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Slide 1JSOMTC, SWMG(A)
SOCM Physical Exam of
the Thorax and Lungs PFN: SOMPYL0Q
Hours: 2.0
Slide 2JSOMTC, 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
Slide 3JSOMTC, 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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Slide 4JSOMTC, 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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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
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The Key Terms Related to the Physical Exam of the Thorax and
Lungs
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Slide 7JSOMTC, 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 of blood‐stained sputum) from the bronchi, larynx, trachea, or lungs
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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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Ventilation (breathing): physical movement of air into and out of the lungs
Key Terms related to Anatomy and Physiology
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Key Terms
Respiration (gas exchange): diffusion of gases either between the alveoli and pulmonary capillaries (external respiration)or between capillaries and other body tissues (internal respiration)
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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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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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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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Breathing (cont’d)
Accessory muscles
• Sternocleidomastoid
• Scalene
• Pectoralis minor
• Internal intercostal
• Rectus abdominis
• Transverse thoracis
Key Terms related to Anatomy and Physiology
Slide 20JSOMTC, SWMG(A)
Common or Concerning Symptoms related to the PE of Thorax
Chest Pain
Dyspnea (Shortness of Breath)
Wheezing
Cough
Hemoptysis
Slide 21JSOMTC, SWMG(A)
Chest Pain
Numerous causes (e.g., pericarditis, bronchitis, pleuritis, or chest wall trauma)
• Start with broad questions "Do you have any pain or 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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Slide 22JSOMTC, SWMG(A)
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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Wheezing
High pitch, musical sound
Caused by a restriction of the lower airways• Secretions
• Inflammation of the airway
• Foreign body
Prolonged expiratory phase
Common or Concerning Symptoms related to the PE of Thorax
Slide 24JSOMTC, 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 andpossible cardiovascular causes
Common or Concerning Symptoms related to the PE of Thorax
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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
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The Exam Techniques Used During a Thorax and Lungs Examination
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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
Slide 29JSOMTC, SWMG(A)
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 of normal breathing punctuated by a single, deep breath or sigh
Examination Techniques
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Irregular respiratory patterns
Tachypnea: rapid, shallow breathing
Examination Techniques
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Flail chest and respiratory distress
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Irregular respiratory patterns
Cheyne‐Stokes breathing: characterized by periods of deep breathing, alternating with apnea
Examination Techniques
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Cheyne‐Stokes breathing
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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
Slide 39JSOMTC, 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 other
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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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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Slide 43JSOMTC, 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
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Examination Techniques
Slide 44JSOMTC, 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
Slide 45JSOMTC, 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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Obstructive breathing: impeded breathing due to restricted airways
Examination Techniques
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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
Slide 48JSOMTC, 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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Slide 49JSOMTC, 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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Examination Techniques
Palpate thoracic expansion (back)
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Examination Techniques
Palpate tactile fremitus (front and back)
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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)
Slide 53JSOMTC, 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
Slide 56JSOMTC, SWMG(A)
Examination TechniquesRelative Intensity
Relative Pitch
Relative Duration
Example of Location
Pathologic Examples
Flatness Soft High Short ThighLarge pleural
effusion
Dullness Medium Medium Medium LiverLobar
pneumonia
Resonance Loud Low Long Healthy lungSimple chronic
bronchitis
Hyper-resonance
Very loud Lower Longer Usually noneCOPD,
pneumothorax
Tympany Loud High* *
Gastric air bubble or puffed-out
cheek
Large pneumothora
x
* Distinguished mainly by its musical timbre.
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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
Slide 59JSOMTC, 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
Slide 60JSOMTC, SWMG(A)
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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Slide 61JSOMTC, SWMG(A)
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 over six fields, no adventitious sounds.
• Palpation:
Chest walls intact. No grimace.
• Percussion: Lungs are normoresonant
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Questions
Slide 71JSOMTC, 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% on the written exam IAW course standards
Slide 72JSOMTC, 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 73JSOMTC, 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 74JSOMTC, SWMG(A)
BREAK
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