Table of Contents
You can recognize all this just by looking at the patient…
- Tachypnea (> 20/min), stridor, coughing, hoarseness, dyspnea
- Breathing pattern: Kussmaul-breathing, Cheyne-Strokes breathing, Biot breathing
- Accessory respiratory muscles, withdrawal
- Symmetry of the thorax
- Shape of the thorax: barrel chest, kyphoscoliosis, gibbus, pectus excavatum, pectus carinatum
- Is the trachea in the middle?
- Spinal column/rips: pain upon percussion, fracture, Tietze syndrome, rachitis
- Skin emphysema
- Symmetric excursion
- Pain upon compression
What was that again…?
Vocal fremitus: Place your hands laterally on the thorax of the patient and ask him/her to say the number “99” (loud and resounding). Palpable vibrations during infiltration of the lung (pneumonia, bronchiectasis, pulmonary congestion) are pathologically intensified. A weakened fremitus can be felt in cases of air or liquid in the pleural space (pneumothorax, pleural effusion).
- Technique: Hearing AND Feeling
- Ventral and dorsal, comparison of sides
- Movability of the diaphragm: normal are 4 – 5 cm
- Quality of percussion sound:
|Hyper Sonor||emphysema, pneumonthorax|
|Sonor||normal, bronchitis, central pneumonia, pulmonary edema|
|Hypo Sonor||pleural effusion, infiltrate, tumor, pleural|
- Respiratory sounds: tracheal, bronchial, bronchovesicular, vesicular (normal findings are known from many clinical reports: vesicular respiratory sounds)
- Weakened/missing respiratory sounds: emphysema, status asthmaticus, pneumothorax, effusion, pleural fibrosis, tumor
- Bronchial breath sounds: children, consolidation (in case of pneumonia, hemorrhages, edema)
- Pleural rub (pleuritis)
- Adventitious breath sounds:
- Continuous wheezes and humming
- Discontinuous: Fine bubble rales are usually of high frequency and occur due to an opening of the small airways: Pulmonary fibrosis, beginning lung edema. Coarse bubble rales are usually of low frequency and occur due to liquid in the small airways: bronchitis, lung edema
What was that again…?
- Bronchophony: Examination of the forwarding of higher tones. Ask your patient to say the number “66” in a high (slightly hissing) voice. The number can be heard better via infiltrated areas (pneumonia) due to a better forwarding. In case of pneumothorax or pleural effusion you might hear little or nothing at all!
Not only the lung can give indications of pulmonary diseases…
Hands: The typical signs of chronic hypoxia are Hippocratic fingers and Hippocratic nails. Pay attention to venous filling and heart rate!
Head: Color reveals a lot: Anemia, jaundice, cyanosis of the lips? How do the veins on the base of the tongue and the buccal mucosa look like?
Extremities: Diseases that show frequent pulmonary manifestation can also present symptoms at other areas like sarcoidosis or hypertrophic osteoarhropathy. Are there signs of thrombosis on the lower leg? >> lung embolism. Edema would be a sign of right ventricular insufficiency with a backlog amongst others into the lung.
- Erythema multiforme: mycoplasma pneumoniae
- Erythema nodosum: tubercolosis, sarcoidosis, histoplasmosis
- Purpura: vasculitis
- Lupus pernio: sarcoidose
- Lupus vulgaris: tuberculosis
For the Pocket in your Doctor’s Coat: Everything Important at One Glance
|Status asthmaticus||Hyperinflation, auxiliary respiratory muscles||Fremitus||Hyperresonant, depression of the diaphragm||Expiration, wheezes|
|Pneumothorax||Excursion||Fremitus, shift of the trachea to the healthy side||Hyperresonant||Faint/no respiratory sound|
|Pleural effusion||Excursion||Fremitus, shift of the trachea to the healthy side||Damped||Faint respiratory sound|
|Atelectasis||Excursion||Fremitus, shift of the trachea to the diseased side||Damped||Faint respiratory sound|
|Consolidation||Excursion||Fremitus||Damped||Bronchial breath sounds, bronchophony|