MED CSL

MED CSL

RS
Dr K Tsang

Medicine

Wed 04-09-02
GENERAL EXAMINATION & INSPECTION

Temperature, pulse, BP

Cachexia (cancer and TB) or obesity (OSA)

Tongue (central cyanosis) and lips (peripheral cyanosis)

Fingers for clubbing

Breathing pattern

Character of cough

Inspection of chest

Movement

Sputum (blood and colour)

Listen for abnormal sounds (eg. wheezing in asthma)

CYANOSIS

> 5g/dl of reduced Hb
Peripheral: due to poor peripheral circulation
Central: blue discoloration of usually well circulated various such as tip of tongue, conjunctiva, earlobes
Central cyanosis indicates desaturation of arterial blood
Frank central cyanosis indicates PaO2 < 6 kPa

CLUBBING

Loss of angle between nail-bed and the skin
Base of nail might become palpable through the skin (abnormal sponginess)
Assoc. with

Bronchial carcinoma: common
Bronchiectasis
Pulmonary fibrosis: rare
Bacterial endocarditis: rare
Cyanotic heart disease: rare
Liver cirrhosis: common

BREATHING PATTERN

Note breathlessness, respiratory distress, wheezing, panting etc
Measure RR over 15 sec (12-18/min, rhythm for irregularity, depth)
Eg. Put watch near chest and talk to Pt (so breathing is natural)

CHAR OF NORMAL COUGH

Explosive noise produced only when good muscle power and normal movt of vocal cords
Pt instructed to give several sharp coughs
Abnormal in respiratory diseases
Commonly ignored but most valuable sign
Pt instructed to give several sharp coughs
Rattling sound: abundance of bronchial secretions
Bovine cough: lack of explosive onset suggests presence of vocal cord paralysis (eg. Lung ca, bilateral stroke)
Muffled wheezing cough: suggestive of aw obstruction such as chronic bronchitis

STRIDOR

Often a sinister sign
More likely to be noticed while inspecting the Pt
Can be imitated
Indicates localised obstruction in the: larynx, trachea, large bronchi
Low-pitched inspiratory noise (like you are being strangled)

JUGULAR VENOUS PRESSURE

Semi-reclined position at 45 degrees
Head fully supported and SCM relaxed
Assessment difficult if breathing is laborious

CHEST INSPECTION

Overall view of chest wall and spines to note kyphosis, asymmetry, scars (previous injury or surgery), prominent veins, deformities, etc
Must include anterior and posterior aspects
Flattening or over-inflation may be better assessed from the side
Observe landmarks: nipple, lower ribs

RESP MOVEMENTS

Regional asymmetry: diseased side moves less

PALPATION

Cervical LN: from behind Pt, keep fingers together

Anterior / Posterior triangle
Supraclavicular fossa (1st metastasis from lung ca): dig one finger in to test for small lumps

Position of mediastinum

Trachea: normally central, but can deviate to either side - an uncomfortable procedure
Apex beat (5th IC, MCL)

Ribs: palpate carefully for localised tenderness

COPD: # ribs

Chest movements

Ask Pt to put hands on hips
Breathe in and out

Press skin down and pull together

Movt of upper chest assessed by placing the hands exactly symmetrically on either side of the upper chest
Expansion of the lower zones assessed by stretching fingers and thumbs over the lower ribs: hook onto skin

PERCUSSION

Symmetrical areas percussed on both sides

Pt sitting up or at 45 degrees, hands on hips, examine Pt from R side

Normally resonant

Dullness: poorly aerated lungs - eg. Collapse, consolidation or presence of fluid in pleura

Percuss at MCL: Anterior, Posterior

Anterior: clavicles, 5 IC areas, 2 on each side - then 2 other side

Posterior: apex of lung, finger to be percussed vertical (give Pt pillow to lean on, elbows touching, lean forward), don't move progressively towards spinal cord

Horizontally rest left middle finger onto chest wall between ribs

Swing the flexed middle finger of the right hand to percuss the left middle finger

