Dyspnea Week 1 of 2. LGA Clinical Content & Activities Thoracic and Pulmonary Exam

Vitals are quite helpful • What is the normal respiratory rate for an adult (14 – 20) – anything greater than 20 needs and explanation; Heart rate and rhythm (in most circumstances tachycardia – rate > 100 needs explanation as does an irregular rhythm – more next week; obviously fever will point to an infectious etiology of the dyspnea Inspection • “Using your oculometer” (most useful to look for include obvious distress, cyanosis/pallor, JVD, accessory m of resp) Palpation • Mostly used to assess for tenderness • Fremitus (palpatory sound) is associated with enhanced transmission of sound (for example with consolidation) or decreased transmission of sound (for example with pleural effusions) • Put the balls of your hands over your trachea and say 99 – the vibration you feel is tactile fremitus. • Tactile fremitus is normal over the trachea, but is commonly abnormal when felt in parts of the thorax distant from the large airways Percussion (not used a lot but has its place) • Percussing your air-filled cheek (this is tympanitic) • Percuss your thorax (this is normal resonance) • Percuss your thigh (this is dull) • Percussion Penetrates 1 – 2 inches Auscultation (the key to the pulmonary exam) is the transmission of turbulent flow thru the airways transmitted to the chest.

• Identify: • Are the breath sounds are present or absent (or diminished) AND if present, • Are the breath sounds symmetric? • The I to E ratio is the percentage of inspiration that a breath sound is heard compared to the percentage of expiration that a breath sound is heard | this is an underappreciated but important point. In order to establish the I/E ratio you need to: • Have the patient breath thru their mouth, AND • Listen to an entire respiratory cycle (both all of inspiration and all of expiration) before moving your stethoscope • I > E characteristic of vesicular breath sounds • I < E characteristic of bronchial (AKA tracheal) • Important point: If you hear bronchial BS in an area where you expect to hear vesicular BS this is abnormal • “Rule of 2” = listen (or percuss) no more than 2 times on one side before changing to the other side • Train your ear to listen for added (adventitious) sounds: Crackles, Wheezes, Rubs • Transmitted sounds occur when the normal, air-filled alveoli contain fluid/pus. • Fluid transmits sounds better than air, therefore the intensity of sound is increased -> bronchophony, egophony, and whispered pectoriloquy.

Descriptors of pulmonary physical findings Percussion notes (note Bates identifies 5 notes including Flat and Tympanitic)

● Dull ● Resonant ● Hyperresonant Tactile fremitus

● Symmetrical or Increased/decreased on one side Breath sounds

● Absent ● Diminished ● Present o If present (over peripheral lung fields), are the sounds… ▪ Vesicular, or ▪ Bronchovesicular, or ▪ Bronchial Are added sounds present

● None ● Crackles ● Rub ● Wheeze (note rhonchi are technically low-pitched wheezes – and commonly disappear with coughing) Are transmitted sounds present

● Bronchophony ● Egophony ● Whispered pectoriloquy

Clinical cases A chest x-ray will be displayed for each of the following cases in class. You will be asked a question for each (in Tophat) on, a) the site of primary pathology; b) the likely diagnosis; and then you will be asked to fill out the following table with the anticipated physical exam findings for each of the cases. Case 1. A 75-year-old female with a history of COPD and known coronary artery disease (s/p CABg) presents with a sudden onset of right-sided chest pain and dyspnea. Case 2. A 69-year-old male with a history of immunosuppression presents with a 24-hour history of left-sided chest pain, dyspnea, cough and fever. Case 3. A 73-year-old male with a 56-pack year history of smoking presents with dyspnea, cough and sputum production. Case 4. A 69-year-old female with a 45-pack year history of smoking and known lung cancer, presents with the gradual onset of dyspnea and hypoxia.

Percussion Breath Sounds Added Sounds Tactile Fremitus Transmitted Voice Sounds note Normal Resonant Vesicular over None Normal Normal peripheral lung zones Case 1

Case 2

Case 3

Case 4