advanced chest exam voice

The Chest Exam : The Chest Exam Dr Michael Zychowicz Nurse Practitioner Associate Professor of Nursing Mount Saint Mary College

Surface anatomy : Surface anatomy

Surface anatomy : Surface anatomy

Landmarks : Landmarks

More anatomy : More anatomy

Pulmonary anatomy : Pulmonary anatomy

Pulmonary Ventilation : Pulmonary Ventilation Boyles Law Pressure decreases – volume expands Pressure increases – volume decreases Intrapulmonary pressure drives air exchange Based on Boyles law Diaphragm and external/ internal intercostals Accessory muscles Scalene, sternocleidomastoid, and trapezius

Specific Symptoms: Cough : Specific Symptoms: Cough Dry/ hacking Viral infection, interstitial lung disease, tumor, allergies, anxiety Chronic productive Bronchiectasis, chronic bronchitis, abscess, Tb, bacterial pneumonia Wheezing Bronchospasm, asthma, allergies, CHF Barking Epiglottal disease (croup)

Specific Symptoms: Cough : Specific Symptoms: Cough Stridor Tracheal obstruction Morning cough Smoking Night time cough Post nasal drip, CHF, GERD Inadequate cough Debility, weakness With eating or drinking Neuromuscular disease of the upper esophagus

Specific symptoms: Sputum Production : Specific symptoms: Sputum Production Mucoid/ mucopurulent Asthma, tumors, Tb, emphysema, pneumonia Yellow/ green purulent Chronic bronchitis, bronchiectasis Rust colored purulent Pneumococcal pneumonia Red currant jelly Klebsiella pneumonia Foul odor Lung abscess

Specific Symptoms: Sputum Production : Specific Symptoms: Sputum Production Pink, blood tinged Streptococcal or staphylococcal pneumonia Gravel Broncholithiasis Pink frothy Pulmonary edema Profuse and colorless Alveolar cell carcinoma Bloody Pulmonary emboli, bronchiectasis, abscess, Tb, tumor, cardiac in origin, bleeding disorders

Hemoptysis Vs. Hematemesis : Hemoptysis Vs. Hematemesis Coughing ? Hx of heart/ lung disease Frothy appearance Bright red Mixed with pus Assoc. w/ dyspnea N+V ? Hx of GI disease Not frothy Dark red/brown/ or “coffee ground” Mixed with food Assoc w/ nausea

Common Symptoms: Dyspnea : Common Symptoms: Dyspnea Orthopnea SOB while lying flat CHF, severe asthma, emphysema, mitral valve disease Trepopnea SOB relieved while lying on one side CHF Platypnea SOB while sitting upright Neurologic diseases, cirrhosis, S/P pneumonectomy Paroxysmal nocturnal dyspnea Sudden onset of SOB while asleep

Common Symptoms: Wheezing : Common Symptoms: Wheezing Asthma Bronchospasm “ All that wheezes is not asthma” Foreign bodies/ secretions Obstruction of airway Tumor Obstruction of airway Stridor – non wheezing noisy breathing obstruction Voice changes with or w/o wheezing Inflammation or laryngeal nerve damage

Common Symptoms: Chest Pain : Common Symptoms: Chest Pain First, think cardiac problem!!!! Sharp, stabbing, worse on inspiration Pleuritic pain Parietal pleura inflammation

Inspection : Inspection General appearance? Do they look like they are having difficulty? Flaring nostrils? Pursed lip breathing? COPD Attempt at positive pressure Preventing alveolar collapse Also aiding exhalation Able to talk? Respirations Rate, pattern, depth, symmetry, audibility, patient position, mode of breathing 12 – 20/ min

Inspection : Inspection Intercostal spaces Retraction or bulging Asthma, laryngeal obstruction, foreign body, tension pneumothorax, emphysema, tumor Muscles of respiration Accessory muscle use Exercise, asthma, pneumonia, pulmonary edema, pneumothorax,

Inspection : Inspection Shape of the thorax AP: transverse diameter 1:2 Barrel chest 1:1 AP:transverse diameter COPD/ hyper-inflated airways from air trapping Pectus carinatum or excavatum, kyphosis, scoliosis Symmetry of chest wall Asymmetry – trauma, scoliosis Presence of superficial veins on thorax Superior vena cava obstruction (tumor)

Inspection : Inspection Costal angle Normal < 90 degrees Barrel chest > 90 degrees Skin color/ oxygenation Pink, pale, Cyanosis Clubbing of fingers COPD

Thoracic shape : Thoracic shape

Barrel chest changes : Barrel chest changes

Breathing patterns : Breathing patterns Cheyne stokes Crescendo-decrescendo-apnea Central cerebral or high brain stem lesions/ injury Ataxic No pattern Medullary damage Apneustic Prolonged gasping with inspiration Followed by short inefficient expiration Brain injury to pons

Breathing patterns : Breathing patterns Agonal Impending death Kussmauls Extreme depth and rate, regular rhythm DKA and metabolic acidosis

Breathing Patterns : Breathing Patterns

Palpation : Palpation General palpation Pulsations, masses, thoracic tenderness, crepitus Thoracic expansion Assess anterior and posterior Decreased Pneumonia, pneumothorax, pleural effusion, emphysema

Palpation : Palpation Tactile fremitus Anterior and posterior Use hands to feel vibration on chest Pt says “99” or “1,2,3” Buzzing – normal Increased pneumonia Decreased COPD, atelectasis, bronchial obstruction, pleural effusion, pneumothorax, obese or muscular

Pattern for tactile fremitus : Pattern for tactile fremitus

Palpation : Palpation Tracheal position - midline Normally lines up with suprasternal notch Deviation – tumor, large pleural effusion, pneumothorax

Tracheal position : Tracheal position

Percussion : Percussion Anterior and posterior General percussion All lung fields and compare bilaterally Resonant Normal Medium/loud low pitched Hyperresonant Pneumothorax, emphysema Loud low pitched “booming” Dull Pulmonary edema, hemothorax Soft high pitched

Percussion : Percussion Diaphragmatic excursion Posterior percussion Percuss with inhalation and exhalation Mark difference Normally 4-5 cm movement Decreased Emphysema, ascites, enlarged liver, abdominal mass Absent Trauma/ rupture, nerve injury

Auscultation : Auscultation General auscultation Bell (low) and diaphragm (high) Normal Breath Sounds Tracheal, bronchial, bronchovesicular, vesicular

Adventitious Breath Sounds : Adventitious Breath Sounds Crackles Airway secretions Bronchitis, infection, pulm. Edema, atelectasis, CHF Wheezing Airflow through obstruction Asthma, pulm. Edema, bronchitis, CHF Rhonchi Transient airway plugging bronchitis pleural friction rub Pleural inflammation Pneumonia, pulmonary infarction

Auscultation : Auscultation Bronchophony Pt says “99” listen with stethoscope over posterior thorax Normal – muffled “nine-nine” Consolidation – clear, loud, ”ninety-nine”

Auscultation : Auscultation Whispered pectoriloquy Pt whispers “1, 2, 3” or “99” Listen over posterior thorax Normal – muffled sounds heard Consolidation – clear “1, 2, 3” or “99” Egophony Pt says “eee” Listen over posterior thorax Normal – muffled “eee” Consolidation – “eee” changes to “aaa”