1 Reason As a SOF Medic your ability to understand and perform a - - PDF document

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Slide 1 JSOMTC, SWMG(A)

SOCM Physical Exam of the Thorax and Lungs PFN: SOMPYL0Q

Hours: 2.0

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JSOMTC, SWMG(A)

Terminal Learning Objective

 Action: Communicate knowledge of

“Physical Exam of the Thorax and Lungs”

 Condition: Given a lecture in a classroom

environment

 Standard: Received a minimum score of

75% IAW course standards on the formative quizzes and the Physical Exam Practical Test grade sheet

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JSOMTC, SWMG(A)

References

 Essentials of Anatomy and Physiology (6th

edition; 2013; Martini; Bartholomew)

 Bates’ Guide to Physical Examination and

History Taking, (11th Edition, 2013, Chapter 8, Pages 293‐331.)

 History and Physical Examination: A

Common Sense Approach, (1st edition, 2014, Chapter 11, Pages 300‐314.)

 Health and Physical Assessment in Nursing,

(2nd Edition, 2012, Chapter 9, Pages 113‐ 129.)

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JSOMTC, SWMG(A)

Reason

As a SOF Medic your ability to understand and perform a thorax and lung physical exam is essential for the proper diagnosis and treatment of common respiratory

• complaints. Your objective as a provider

should be, at a minimum, to conduct a brief chest and lung PE of every patient you see.

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JSOMTC, SWMG(A)

Agenda

 Define the key terms related to the physical

exam of the thorax and lungs

 Communicate the exam techniques during

a thorax and lungs examination

 Communicate how to record thorax and

lungs exam findings

Slide 6 JSOMTC, SWMG(A)

The Key Terms Related to the Physical Exam of the Thorax and Lungs

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JSOMTC, SWMG(A)

Key Terms

 Dyspnea: difficult or labored breathing;

shortness of breath

 Cough: a reflex response to stimuli that

irritate receptors in the larynx, trachea, or large bronchi

 Hemoptysis: the expectoration of blood (or

• f blood‐stained sputum) from the bronchi,

larynx, trachea, or lungs

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JSOMTC, SWMG(A)

Key Terms

 Paresthesia: an abnormal or unusual

sensation with no apparent physical cause

 Flail chest: paradoxical movement of the

chest wall, resulting from a fracture of 3 or more ribs in two locations each

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JSOMTC, SWMG(A)

 Ventilation (breathing): physical

movement of air into and out of the lungs

Key Terms related to Anatomy and Physiology

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JSOMTC, SWMG(A)

Key Terms

 Respiration (gas exchange): diffusion of

gases either between the alveoli and pulmonary capillaries (external respiration)

• r between capillaries and other body

tissues (internal respiration)

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JSOMTC, SWMG(A)

Key Terms

 Tactile Fremitus: refers to the palpable

vibrations felt on the human body during phonation

 Lung Resonance: on percussion the note‐

like sounds that are measured by intensity, pitch, and duration in order to objectively determine the lungs’ volume of air

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Key Terms related to Anatomy and Physiology

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Key Terms related to Anatomy and Physiology

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JSOMTC, SWMG(A)

Key Terms related to Anatomy and Physiology

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 The carina

• The bifurcation of the

trachea into the primary bronchi

• Located at
• Sternal‐angle

anteriorly

• T4 spinous process

posteriorly

Key Terms related to Anatomy and Physiology

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Key Terms related to Anatomy and Physiology

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JSOMTC, SWMG(A)

 Muscles of ventilation

• The diaphragm
• The primary muscle of inspiration
• Works in conjunction with external intercostal

muscles to perform inspiration

Key Terms related to Anatomy and Physiology

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 The diaphragm

• Origin
• Sternal ‐ posterior

aspect of xiphoid

• Lateral ‐ inner aspect of

ribs 4‐10

• Vertebral ‐ anterior

aspect of L1‐L2 (left) and L1‐L3 (right)

