( This again makes use of one lung as a source of comparison for the other.) The entire posterior chest can be covered by listening in roughly 4 places on each side. Of course, if you hear something abnormal, you'll need to listen in more places. Dr: Rabie Zahran Slide 84: Lung Auscultation Dr: Rabie Zahran Slide 85: Front sites Dr: Rabie Zahran Slide 86: Back sites Dr: Rabie Zahran Slide 87: 3. The lingula and right middle lobes can be examined while you are still standing behind the patient.
4. Then, move around to the front and listen to the anterior fields in the same fashion. This is generally done while the patient is still sitting upright. Asking female patients to lie down this will allow their breasts to fall away laterally, which may make this part of the examination easier. Dr: Rabie Zahran Slide 88: A few additional things worth noting.
Don't get in the habit of performing auscultation through clothing. Dr: Rabie Zahran Slide 89: Dr: Rabie Zahran Good exam options Slide 90: Dr: Rabie Zahran 2. Ask the patient to take slow, deep breaths through their mouths while you are performing your exam. This forces the patient to move greater volumes of air with each breath, increasing the duration, intensity, and thus detect-ability of any abnormal breath sounds that might be present.
3. Sometimes it's helpful to have the patient cough a few times prior to beginning auscultation. This clears airway secretions and opens small atelectatic (i.e. collapsed) areas at the lung bases. Slide 91: 4. If the patient cannot sit up (e.g. in cases of neurologic disease, post-operative states, etc.), auscultation can be performed while the patient is lying on their side. Get help if the patient is unable to move on their own. In cases where even this cannot be accomplished, a minimal examination can be performed by listening laterally/posteriorly as the patient remains supine.
5. 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. Dr: Rabie Zahran Slide 92: What can you expect to hear? A few basic sounds to listen for:
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 vesicular breath sounds. Dr: Rabie Zahran Slide 93: Wheezes are whistling-type noises produced during expiration (and sometimes inspiration) when air is forced through airways narrowed by broncho-constriction, secretions, and/or mucosal edema.
As in asthma and emphysema,
It is frequently audible in all fields. Dr: Rabie Zahran Slide 94: Occasionally, focal wheezing can occur when airway narrowing if restricted to a single anatomic area, as might occur with an obstructing tumor or broncho-constriction induced by pneumonia. Dr: Rabie Zahran Slide 95: Dr: Rabie Zahran Wheezing heard only on inspiration is referred to as stridor and is associated with mechanical obstruction at the level of the trachea/upper airway.
This may be best appreciated by placing your stethoscope directly on top of the trachea. Slide 96: Rales (crackles) are scratchy sounds that occur in association with processes that cause fluid to accumulate within the alveolar and interstitial spaces. The sound is similar to that produced by rubbing strands of hair together close to your ear.
As in Pulmonary edema, and results in symmetric findings.
This occur first in the most dependent portions of the lower lobes and extend towards the apices as disease progresses. Dr: Rabie Zahran Slide 97: Pneumonia, on the other hand, can result in discrete areas of alveolar filling, and therefore produce crackles restricted to a specific region of the lung.
In pulmonary fibrosis :
diffuse, dry-sounding crackles, similar to the noise produced when separating pieces of Velcro, are heard. Dr: Rabie Zahran Slide 98: Dr: Rabie Zahran Slide 99: Dense consolidation of the lung parenchyma, as can occur with pneumonia, results in the transmission of large airway noises (i.e. those normally heard on auscultation over the trachea… known as tubular or bronchial breath sounds) to the periphery.
In this setting, the consolidated lung acts as a terrific conducting medium, transferring central sounds directly to the edges. Dr: Rabie Zahran Slide 100: Furthermore, if you direct the patient to say the letter 'eee' it is detected during auscultation over the involved lobe as a nasal-sounding 'aaa'. These 'eee' to 'aaa' changes are referred to as egophony. Dr: Rabie Zahran Slide 101: 5. Secretions that form/collect in larger airways, as might occur with bronchitis or other mucous creating process, can produce a gurgling-type noise, similar to the sound produced. These noises are referred to as ronchi. Dr: Rabie Zahran Slide 102: 6. Auscultation over a pleural effusion will produce a very muffled sound. If, however, you listen carefully to the region on top of the effusion, you may hear sounds suggestive of consolidation, originating from lung which is compressed by the fluid pushing up from below. Asymmetric effusions are probably easier to detect as they will produce different findings on examination of either side of the chest. Dr: Rabie Zahran Slide 103: 7. Auscultation of patients with severe, stable emphysema will produce very little sound .Those patients suffer from significant lung destruction and air trapping, resulting in their breathing at small tidal volumes that generate almost no noise. Wheezing occurs when there is a superimposed acute inflammatory process. Dr: Rabie Zahran Slide 104: Most of the above techniques are complimentary. Dullness detected on percussion, for example,
may represent either:
* lung consolidation or
On Auscultation over the same region: consolidation generates bronchial breath sounds while an effusion is associated with a relative absence of sound. Similarly,
fremitus will be increased over consolidation and decreased over an effusion. Dr: Rabie Zahran Slide 105: As such, it may be necessary to repeat certain aspects of the exam, using one finding to confirm the significance of another.
Few findings are pathognomonic. They have their greatest meaning when used together to paint the most informative picture. Dr: Rabie Zahran Slide 106: Normal breath sounds Dr: Rabie Zahran Adventitious sounds : Adventitious sounds Dr: Rabie Zahran Auscultation of anterior thorax : Auscultation of anterior thorax Dr: Rabie Zahran Auscultation of posterior thorax : Auscultation of posterior thorax Dr: Rabie Zahran Slide 110: Dr: Rabie Zahran شكرا لحسن إستماعكم د:ربيع زهران