Thursday, September 11, 1997:
Respiratory symptoms
Stridor – Noisy breathing
Voice changes
Swelling of ankles- dependent edema (heart failure, renal ds, liver ds, obstruction of venous flow)
anasarcageneralized fluid
Other factors in the pt information or ROS that indicate the need for a respiratory exam:
Related HX. Risk factors
Employment, Nutritional status, Home environment, Traveling, Tobacco use, Hobbies, Exposure to
Resp.
infections.
Risk Factors Associated With Respiratory Disability: Table located in Folder in the Library:
COUGH:
OPPQRST Describe Assoc. Sx.
Smoking is the most common cause of chronic coughing – marked A.M.
Note: Pack-years of smoking.
Descriptors of cough: Possible Cause:
Dry, hacking Viral inf. Tumor, allergies, stress,
Chronic Productive Bronchiectasis, TB, abscess, chronic bronchitis, bact. pneum
Wheezing Bronchiospasm-asthma, allergy
Barking Croup
Stridor Tracheal obstruction
Morning Smoking
Nocturnal Post nasal drip, CHF
Assoc. with eating Esophageal NMS ds
Chronic bronchitis: person has chronic productive cough for at least three months during a year for two
consecutive years. Exam
findings may be normal.
Wednesday, September 17, 1997:
20 minutes late:
Sputum
Appearance Possible Cause
Mucoid Tumor, asthma, TB, emphysema
Mucopurulent " " & pneumonia
Purulent-Rusty Bacterial pneumonia
Purulent – yellow/green Chronic Bronchitis, bronchiectasis, TB, pneumonia
Foul odor Lung abscess, bronchiectasis
Blood tinged bacterial pneumonia, CHF
Pink, frothy Pulmonary edema CLASSIC FOR PULMONARY EDEMA
Profuse, colorless carcinoma, advanced and large tumor in the apical area.
Bloody Pulmonary emboli, TB, tumor, abscess, bronchiectasis, CA,
Cardiac problems, bleeding disorder
HEMOPTYSIS:
Do you smoke? Did this occur suddenly? Recurrent? How long? Blood tinged or actual clots
Associated symptoms – Vomiting, coughing, nausea, SOB, hoarseness
Recent surgery? Oral contraceptives, blood thinners
Coughed up blood (hemoptysis) vs. vomited blood (Hematemesis)
Features: Hemoptysis Hematemesis
Preceded by: coughing N/V
Past history: ? Hx./CR ds ? Hx./GI ds
Appearance: frothy airless
Color: br. Red br. Red or dark
Contains: nothing/pus ? Food
TABLE 2-5: Cough and Hemoptysis
CHEST PAIN
Cardinal symptom of cardiac disease
Pulmonary disease associated with diseases of chest wall or parietal pleura
OPPQRST
Chest wall – NMS diseases & quality of pain varies with problem
Parietal pleura - term: Pleuritis or pleurisy caused by irritation or inflammation (pneumonia, TB, empyema,
tumor pneumothorax) pain described
as sharp, stabbing, localized to one side felt more on inspiration and patient may splint to avoid pain.
TABLE 2-3: Chest pain.
Other systems besides cardiovascular can lead to chest pain. Parietal pleura is one of the most common.
Dyspnea: Shortness of breath, a subjective difficulty or distress in breathing, usually associated with
disease of the heart or lungs; occurs
normally during intense physical exertion or at high altitude.
Can also be positional
Next part will be on TEST!
Paroxysmal Nocturnal Dyspnea (PND) - Sudden Onset of SOB occurring at night while a pt. Sleeps. Pt.
Sits up and improves.
Orthopenia – SOB while lying flat, pt requires more pillows mc assoc. with: CHF, mitral valve ds
Trepopnea – pt more comfortable breathing lying on side associated with CHF
Platypnea – rare symptom where patient breaths easier in a recumbent position, associated with brainstem
or spinal lesions.
Important to qualify the dyspnea – exercise tolerance (DOE Dyspnea on Exertion)
Grade 1 – excessive activity or exercise (relative to that person)
Not necessarily abnormal. If a person runs a marathon look at the recovery time
Grade 2 – moderate activity
Grade 3 – mild activity
Grade 4 – minimal activity
Grade 5 – dyspnea at rest
WHEEZING
(N) Breath sounds: quiet, easy, barely audible near the open mouth, no definite pitch (a.k.a. – white noise)
Onset? Occurrence? Smoking history
Precipitating factors-allergies?