• Insertion
• Central tendon
• Innervation
• Phrenic N. (C3 ‐ C5)
• Motor and sensory

Key Terms related to Anatomy and Physiology

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JSOMTC, SWMG(A)

 Breathing (cont’d)

• Accessory muscles
• Sternocleidomastoid
• Scalene
• Pectoralis minor
• Internal intercostal
• Rectus abdominis
• Transverse thoracis

Key Terms related to Anatomy and Physiology

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JSOMTC, SWMG(A)

Common or Concerning Symptoms related to the PE of Thorax

 Chest Pain  Dyspnea (Shortness of

Breath)

 Wheezing  Cough  Hemoptysis

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JSOMTC, SWMG(A)

 Chest Pain

• Numerous causes (e.g., pericarditis, bronchitis,

pleuritis, or chest wall trauma)

• Start with broad questions "Do you have any pain
• r discomfort in your chest?"
• Start to narrow in with questions about dyspnea,

coughing, and wheezing

• Also ask questions about pain on respirations,

exertion, palpitations, and edema

• Consider also conducting a cardiovascular

exam history

Common or Concerning Symptoms related to the PE of Thorax

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 Dyspnea‐ Difficult or

labored breathing

• Ask about timing

(e.g., at rest or during exertion)

• How has this affected

activities of daily living

• Always consider both

respiratory and cardiovascular origin

Common or Concerning Symptoms related to the PE of Thorax

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JSOMTC, SWMG(A)

 Wheezing

• High pitch, musical

sound

• Caused by a restriction
• f the lower airways
• Secretions
• Inflammation of the

airway

• Foreign body
• Prolonged expiratory

phase

Common or Concerning Symptoms related to the PE of Thorax

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JSOMTC, SWMG(A)

 Cough

• Reflex to irritation of

the larynx, trachea, or large bronchi

• Causes range from

benign to lethal (e.g., inflammation of respiratory mucosa or left‐sided heart failure)

• Should investigate

respiratory and possible cardiovascular causes

Common or Concerning Symptoms related to the PE of Thorax

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JSOMTC, SWMG(A)

 Hemoptysis

• May vary from blood‐

streaked sputum to frank blood

• Try to determine

source of bleeding with history and physical exam

Common or Concerning Symptoms related to the PE of Thorax

Slide 26 JSOMTC, SWMG(A)

The Exam Techniques Used During a Thorax and Lungs Examination

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JSOMTC, SWMG(A)

Examination Techniques

 General techniques

• Allow the patient to take a position of comfort
• If conscious, then allowing to the patient to sit up,

takes the pressure of the abdominal contents off the diaphragm

• If unconscious, rolling to patient to the side allows

you to examine the posterior

• Always compare one side of the thorax with

the other

• Proceed in an orderly fashion: inspect,

auscultate, palpate, and percuss (IAPP)

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Examination Techniques

 Inspect the anterior and posterior thorax

• Observe patient’s respiratory effort
• Respiratory vital signs:
• Rate ‐ normally 12‐20 breaths per min.
• Rhythm ‐ regular vs. irregular
• Depth ‐ deep vs. shallow
• Effort ‐ amount of work to breath
• Other signs of respiratory distress
• Inspect skin
• Color, scars, lesions, or moles
• Signs of trauma

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Examination Techniques

 Inspect the anterior and posterior thorax

(cont'd)

• Inspect for skeletal symmetry and bilateral rise

and fall of chest

• Inspect musculoskeletal development
• Inspect spinal alignment and posture
• Atrophy
• Signs of increased accessory muscle use

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 Irregular respiratory patterns

• Bradypnea: slow breathing

Examination Techniques

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 Irregular respiratory patterns

• Sighing respiration: characterized by periods
• f normal breathing punctuated by a single,

deep breath or sigh

Examination Techniques

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JSOMTC, SWMG(A)

