Examination of Respiratory System — OmpathStudy

Continued from $1. 4.0 PERCUSSION 4.1 Introduction Is a technique to produce sound waves Require practice When the chest is percussed the lungs and chest wall are set into vibration and result in sound Quality of sound depends on the amplitude, rate (Pitch), duration and intensity of vibrations. Hence different surfaces e.g. air, fluid or solid result in different sounds. Methods of percussions: 1) Direct (Immediate) percussion - percussing finger strikes directly over the bony regions e.g. clavicle; also called heavy percussion – Need posteriorly due to muscle thickness. 2) Indirect (Mediate) percussion - used over the chest, pleximeter and plexor fingers are used 3) Ascultatory percussion 4.2 Technique 5) Place left hand over the chest wall with the palm downwards and fingers slightly separated. 6) Second phalanx of the middle finger (Pleximeter) should be over the area to be percussed, usually an intercostal space. 7) Firmly press left middle finger against the chest wall. 8) Right middle finger should be held at a right to produce a hammer effect with the entire movement coming from the wrist joint. 9) Strike the Centre of the 2nd phalanx with tip of right middle finger. 10) Compare notes obtained from identical sites on the 2 sides 11) Map out areas of different percussion notes e.g. Cardiac and hepatic dullness. Hand Position Hand and Finger placement 4.3 Ascultatory percussion Conventional physical examination of the chest can miss pleural effusion in obese patients or those with small effusions or thick chest walls and it also cannot distinguish pleural effusion from pleural thickening or underlying lung disease. 4.4 Percussion Sites Anterior chest wall o Clavicle o Infraclavicular region o 2nd to 6th intercostals spaces Lateral chest wall o 4th – 7th intercostals spaces Posterior chest wall o Trapezius, percussing downwards on lung apex o Above level of spine of scapula o At intervals of 4-5 cm from below the level of spine of scapula down to the 11th rib. Anterior Posterior 4.5 Interpretation Percussion note Description Cause Tympanic Hollow viscus Hyperresonant Hyperiinflation Emphysema, Asthma Pneumothorax, very thin people Resonant Normal lung tissue Dull Presence of Pulmonary consolidation, consolidation pulmonary fibrosis, pulmonary collapse Stony dull Presence of fluid pleural effusion Pleural effusion Accumulation of fluid in the pleura Causes 1) Transudates Protein content less than 30 gm per litre Lactic hydrogenese less than 200 i.u per litre a. Cardiac Failure b. Nephrotic Syndrome c. Constrictive pericarditis d. Hypothyroidism e. Meig’s syndrome (Ovarian tumour producing right-sided pleural effusion) f. Cirrhosis g. Peritoneal dialysis 2) Exudates Protein content more than 30 gm per litre Lactic hydrogenase more than 200 i.u per litre a. Infections e.g. bacterial infections e.g. pneumonia, tuberculosis, fungal infections, viral infections and parasitic infections b. Neoplastic e.g. metastatic and mesothelioma c. Pulmonary embolism d. GIT Diseases e.g. oesophageal perforation, pancreatic disease, intra-abdominal abscess, diaphragmatic hernia and after liver transplant e. Collagen-vascular disease e.g. rheumatoid pleuritis and S.L.E. f. Iatrogenic injury g. Drug induced pleural disease e.g. nitrofurantoin and bromocriptine h. Ovarian hyperstimulation syndrome i. Pericardial disease j. Radiation therapy Pneumothorax Air in the pleural space Causes 1) Traumatic e.g. open due to penetrating injury and closed due to rib fracture 2) Spontaneous Primary Secondary Due to an underlying lung condition e.g. obstructive air way disease, emphysema, bullous lung disease, tuberculosis, lung abscess and carcinoma Lung Collapse Causes: 1) Enlarged tracheobronchial lymph nodes due to e.g. malignant disease, tuberculosis 2) Tumours 3) Inhaled Foreign bodies - in children, usually in right main bronchus 4) Bronchial casts or plugs e.g. allergic bronchopulmonaryaspergillosis 5) Retained secretions e.g. post-operatively, debilitated patients Pulmonary Fibrosis Is the end result of many diseases of the respiratory tract May be: a) Localized – e.g. following unresolved pneumonia b) Bilateral – e.g. in tuberculosis c) Widespread (also called honeycomb lung) .e.g. cryptogenic fibrosingalveolitis, drugs (busulphan, cyclophosphamide) Localized Systemic sclerosis Sarcoidosis Tuberculosis Asbestosis, Berylliosis Diffuse Cryptogenic fribrosingalveolitis Rheumatoid lung Histiocytosis Neurofibromatosis 5.0 AUSCULTATION 5.1 Introduction Normal breath sounds are caused by turbulent flow in large airways 5.2 Technique Auscultate using the diaphragm of your stethoscope Ask the patient not to speak and to breathe deeply through the mouth You should listen to at least one full breath in each location It is important that you always compare what you hear with the opposite side Generally, you should listen to at least 6 locations on both the anterior and posterior chest Begin by auscultating the apices of the lungs, moving fro