Compare L and R on same level (except side, do 1 and 2 on same side, then other side)

Poor technique yield poor results

Percussion of lung apex from posterior

Presence or absence of hepatic and cardiac dullness

Upper border of liver - 5th IC at MCL

AUSCULTATION

Symmetrical auscultated on both sides: Anterior, Posterior

Same areas as percussion areas

Compare both sides during examination

Compare voice sound (vocal resonance)

Breath sounds arise from turbulence in larynx and central aw's and heard over chest wall

Normal breath sounds: faint, low-pitched rushing sound with gentle beginning and end during inspiration

Compare both sides of Pt

There is variation in the intensity and character of normal breath sounds due to chest wall thickness (thinner = louder breath sounds)

Use mouth to breathe in and out - people may have blocked noses (adds more sounds), ask Pt to turn head away from you

Use diaphragm

Hold neck of stethoscope

BRONCHIAL BREATH SOUNDS

Usually heard over consolidated areas of the lung (eg. Pneumonia)
These areas conduct the high-frequency "hiss" component from the larger aw's well
Bronchial breathing is characteristically similar in inspiration and expiration with a momentary silent pause between them
The sound can be imitated by listening over the larynx with a stethoscope

VOCAL RESONANCE

Observed by auscultation over chest wall during speech
Normal lungs transmits the booming low-pitched components of speech and attenuates the high frequencies
Ask Pt to say ‘1,2,3’

VOCAL FREMITUS

Normal aerated lung transmits voice well which is easily palpable as a buzzing sensation
Consolidated lung transmits fremitus less well
Pleural effusion severely dampens vocal fremitus

ADDED SOUNDS

Wheezing (rhonchi)
Crackles (formerly crepitations)
Early inspiratory crackles
Pan-inspiratory or late inspiratory crackles
Pleural rub (eg. Pleurisy); sounds like sandpaper rubbing

WHEEZING

Sustained musical sounds of varying length and pitch
Inspiratory or expiratory
Produced y flow-limiting mechanism
Present in aw obstruction but poor indication of level of obstruction

CRACKLES

Coarse and high-pitched
Roll hairs near ears
Produced by opening of previously closed bronchioles
Early inspiratory crackles: aw obstruction but not pul oedema
Pulmonary oedema, fibrosis of lung

SPUTUM INSPECTION

Truly clear sputum is unusual in city dwellers
Greyish fragments usually present in true mucoid sputum
Very tenacious sputum in asthma (yellow glue)
Purulent (creamy or yellow) reflects bronchial inflammation usually caused by infection
Brown sputum may represent altered blood for intra-alveolar haemorrhage

SIGNS OF LOCALISED LUNG DISEASE

Common conditions - therefore, common examination cases

Consolidation
Collapse
Pleural effusion
Pneumothorax
Pleural thickening
Pulmonary fibrosis

CONSOLIDATION

Reduced chest wall movt
Full percussion note
Reduced vocal fremitus
Bronchial breathing
Pan-inspiratory or late inspiratory crackles
Whispering pectoriloquy

SIGNS OF COLLAPSE

Reduced chest wall movt
Flattening of chest wall
Displacement of mediastinum toward collapsed side
Reduced breath sides
Concomitant presence of consolidation

PLEURAL EFFUSION

Mediastinum shift away
Reduced chest wall movt
Stony dullness on percussion (eg. Percussing thigh)
Reduce vocal fremitus
Reduced breath sounds (pleural effusion separates lung from chest wall, therefore signs not heard so well)
X-ray: homogenous opacity

LARGE OR TENSION PNEUMOTHORAX

No signs
Mediastinum shift
Hyper-resonance
Reduced breath sounds
Reduced vocal resonance and vocal fremitus
Signs of respiratory failure (cyanosis)
Chest drain needed

LOCALISED PUL FIBROSIS

Often difficult to distinguish from collapse
Upper lobe fibrosis may produce tracheal deviation
Affected sides may be flattened with reduced movt (scar pulls lung down)
Dullness on percussion
Bronchial breath sounds
Crackles on auscultation