 Irregular respiratory patterns

• Tachypnea: rapid, shallow breathing

Examination Techniques

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JSOMTC, SWMG(A)

Flail chest and respiratory distress

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JSOMTC, SWMG(A)

 Irregular respiratory patterns

• Cheyne‐Stokes breathing: characterized by

periods of deep breathing, alternating with apnea

Examination Techniques

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JSOMTC, SWMG(A)

Cheyne‐Stokes breathing

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JSOMTC, SWMG(A)

 Irregular respiratory patterns

 Hyperpnea (hyperventilation): rapid deep

breathing

Examination Techniques

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Kussmaul breathing

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 Irregular respiratory patterns

• Ataxic breathing (Biot's breathing): breathing

which is unpredictable irregular and without pattern

Examination Techniques

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JSOMTC, SWMG(A)

Examination Techniques

 Auscultate 6 fields on the anterior and

posterior

• Listen to the breath sounds with the

diaphragm of a stethoscope after instructing the patient to breathe deeply at a normal rate through an open mouth (head turned away)

• Listen for any adventitious sounds
• Use a pattern moving from one side to the
• ther
• Always keep anatomy and position of the

stethoscope in mind!

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Examination Techniques

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Examination Techniques

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JSOMTC, SWMG(A)

 Normal breath sounds

• Vesicular:
• Soft and low pitched; usually heard over

most of both lungs

• Bronchial:
• Louder and higher in pitch; usually

heard over the manubrium

• Bronchovesicular:
• Intermediate intensity and pitch
• Usually heard over the 1st and 2nd

interspaces

Examination Techniques

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JSOMTC, SWMG(A)

 Adventitious (added) sounds:

• Crackles (rales): intermittent and brief

explosive breath sounds

• Produced by rapid opening of small airways and

alveoli collapsed by fluid or exudate

• Note:
• Loudness, pitch, and duration
• Number and timing in the respiratory cycle
• Location on chest wall and persistence of the

pattern

• Any change after a cough or change in pt.'s

position

 Download from:

Examination Techniques

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JSOMTC, SWMG(A)

 Adventitious (added) sounds (cont'd):

• Rhonchi: coarse, low pitched, continuous

sounds with a snoring‐like quality

• Produced due to secretions in the bronchial airways
• Note:
• Timing and location
• If they change with deep breathing or coughing

Examination Techniques

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JSOMTC, SWMG(A)

 Adventitious (added) sounds (cont'd):

• Wheezes: a high pitched, whistling sound
• Produced by constriction or obstruction of the

lower airways during respiration

• Note:
• Timing and location
• If they change with deep breathing or coughing

Examination Techniques

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JSOMTC, SWMG(A)

 Obstructive breathing: impeded breathing

due to restricted airways

Examination Techniques

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JSOMTC, SWMG(A)

 Adventitious (added) sounds (cont'd):

Stridor: high pitched sound often heard without the aid of a stethoscope

• Produced by obstruction or stenosis (narrowing) of

the epiglottis or trachea

• Note timing:
• Inhalation
• Exhalation

Examination Techniques

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JSOMTC, SWMG(A)

 Adventitious (added) sounds (cont'd):

• Pleural friction rubs: harsh scratching or

crinkling sound

• Produced by inflamed visceral and parietal pleura

rubbing together; also known as "pleuritis" or "pleurisy"

Examination Techniques

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JSOMTC, SWMG(A)

Examination Techniques

 Palpate (anterior and posterior” and

“bilateral”) chest for:

• Stability
• Crepitus
• Tenderness
• Squeeze palms on the sternum and thoracic spine
• Rule out fracture vs. soft tissue injury

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JSOMTC, SWMG(A)

Examination Techniques

 Palpate thoracic expansion (back)

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Examination Techniques

 Palpate tactile fremitus (front and back)

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JSOMTC, SWMG(A)

