Table of Contents
The following can be studied just by looking at a 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 where air or liquids are trapped in the pleural cavity (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: consolidation (in case of pneumonia, hemorrhages, edema)
- Pleural rub (pleuritis)
- Adventitious breath sounds:
- Continuous wheezing and humming
- Discontinuous: Fine bubbling 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 trapped 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!
The lung is not the only organ that 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: Sarcoidosis or hypertrophic osteoarthropathy are examples of diseases that can present symptoms of frequent pulmonary manifestation in other parts of the body. Are there signs of thrombosis on the lower leg? >> lung embolism. Edema would be a sign of right ventricular insufficiency with a backlog of blood and other problems with the lungs.
- Erythema multiforme: mycoplasma pneumoniae
- Erythema nodosum: tuberculosis, 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|