Palliative/Provocative
Causes:
Bronchiospasm – asthma, severe CHF
Aspirated foreign bodies or secretions – mucosal edema
Extrinsic compression of bronchus – tumor
CYANOSIS
Location? Onset? Palliative/Provocative.?
Associated symptoms: SOB, cough, bleeding
Differentiate central vs. peripheral
Central peripheral
Decreased O2 in lungs inc. extraction of O2
Chronic lung disease exposure to cold
Lips, mucosa, nail beds tips of fingers, toes, nose
Inc. w/warming disappears w/warming
Dec. O2 intake: foreign body, emphysema, and asthma
Dec. O2 absorption: pulmonary fibrosis, emphysema, and metastatic carcinoma
INFANT EVALUATION AT BIRTH – APGAR SCORING SYSTEM
012
1.Heart rate absent Slow > 100 BPM
2.Respiratory effort absent Slow/Irregular Good crying
3.Muscle tone Limp some flexion active motion
4.Response to catheter No response Grimace Cough or sneeze
In nostrils (tested after
Orophaynx is clear)
5.Color Blue/Pale Body Pink Completely Pink
__ Extremities Blue
Anterior:
MCL – Mid clavicular line
AAL – Anterior Axillary Line
Lateral side:
PAL – Posterior axillary line
MAL – Mid Axillary Line
AAL – Anterior Axillary Line
KNOW WHERE LUNGS GO BY DIMENSION AND IMPORTANT LAND MARKS ON EXPIRATION
AND INSPIRATION. This is good for her
test and for boards.
Frequently asked to demonstrate the right middle lobe in testing situations
The right middle lobe CANNOT be evaluated posteriorly. It can only be assessed in the mid-axillary
line in the anterior.
COMPONENTS OF THE EXAM
Inspection
Palpation
Percussion
Auscultation
Inspection:
Note shape of the chest and the movement
Normal adult chest is wider than deep and lateral diameter is larger than it’s AP diameter
In children the two dimensions approximate due to increased thoracic kyphosis
COPD and emphysema lead to a barrel shaped chest. An increase in the AP diameter.
Abnormal motion of the chest or paradoxal movement. Happens at area of multiple rib fracture. Flail
chest is another term for this.
Funnel chest associated with Marphans. Depression of lower portion of sternum. Murmurs.
Associated with rickets but not too
often. Important thing to note is compression of mediastinal structures.
Note patient’s posture
Thursday, September 18, 1997:
Missed first hour of notes:
Talked about lung problems and asthma, deviation of the trachea ect..
Sound transmission can be increased or inhibited with certain conditions.
Causes of INC/DEC tactile fremitus referenced form side-to-side: WE WILL NEED TO KNOW THIS
INCREASED DECREASED (Unilateral)
Pneumonia (Consolidation) Pneumothorax (pleural sp. Air)
Atelectasis Pleural effusion (fluid separates)
Bronchial obstruction (fibrosis)
Inflitrative tumor
DECREASED (Bilaterally)
COPD
Chest wall thickening (Fat, mm)
Percussion Notes: & their characteristics
Will only asses superficial changes, no deep seeded changes unless they are consistent all the way through.
She will not test on the chart for percussion.
She will test on certain notes where the sound can be produced and what diseases associated
KNOW THIS INFORMATION FOR HER EXAMS AND OTHER EXAMS:
Percussion Notes Example Pathology
Flatness Thigh Large Pleural Effusion
Dullness Liver Lobar Pneumonia (consolidation)
Resonance Normal lung Bronchitis
Hyperresonance None normally Emphysema, active asthma attack, small pnumthorax
Tympani Gastric air bubble of Large Pneumothorax
Puffed-out cheek
Evaluate lung fields with across and down pattern – ICS
Resonance: over all areas of lung filed
Abn: chronic bronchitis
Dullness: N à 3-4 ICS (L) heart,
Abn: consolidation
Missed the rest of this overhead.
Diaphragmatic excursion:
Done bilaterally. Check diaphragm with full inspiration and expiration. Start at inferior angle of scapula
and work your way down.
Percuss down and you should hear resonant percussion note.
When it changes to a dull percussion note you make a mark.
Anterior aspects do it from the nipple line down. Right will go from resonant to dull. On left side it will
go from resonant to tympani.
It is usually done posteriorly but can be done posteriorly also.
Diaphragmatic excursion:
Level between the dullness of on full expiration and full inspiration --- N: 4-6 cm
Decrease excursion: emphysema, obesity, collapses
Absent excursion: inflammation of diaphragm or visceral below, phrenic nerve palsy, peritonitis
AUSCULTATION:
4 Normal breath sounds heard: (H.O.)
Tracheal
Bronchial
Vesicular
Bronchovesicular
Inc. Intensity of breath sounds: by consolidation, which promotes sound transmission better than air-filled
alveoli.
