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PHYSICAL DIAGNOSIS

PHYSICAL DIAGNOSIS. THE CHEST DR SHAM A. CADER. THE ORGANS. ANATOMY. One should have a clear understanding of anatomy of the respiratory system to perform a proper physical exam. Some of the important anatomical details are outlined below. . TRACHEA.

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PHYSICAL DIAGNOSIS

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  1. PHYSICAL DIAGNOSIS THE CHEST DR SHAM A. CADER

  2. THE ORGANS

  3. ANATOMY • One should have a clear understanding of anatomy of the respiratory system to perform a proper physical exam. Some of the important anatomical details are outlined below.

  4. TRACHEA • Starts from cricoid cartilage to sternal angle anteriorly and T4 spinous process posteriorly, where it divides into left and right main stem bronchi. This information is important in understanding D'spine sign seen in patients with large Mediastinal mass. • Trachea is slightly slanted to right. Bronchovesicular breathing heard in right infraclavicular region is due to this phenomenon. • Trachea has intra and extra thoracic components. This has important bearing in the understanding of physiology of variable obstruction.

  5. MANUBRIUM ANGLE • The angle between the body and Manubrium. Many important land marks occur at this level. It is called Louis Angle. • 2nd rib articulates to Manubrium at this site. The ribs are counted anteriorly starting from this point. • Carina of trachea is at this level. • Mediastinum is divided into superior and inferior at this level.

  6. RIBS • Anteriorly ribs are counted down starting from 2nd rib. There are 12 ribs and 11 interspaces. You can also count up from 12th rib. Inferior angle of scapula sits on 7th rib posteriorly.

  7. SPACES • Anteriorly there are supra clavicular, infraclavicular, precardiac and Traube's space. Posteriorly we have interscapular, supra, and infra scapular spaces. • Infraclavicular: Space below clavicle • Supraclavicular: Space above clavicle • Precardiac: Space in front of heart • Traube's: Space overlying stomach • Interscapular: Space between scapula • Suprascapular: Space above scapula • Infrascapular: Space below the scapula

  8. LINES • Midsternal Line: A vertical line down the middle of sternum • Parasternal Line: A vertical line along lateral edge of sternum • Mid-Clavicular Line: A vertical line from middle of clavicle • Anterior Axillary Line: A vertical line along anterior axillary fold • Mid-Axillary Line: A vertical line at mid point between anterior and posterior axillary line. • Posterior Axillary Line: Along post axillary fold • Scapular Line: Inferior angle of scapula • Vertebral line: Over spinous processes in the midline

  9. Right Lung: • With a marking pen start 3 centimeters above clavicle in midclavicular line, come down along right parasternal line , join to 6th rib in midclavicular line, to 8th rib in mid-axillary line, to 10th rib posteriorly, to vertebral line posteriorly.

  10. Left Lung: • At angle of Louis, follow the outer margin of heart to 6th rib in mid-clavicular line. • Appreciate that apex of lung is just under the skin easily palpable in the supraclavicular space. • Pancoast tumor and TB occur at this site. Hence, the apex of lungs should be routinely examined.

  11. Surface Anatomy of Lobes • Draw oblique fissure by drawing a line strait from 6th rib in MCN. to 5th rib in mid axillary line and along the medial margin of scapula (with the patients hands on head) to 3rd spinous process • Transverse fissure can be drawn by drawing a line from 5th rib in mid-axillary line to 4th rib anteriorly

  12. Once the fissures are drawn over the outline of lungs, one can easily recognize the surface anatomy of lobes of lungs. One can then appreciate the importance of examining the patient all around the chest to cover the lobes. Most of lower lobe is in back, upper lobe is in front and all of middle lobe is in front. In the axilla all of the three lobes can be seen.

  13. DIAPHRAGM

  14. Pleura: Once the diaphragm has been outlined you can appreciate that the pleural gutter is deep posteriorly. Fluid thus tends to accumulate posteriorly • Mediastinumis the space between lungs from inlet to outlet of thorax. Anteriorly it is between parasternal lines. Posteriorly it is at vertebral line. Mediastinum is narrow posteriorly and widens anteriorly. Inferiorly it extends to xiphisternum. Superiorly it starts at suprasternal notch. Since the inlet of thorax is slanted, only posterior Mediastinum extends to neck.

  15. Sternal angle separates superior from inferior Mediastinum. The inferior Mediastinum is divided into anterior, middle and posterior compartments. The space in front of heart is anterior Mediastinum and behind is posterior Mediastinum. Heart itself defines the middle Mediastinum. The posterior Mediastinum is divided into paravertebral and prevertebral space. Superior Mediastinum extends into the neck and is called cervico-Mediastinal space

  16. It is important to know the structures in each compartment. In the differential of masses in the Mediastinum one uses this knowledge.

  17. COSTAL ANGLE • Costal angle is formed by the 10 rib with Costal cartilage on either side and xiphisternum in the middle. The normal angle is . Both sides are symmetrical. Volume changes in each hemithorax will alter this relationship. Hyperinflated lungs will increase the Costal angle. Diaphragmatic paralysis also alters the symmetry of Costal angle.

  18. Spinous Process • The most prominent spinous process is 7th cervical vertebra. You can count down the thoracic vertebra and the ribs using this landmark.

  19. Respiratory Rate and Pattern of Breathing • The patient should not be aware that you are counting his respiratory rate. Count the respiratory rate while pretending to take the patient's pulse. • Note the rate, pattern and comfort of respiration.

