SEMI FINALS (HEART, LUNGS AND THORAX)

• Problem-Based History


  • Cough
  • Shortness of Breath (SOB)
• Cough


  • Onset? Gradual or sudden? Frequency?
  • Continuous throughout day – acute illness (respiratory infection)
  • Afternoon/evening – may reflect exposure to irritants at work
  • Night – postnasal drip, sinusitis
  • Early morning – chronic bronchial inflammation of smokers
• Sputum characteristics


  • White of clear mucoid – colds, viral infection, bronchitis
  • Yellow or green – bacterial infection
  • Rust colored – TB, pneumococcal pneumonia
  • Pink, frothy – pulmonary edema, medications?
• Chronic bronchitis


  Productive cough for 3 months of the year for 2 years in a row
• Shortness of Breath (SOB)

  • Onset, associative factors
  • Affected by position?
  • Time of day/night
  • Allergies?
  • Asthma factors
  • Alleviating factors
• Orthopnea – difficulty breathing when supine (heart failure?)
• Paroxysmal Nocturnal Dyspnea – Awakening from sleep with SOB and needling to be upright to achieve comfort
• AP diameter


  • Normal 1:2 to 5:7
  • AP diameter = transverse diameter, "barrel chest". Occurs with normal aging, chronic emphysema, and asthma
• Abnormal Findings


  • Nasal flaring, cyanosis, cyanotic nails
  • Tripod Position
  • Pectus Carinatum (Pigeon Chest)
  • Pectus Excavatum (Funnel Chest)
  • Scoliosis
  • Kyphosis
• Palpation


  1. Symmetric chest expansion

  2. Unequal chest expansion occurs with atelectasis, pneumonia, thoracic trauma

  3. Pain accompanies deep breathing when pleurae are inflamed

  
• Tactile Fremitus


  Palpable vibration transmitted through patent bronchi and lung parenchyma to the chest wall where they can be felt as vibrations

  
• Abnormalities in Fremitus


  • Decreased Fremitus – Obstructed bronchus, Pleural effusion or thickening, Pneumothorax, Emphysema
  • Increased Fremitus – Lobar pneumonia
  • Rhonchal Fremitus – palpable with thick secretions
• Percussion


  1. Start at the apices and percuss across tops of both shoulders and down the lung region at approx. 5cm intervals

  2. Make a side to side comparison

  3. Avoid damping effect of scapulae
• Normal Findings


  • Resonance percussion tone elicited over normal lung tissue
  • Percussion elicits flat tones over the scapula
  • Dullness over liver and viscera
• Abnormal Findings


  • Hyperresonance – Elicited in cases of trapped air (Emphysema or pneumothorax)
  • Dullness – Present when fluid or solid tissue replaces air in the lungs or occupies the pleural space (Lobar Pneumonia, Pleural Effusion or Tumor)

  
• Diaphragmatic Expansion


  1. Lower lung borders in expiration & inspiration

  2. 1st exhale & hold - percuss down the scapulae line until sound changes from resonant to dull. Mark with marker

  3. Now take deep breath & hold

  4. Percuss from mark to dull sound and mark

  5. Measure the difference. Should be + bilaterally 3-5cm in adult may be 7-8cm in well-conditioned person