Consolidation
Ateclestias
Pneumonia
Characteristics of breath sounds chart will be in the library and we have one in our book.
Dec. intensity of breath sounds: by impedance of airflow through bronchi and alveoli or when the
transmission of sound is poor:
Bronchial obstruction
Pneumothroax
Pleural effusion
Emphysema
COPD
Obesity
In an upright position, breath sounds are heard earlier in the upper part of lung.
Tracheal breath sounds are very loud because there is not very much overlying tissue.
Adventitious sounds (added) H.O.
Superimposed on Normal (N) sounds
Crackles (rales)
Wheezes & rhonchi
Pleural friction rub
Stridor
Transmitted Voice Sounds – Vocal Resonance:
Used to further evaluate abnormal Exam finding
Normal voice sounds are muffled & unclear
Wednesday, September 24, 1997:
20 minutes late to class
Auscultation
Tracheal: harsh and loud because there is nothing covering trachea.
Bronchial
Vesicular
Bronchovesicular
Increase intensity of breath sounds: by consolidation, which promotes sound transmission better than
air-filled alveoli.
Decrease intensity: of breath sounds by impedance of airflow through bronchi and alveoli or when the
transmission of sound is poor.
Bronchial obstruction
Pneumothorax
Pleural effusion
Obesity
COPD
Look for scenarios on test:
Shortness of breath, barrel shaped chest with diminished chest motion. Tactile fremitus diminished with no
sore spots. Change in angulatoin
becoming more horizontal toward ribs. Percussion is hyperresonant and breath sounds diminished
throughout the whole field.
DIAGNOSIS IS EMPHYSEMA
Adventitious Sounds (Added) H.O. Superimposed on N Sounds
Crackles (rales): fluid is inside lung tissue surrounding alveoli. Alveoli don’t open up as well and when
they open, they snap or pop
open. Sounds like rice crispies.
Wheezes & rhonchi
Pleural friction rub
Stridor: harsh inspiratory wheeze due to obstruction in either the larynx or trachea
TABLE 8-4 IN TEXT:
Transmitted voice sounds – Vocal Resonance:
Used to further evaluate abnormal exam findings
Normal voice sounds are muffled and unclear
Abnormal Conditions: (do not need to do all of them but in a testing situation you should assess. These are
transmitted vocal resonance test)
Bronchophony: greater clarity or increased loudness
Egophony: specific type of Bronchophony. When pt. Says e, it will sound like a
Whispered Pectoriloqy: whisper sounds will have increased appreciation.
Assess when you have Bronchovesicular sounds where they should not be.
If you have bronchial sounds where you should have vesicular sounds do one of these tests.
Increased Vocal Resonance: consolidation, collapse.
Decreased Vocal Resonance: (blockage of respiratory tree) emphysema.
TABLE 8-5 IN TEXT "You will absolutely learn it or learn to hate it"
Second hour watch video:
Respiratory sound video from the library.
Wednesday, September 24, 1997:
Extra hour for case studies:
She likes to test on the location of the middle lobe of the right lung.
Pattern to look at on a chest x-ray
Look at soft tissue of the neck and supraclavicular
Examine bony thorax and look for bony symmetry
Diaphragm should be relatively smooth
AP Chest Radiograph:
Patient in for routine physical. Had chronic productive cough for years. It was clear with little black
specks occasionally (tobacco).
Suffers from nocturnal as well as morning cough.
Clavicle appears to be missing on the right. There are no scars.
Clavicle was still there but it was diminished enough that it did not show up on x-ray.
There is bony destruction in this patient. Neoplasia leads to bony destruction. Metastasis from the lungs
to the clavicle.
Diaphragm is elevated on the left as to the right. This is because of the liver. There is a problem with the
diaphragm
There is respiratory lag, reduced diaphragmatic excursion, labored breathing
Can usually see lung vessels, if you cannot see them it could be pneumothorax
.
In this patient do tests to rule out neoplasia. Do bone scan, blood tests, biopsy ect…
NEW CASE:
Lateral x-ray: look at pre-cardiac space, cardiac space and post-cardiac space.
39 year old female and sent her x-rays as a new patient. (Chest x-rays)
Mid thoracic pain with a 39 year old female with no exam findings because she is not there yet.
Only one breast shadow on patient.
Vascularity on side of no breast increases the film density.
This patient has had a mastectomy. Make sure you do a very thorough examination.