  20. Normal • Resting rate is between 10-14 per minute, regular with no apparent discomfort.. • Chest wall and abdomen expand during inspiration and is symmetrical. • Abdominal component of expansion is dominant in men and thoracic component in women. • Periodic deep breathing (Sighs) less tha 5 per minute.

  21. Abnormal Finding • Minor changes in rate and rhythm of respiration occur due to anxiety and while it may represent an abnormality, it may not be significant • Rate • Rate below 10/min: Bradypnea: (Narcotics, raised intracranial tension, myxedema) • Rate above 20/min: Tachypnea: (Interstitial, vascular and multitude of diseases, anxiety

  22. Pattern • Periodic breathing. Cyclical increase and decrease in depth of respiration: Cheyne-stokes breathing: (CHF, Cerebrovascular insufficiency) • Slow deep breathing: Kussmaul: (Ketoacidosis) • Totally irregular with no pattern:Biot's breathing: (CNS injury) • Periodic deep breathing: Sighs: (Anxiety state) • Instead of simultaneous chest and abdominal expansion with inspiration abdomen retracts while chest expands: Abdominal paradox: (Diaphragmatic paralysis)

  23. On the side of unstable chest wall hemithorax retracts while the normal side expands with inspiration: Thoracic paradox: (Flail chest) • With lips pursed patient controls expiration slowly: Pursed lip breathing: (Obstructive lung disease) • No abdominal component : ( Acute abdomen) • No thoracic component: (Pleurisy, Chest wall pain, Ankylosing spondylitis)

  24. Discomfort • Labored breathing: (Heart and Lung diseases) • Unable to assume supine position because of worsening shortness of breath: Orthopnea: (CHF, Diaphragmatic paralysis, SVC syndrome, Anterior mediastinal mass) • Unable to erect position because of worsening shortness of breath, more comfortable in supine position : Platypnea: (Pulmonary spiders in cirrhotic)

  25. Size of Thorax • The size of thorax is determined by the balance between elastic recoil of lungs and chest wall compliance. In normal, the FRC position is usually at 60% of the TLC. At this position muscle length tension curve is optimal for muscle contraction. If the elastic recoil of lung decreases the resting position of thorax will be larger, it maybe 80% of the TLC position. This position is very inefficient to generate force by muscles and leads to shortness of breath.

  26. Symmetry of Hemithorax • Both sides are equal in size and asymmetry is abnormal. Unilateral lung or pleural disease alters negative pressure in pleura, affecting the resting size of hemithorax. e.g. In pneumothorax the negative pressure in pleura is lost and there is nothing to hold chest wall down. Hemithorax on that side will assume TLC position. In patients with atelectasis the negative pressure in pleura increases and the size of hemithorax will become smaller

  27. It is best to assess symmetry of hemithorax with patient laying flat in bed without pillows. Stand either at head or foot end and look tangentially at the thorax level to assess asymmetry

  28. Accessory Inspiratory Muscles

  29. Accessory Expiratory Muscles • Normal tidal expiration is passive and there is no muscle contraction. Expiratory muscle contraction is always accessory. When you force expiration, expiration muscles come into play. Abdominal muscles and intercostals are expiratory muscles. If a patient is contracting abdominal muscles for quiet respiration it is abnormal and he is attempting to force expiration.

  30. Forced Expiration • Only peak flows can be increased by forced expiration. The flow rates cannot be increased for most of expiratory phase by forcing expiration. The increasing positive pressure in pleura compresses airway and further decreases airway size thus countering the increased force to expire.

  31. In patients with increased airway resistance patients attempt to increase airflow. They have two options either to adopt a rapid shallow breathing or to use pursed lip breathing to counter auto-peep and enhance emptying of lung. When airways are severely narrowed, air trapping occurs and patient may breath with a very high FRC and the only way he can breath is to adopt a rapid shallow breathing.

  32. Negative Pleural Pressure Assessment • Only peak flows can be increased by forced expiration. The flow rates cannot be increased for most of expiratory phase by forcing expiration. The increasing positive pressure in pleura compresses airway and further decreases airway size thus countering the increased force to expire.

  33. In patients with increased airway resistance patients attempt to increase airflow. They have two options either to adopt a rapid shallow breathing or to use pursed lip breathing to counter auto-peep and enhance emptying of lung. When airways are severely narrowed, air trapping occurs and patient may breath with a very high FRC and the only way he can breath is to adopt a rapid shallow breathing.

  34. Method Of Exam • Position yourself in front of the patient and note the position of the thyroid cartilage. • Inspect for the symmetry of clavicular insertion of both sternomastoids. • Tracheal Position: Gently bend the head to relax the sternomastoids. By inserting your finger between the trachea and sternomastoid, assess and compare the space on either side

  35. Trachea: PositionTo evaluate the position of the upper mediastinum • Normal: Trachea is slightly tilted to right. As a result, the clavicular insertion of right Sternomastoid is slightly more prominent and the space between trachea and sternomastoid is smaller compared to left.

  36. Abnormal Finding • Tracheal deviation could be either due to Lung, pleural, Mediastinal or Chest wall disease. The mediastinum can be either pulled or pushed away from the lesion

  37. Lung Pull: ( Loss of lung volume) • Atelectasis • Fibrosis • Agenesis • Surgical resection Push: (Space occupying lesions) • Large mass lesions

  38. Pleura 1. Push: • Pneumothorax • Pleural effusion 2. Pull: • Pleural fibrosis Mediastinal masses and thyroid tumors Kypho-scoliosis

  39. Atelectasis

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