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Physical Exam of the Chest: Auscultation

Physical Exam of the Chest: Auscultation. Steve S. Kraman, M.D. Professor of Pulmonary, Critical Care & Sleep Medicine, University of Kentucky. Mechanics of Respiration. Figure 16-10. p. 454. Anterior Location of Lungs. Figure 16-6. p. 451. Posterior Location of Lungs.

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Physical Exam of the Chest: Auscultation

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  1. Physical Exam of the Chest:Auscultation Steve S. Kraman, M.D. Professor of Pulmonary, Critical Care & Sleep Medicine, University of Kentucky

  2. Mechanics of Respiration Figure 16-10. p. 454.

  3. Anterior Location of Lungs Figure 16-6. p. 451.

  4. Posterior Location of Lungs Figure 16-7. p. 451.

  5. Right Lateral Location of Lung Figure 16-8. p. 452.

  6. Left Lateral Location of Lung Figure 16-9. p. 452.

  7. Brief Survey of Chest and Respiration • Is the patient in distress? • Observe the rate, rhythm,and depth of respiration. • Audible sounds? • Respirations should be easy, quiet, and regular.

  8. Symmetric Chest Expansion Figure 16-13. p. 461.

  9. Tactile Examination of the ChestTactile fremitus • Palpable vibration of the chest wall from sounds transmitted from the phonating larynx. • “Ninety-nine.” • Compare symmetry. • Abnormality MAY be é‘ed or ê‘ed.

  10. Tactile Fremitus Figure 16-14. p. 462.

  11. Assess Tactile Fremitus Figure 16-22. p. 472.

  12. Percussion • Systematic • Progress from apices to base • Side to side • Intensity, duration, and pitch • Normal = resonance • Note location of abnormalities

  13. PERCUSSION • RESONANCE - NL • HYPERRESONANCE - too much air such as emphysema or pneumothorax • DULLNESS - abnormal density due to possible pneumonia, pleural effusion, atelectasis or tumor • These are subtle and often equivocal findings

  14. Sequence for Percussion Figure 16-15. p. 463.

  15. Sequence for Percussion Figure 16-23. p. 473.

  16. Expected Percussion Notes – Posterior Chest Figure 16-16. p. 463.

  17. Expected Percussion Notes Figure 16-24. p. 473.

  18. Diaphragmatic Excursion Figure 16-17. p. 464.

  19. Bronchophony: • Voice sounds are increased and clearer, even though one can not understand words. • Heard under similar circumstances as bronchial breath sounds, such as when there is consolidation of the lung but the airways leading into the consolidation are open.

  20. Whispered pectoriloquy • Pectoriloquy means “chest speaking.” • When a person with normal lungs whispers it is poorly heard with a stethoscope. • With whispered pectoriloquy one can hear words that are whispered with the stethoscope. This is usually heard under the same circumstances as bronchial breath sounds and broncophony has similar significance.

  21. Egophony • The word egophony means "goat sound" from the Greek root "ego" (goat). • This term describes a high-pitched bleating sound heard through an area of parenchymal consolidation

  22. Egophony: • When a normal (healthy) individual says "E" it is heard under normal circumstances as an "E" with a stethoscope. • With egophony this "E" becomes "A" when listening through a stethoscope. • Usually heard under the same conditions as bronchial breath sounds and bronchophony and has similar meanings.

  23. What you hear • When listening to lung sounds, you hear: • Lung sounds • Heart sounds • Muscle sounds (respiratory muscles) • Breath sounds transmitted through the air from the mouth

  24. General Principals and Practice • A word about stethoscopes • Acoustic • Electronic • Integrity • Practice

  25. Generally Accepted Nomenclature

  26. Observer Variability • Sensitivity of the human ear

  27. A Way to Think About Lung Sounds • The acoustic repertoire of the respiratory system. • The thorax as a damped drum • The airways and parenchyma as noise makers • continuous noises • impulse noises

  28. A Way to Think About Lung Sounds • Sounds created within the chest, or introduced from outside (e.g., percussion), are colored by the damped resonant behavior of the thorax. • E.g., normal voice transmission.

  29. Anatomy of the Thorax

  30. “1-2-3” Mouth Chest

  31. Normal Lung Sounds • Vesicular sounds • what do they mean? • Where do they come from? • How far do they travel? • Bronchial sounds • Tracheal sounds • Normal crackles?

  32. Origin of Normal Lung Sounds

  33. Vesicular sounds: Not from Alveoli |--1mm-- |

  34. SEM of Metallic Injection of Alveoli

  35. Normal Variation Dosani and Kraman. Chest 1983;83:628-631

  36. Normal Lung Sounds • Normal Crackles

  37. Abnormal Lung Sounds • Too-faint vesicular sounds (more later) • Bronchial sounds (where abnormal) • Wheezes • Rhonchi • Crackles • Pleural sounds • Stridor • Squawks

  38. Abnormal Lung Sounds • Wheeze Inspir Expir Multiple Single Trachea Mouth

  39. Wheeze v. Obstruction

  40. Abnormal Lung Sounds • Rhonchus Inspiration Expiration

  41. Abnormal Lung Sounds • Crackles Fine Course Murphy, RLH. Sem. Respir. Med. 1985:6:210-219

  42. Abnormal Lung Sounds • Fine Crackles; how are they made?

  43. Fine Crackles • Why not always? Sarcoidosis Ideopathic Pul. Fibrosis (Baughman, et al, Chest 1991;100:96-101)

  44. Crackles in Asbestosis • Prevalence of Crackles Related to Age Crackles (%) From Shirai et al, Br J Dis Chest 1981;75:386-96 Age (Years)

  45. Coarse Crackles

  46. Abnormal Lung Sounds • Pleural Rubs Inspiration Expiration

  47. Abnormal Lung Sounds • Stridor and “VC Dysfunction Syndrome” Tracheal tumor Baby with croup

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