Breast carcinoma can metastasize into the spine and this was an example of a national board question
77 year old man
Presents with chest pain and shortness of breath following an automobile accident
The whole right side was sore.
Wearing seatbelt as a passenger
Not cyanotic in any way.
Do history, OPPQRST
Past history is working on the docks on the riverfront lifting heavy boxes, is a smoker, and has had a
bout with tuberculosis.
Auto accident 2 days ago and things are getting more irritation for him.
He is leaning into the side when he sits
Breathing is increased and shallow.
See paradoxical motion of the chest
We expect to see fractures and in the X-Ray and we see multiple fractures
66 year old Man complaining of shortness of breath that has been progressive over the years.
Medical doctor told him he has arthritis in his back
Was a salesman who did lots of driving
Smoker of at least 45 years (2-3 packs/day)
Currently smokes ½ pack a day
Has labored breathing but does not purse lips. Uses accessory muscles of respiration
Not cyanotic and you do not note clubbing
Everything moving symmetrically
No respiratory lag but there is not much motion in chest even when he takes deep breath
He is a large man but not obese
Increased thoracic kyphosis
Palpation findings note no areas of tenderness on chest wall
Tender areas in T4-T6 in thoracics and there is no motion
Trachea is midline
Vocal and tactile fremitus
Percussion is hyperresonant all over (diffusely)
Diminished breath sounds on auscultation
DDX is emphysema (bolus emphysema)
Air trapping in upper lungs. Major pockets of air in upper lungs.
60 year old with left lung and chest pain
Pleuritic chest pain is a friction rub
Diaphragm is blunted because of fluid
There is a gigantic mass under the sternum
Mediastinal mass is a bronchiogenic carcinoma.
Lateral sulcus is blunted
DDX is a tumor with pleural effusion.
Thursday, September 25, 1997:
20 minutes late to class
Factors Associated With Breast Cancer
Age (80% of cases occur after age 40)
Early menarche (before age 12)
Late menopause ( after age 50)
Nulliparity (condition of having borne no children)
Late age at birth of first child (after age 30)
Personal history of premalignant mastpathy
Personal history of ovarian, endometral, or colon cancer
Family history of breast cancer
Diet high in animal fats
Obesity (may be a diagnostic factor)
Mass
Questions:
When did your first notice
Change with menses
Tender
Any skin changes
Recent injury
Nipple discharge or retraction
Pain
Questions
OPPQRST
Describe the pain
Unilateral or bilateral (infection is unilateral)
Associated symptoms
Recent injury
Nipple discharge
Questions:
Color of discharge
Onset
Unilateral or bilateral
Related to menses
Associated symptoms
On medication or orat contraceptives
m/c – bloody, serous, milky
Serous – thin & watery, may appear as yellow stain
Intraductal papilloma
Carcinoma
B/L: oral contraceptives
Bloody discharge
Intraductal papilloma
Malignant Intraductal papillary carcinoma
Milky: milk
Late pregnancy: lactation
Persistent lactation – galactorrhea
Pituitary tumor
Fibrocystic changes do not mean carcinoma 100%
Many women get carcinoma without first having fibrocystic changes.
Diet: benefic of soy in the diet. Soy is a precursor to estrogen. Look at this instead of hormone replacement
Ginseng is also a precursor to estrogen.
Exam Procedures (missed most of this overhead)
Inspection
Examination of the axilla (done in seated position as well as supine)
Palpation
Inspection:
Sitting and supine
Number, size shape, symmetry
Slight asymmetry in size is normal
Nipples:
To bring out dimpling or retraction have pt perform various maneuvers
1.raise arms over the heads – stretching skin
2.press hands against hips – contrast pecs
Palpation:
Supine: place a pillow under patients shoulder on side of exam
Proceed systematically: quadrant, linear, circular, zigzag
Note consistency of tissue – N varies widely physiologic nodularity may inc. become painful during or
before menses.
Best time to perform exam is 1-2 weeks or 7-10 days after menses.
Tenderness, mass, temperature of skin.
Note lesions in clock method with cm from the nipple.
Nodules
Size
Shape (round, regular, or irregular)
Consistency (soft, firm or hard)
Delimitation (margins)
Tenderness
Mobility – motility – fixed
Palpate each nipple
Compress or strip
Squeeze nipple and note any discharge
Thickening or blood discharge à cancer
Evaluate Axillary Nodes
Note: number, site, size, tenderness
Mobility
Rash – deodorant, dermatitis
Infection – sweat glands infection
Unusual pigmentation – may mean cancer
Flow sheet of lymph nodes of the breast.