Examination Techniques

 Percussion

• Locate intercostal space to be assessed
• Place middle finger between ribs parallel with

intercostal space

• Strike using the tip of your tapping finger, onto

the DIP of the middle finger of your non‐ dominate hand

• Use the lightest percussion that produces a

clear note

• Percuss symmetrically for resonance (front and

back)

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JSOMTC, SWMG(A)

Examination Techniques

 Percussion (cont'd)

• Perform from side to side to assess for

asymmetry using a "ladder" pattern

• Percussion helps establish whether the

underlying tissues (5‐7 cm deep) are air‐filled, fluid‐filled, or solid

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Examination Techniques

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Examination Techniques

 Percussion (cont’d)

• Percussion notes
• Flatness, dullness, resonance, hyperresonance,

tympany

• Estimate the extent of diaphragmatic excursion

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Examination Techniques

Relative Intensity Relative Pitch Relative Duration Example of Location Pathologic Examples Flatness Soft High Short Thigh Large pleural effusion Dullness Medium Medium Medium Liver Lobar pneumonia Resonance Loud Low Long Healthy lung Simple chronic bronchitis Hyper- resonance Very loud Lower Longer Usually none COPD, pneumothora x Tympany Loud High*

*

Gastric air bubble or puffed-out cheek Large pneumothora x

* Distinguished mainly by its musical timbre. Slide 57

JSOMTC, SWMG(A)

Examination Techniques

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Special Techniques

 Clinical assessment of

pulmonary function

• Inspect AP:Lateral

Ratio

• Measure depth of chest

anterior to posterior (AP) at nipple line

• Measure width of chest

at nipple line (Lateral)

• Normal ratio is

between 1.5: and 2:1

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JSOMTC, SWMG(A)

Special Techniques

 Clinical assessment of basic pulmonary

function

• “Walk Test”
• 8 feet at patient’s pace
• Repeat test
• Note faster time
• Norm: 3.1 seconds
• Observe patient’s
• Rate
• Effort
• Breathing sounds

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Special Techniques

 Clinical assessment of

pulmonary function

 If you suspect

consolidation on auscultation then:

• Bronchophony
• "Toy Boat"
• Egophony
• "EEEEE"…"EEEEEE"
• Whispered

pectoriloquy

• Whisper "1,2,3"

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Special Techniques

 Clinical assessment of pulmonary function

• Forced expiratory time
• Test for COPD
• Maximal expiratory exertion
• Patient takes in deep breath
• Use diaphragm of stethoscope over trachea
• Time duration of audible expiration
• Get 3 readings
• Norm: Less the 5 sec.
• Pathologic: 6 sec. or longer

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Radiological Findings

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Radiological Findings

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Radiological Findings

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Radiological Findings

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Radiological Findings

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Radiological Findings

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How to Record Thorax and Lungs Exam Findings

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Recording Your Findings

 SF 600

• Chest:
• Inspection:
• Thorax is symmetric with good expansion. No

signs of trauma.

• Auscultation:
• Bilateral breath sounds, clear to auscultation
• ver six fields, no adventitious sounds.
• Palpation:
• Chest walls intact. No grimace.
• Percussion: Lungs are normoresonant

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Questions

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Terminal Learning Objective

 Action: Communicate knowledge of

“Physical Exam of the Thorax and Lungs”

 Condition: Given a lecture in a classroom

environment

 Standard: Received a minimum score of

75% on the written exam IAW course standards

Slide 72

JSOMTC, SWMG(A)

Agenda

 Define the key terms related to the physical

exam of the thorax and lungs

 Communicate the exam techniques during

a thorax and lungs examination

 Communicate how to record thorax and

lungs exam findings

25

Slide 73

JSOMTC, SWMG(A)

Reason

As a SOF Medic your ability to understand and perform a thorax and lung physical exam is essential for the proper diagnosis and treatment of common respiratory

• complaints. Your objective as a provider

should be, at a minimum, to conduct a brief chest and lung PE of every patient you see.

Slide 74

JSOMTC, SWMG(A)

BREAK