Axillary nodes à apical (central) ex. Nodes à infraclavicular nodes à thoracic duct & supraclavicular à
Missed the rest of the flow sheet.
Video of breast exam:
Friday, September 26, 1997:
Case Studies (extra lecture)
CASE 1
Late 20’s Female
Chronic cold that lead to productive cough with LBP
Went to family physician and was put on antibiotics for the common cold (10 days)
They feel like they are doing better but after a few days the cough starts turning color. (yellow
productive cough)
Now they have a sharp pain upon coughing but now hurts to cough and bring arm back
Temp 100.8oF, pulse is about 80 bpm, Respirations 22/min, Blood pressure 126/78
Cervical is positive compression and Spurlings
Distraction does not bring relief. George’s maneuver negative
Dermatomes and myotomes normal
Normal active range of motion
Motion palpation with L SI, mid thoracic and rib subluxation
Respiratory is relatively normal upon inspection
No tender spots posteriorly except rib subluxation spot
Tracheal is midline
Mid lateral aspect around ant. Axillary line is increase in vocal tactile fremitus
percussion in this same are (rib 5 & 6) there is a dull note
Auscultation hear Bronchovesicular sounds, on left vesicular, on R 4&5 hear bronchial breast sounds till
about 6th intercostal space
All vesicular sounds on posterior aspect.
Could do Egophony, whisper pectoriloquay, Bronchophony
Bronchophony is positive
There is consolidation of fluid with increased density in the area.
DDX is pneumonia. Probably viral because it is associated with low grade fever.
Order sputum culture, swab out throat.
CASE 2
2 year old with asthma, problems with breathing.
Atelectasis is occurring with this because of bronchial obstruction because of mucous plugs. Closes off
portion of bronchial tree and
have airless lung. This usually happens with children who have chronic asthma. This will not happen
with one asthma attack.
This has pulled the mediastinal structures over to the side of airless lung.
Atelectasis behaves more like pneumonia than emphysema. If it occurs in the lower lobe further away
from bronchus you have
diminished tactile fremitus,
WILL NOT ASK THIS ON THE TEST BECAUSE IT IS A TRICKY SCENARIO.
CASE 3
40 year old male
Presents with back pain on the left side, lumbar region
History of alcoholism and acute pancreatitis, at least three times. Not considered chronic pancreatitis
because after inflammation
pancreatic enzymes are still normal.
Last episode over a year ago. Still has tenderness over the area.
Complains of back pain and cannot take a deep breath without pain.
His thoracic spine is very messed up. There are very many trigger points
Respiratory exam includes diminishment in motion appreciated on anterior and posterior aspect.
Trachea is midline
Tactile fremitus is diminished on posterior aspect on left as well as lateral an anterior.
Percussion: note a dull or flat percussion note along involved area
Diaphragmatic excursion decreased on left side
Auscultation shows diminished breath sounds except for above involved area.
Consider:
Neoplasm
Pseudo-abscess due to acute pancreatitis. (may develop in liver and pancreas)
Respiratory system consider:
X-ray shows more dense on left lower lobe
PULMONARY OR PLEURAL EFFUSION IS THE DDX. (How did it get there?)
Pleurisy could have developed with the inflammation of the pancreas
Blood test should be done to look at pancreatic enzymes
CBC should be done to look at possibility of infection.
CASE 4.
Healthy young man who was outside playing soccer and suddenly has sharp pain on left side and began
having difficulty breathing
Trachea being pulled to left side
Cyanosis of the lips
Labored breathing.
DDX: Spontaneous pneumothorax.
Would be asymmetrical
Person sweating with labored breathing.
Tactile fremitus would be decreased
Percussion note would be hyperresonant or tympanic (if large)
Decreased breath sounds on the side of involvement.
Can see no vascularity on the side involved in the x-ray
Case 5
Patient presents with a complaint of problems around the cervical, thoracic are.
Chronic productive cough
Low grade fever
Night sweats.
DDX IS TB
Apical area is the most common area for this to develop
Chronic fatigue
Weight loss
Chronic sputum production
Chronic coughing
Night sweats (classic)
Case 6
5 years post radiation therapy for Squamous cell carcinoma for epiglottis.
Now having significant respiratory problems
On x-ray there is a significant tumor.
This is a hylar mass
Person will probably develop pleural effusion if they have not already.
The thing about carcinoma in early stages it that there may be normal exam findings.
Must consider history
Shortness of breath in general is grounds for doing a chest x-ray.
If there is a productive cough, sputum test may be ok
END EXAM I NOTES!