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Lung auscultation

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    Lung examination

    Christi Brasted
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    Step 1 - Introductions
 Introduce   yourself to the patient

 Check    the patient’s identity

 Explain    what you are going to do and gain consent
    for the examination

 Ask   patient to undress appropriately

 Wash   hands
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    Step 2 – General appearance
     Doesthe patient look well/cachexic (lost a lot of
     weight)/blue = cyanosed/pink = emphysema?

     Doesthe patient breathe with oxygen/using
     accessory muscles/normally?

        there inhalers/oxygen tank/cigarettes by the
     Are
     bed?
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    Step 3 – Nails
       Clubbing = lung cancer, bronchiectasis, cystic fibrosis, sign of long-term
        hypoxia

       Tar staining = smoker

       Leuconychia (white nails)

       Koilonychia (spoon-shaped nails)

       Peripheral cyanosis (blue fingers)
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    Hands
       CO2 flap on prolonged wrist flexion with arms
        extended = CO2 retention

       Palmar erythema = CO2 retention

       Muscle wasting of small muscles of hand (brachial
        plexus palsy 2o to lung cancer)

       Pulse – regular/tachycardic/pulsus paradoxus

       Respiratory rate – tachypnoeic? Depressed due to
        opiate use?
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    Step 4 - Face

     Conjunctivae   – pale = anaemia, yellow = jaundice

     Horner’s syndrome – ptosis, miosis, anhydrosis due
     to apical lung cancer

     Tongue   – central cyanosis
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    Step 5 - Neck
     Tracheostomy/scars    from surgery?

     Goitre?

     Jugular   venous pressure – raised?

     Central/deviated   trachea?

     Cricosternal   distance

     Lymph     nodes – lymphadenopathy?
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    Step 6 - Chest - INSPECTION
     Rashes

     Scars   from previous surgery/chest drains

     Asymmetrical    breathing?

     Pigeon   chest/barrel chest/funnel chest

     Spinal   curvature – kyphosis/scoliosis

     Don’t   forget to examine back and sides
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    Step 7 - PALPATION/PERCUSSION
       Assess chest expansion – reduced?
       Percuss by playing left hand on patient with middle finger on
        skin and others lifted. Then tap between DIP and PIP joint
        with middle finger of right hand. Start at clavicle and work
        down.
       Always compare one lung to the other.


       Dull = solid = consolidation/liver
       Stony dull = fluid = pleural effusion
       Resonant = normal
       Hyper-resonant = hollow = pneumothorax/bowel
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    Step 8 - AUSCULTATION
 Ask   patient to breathe deeply through mouth.
 Listen   at each location in the slide before.
 Compare     both lungs to each other.
 Make    sure you listen to a full in-breath and out-
    breath each time.
 Normal   = vesicular which sounds like air travelling
    down a small tube
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    Step 9
     Repeat  inspection, palpation, percussion and
     auscultation on the patient’s back by asking the patient
     to sit forward

           vocal resonance by asking patient to say ‘99’ as
     Assess
     you move the stethoscope in each location.

     Muffled   = normal

     Increased   = pneumothorax

     Decreased   = consolidation
   Normal        Abnormal           Adventitious
tracheal      absent/decreased crackles (rales)
vesicular     bronchial         wheeze
bronchial                       rhonchi
broncho-
                                stridor
  vesicular
                                pleural rub

                                mediastinal crunch
                                (Hamman's sign)
Type     Characteristic   Intensity   Pitch   Description        Location


                                              harsh; not
         tracheal         loud        high    routinely          over the trachea

                                              auscultated
         vesicular        soft        low                   .    most of the lungs


                                              sound close to
                          very                stethoscope; gap   over the manubrium
         bronchial        loud
                                      high
                                              between insp &
                                                                 (normal) or
                                                                 consolidated areas
Normal
                                              exp sounds

                                                                 normally in 1st & 2nd

         broncho-                                                ICS anteriorly and
                                                                 between scapulae
                          medium medium                     .    posteriorly; other
         vesicular                                               locations indicate
                                                                 consolidation
                              heard in ARDS, asthma,
                              ateletasis, emphysema,
           absent/decreased   pleural effusion,
                              pneumothora
Abnormal



                              indicates areas of
           bronchial
                              consolidation
+   Characteristic     Intensity   Pitch        Description                               Location




                       soft        high
                       (fine       (fine
                                                discontinuous, nonmusical, brief; more    may sometimes be
                       crackles)   crackles)          commonly heard on inspiration;            normally heard at
                                                      assoc. w/ ARDS, asthma,                   ant. lung bases after
    crackles (rales)                                  bronchiectasis, bronchitis,               max. expiration or
                                                      consolidation, early CHF,                 after prolonged
                       or loud     or low             interstitial lung disease                 recumbency

                       (coarse     (coarse
                       crackles)   crackles)



                                                continuous sounds normally heard on
                                                      expiration; note if monophonic      can be anywhere over the
                                                      (obstruction of 1 airway) or              lungs; produced
    wheeze             high        expiratory         polyphonic (general obstruction);         when there is
                                                      assoc. w/ asthma, CHF, chronic            obstruction
                                                      bronchitis, COPD, pulm. edema




                                                continuous musical sounds similar to
    rhonchi            low         expiratory         wheezes; imply obstruction of
                                                      larger airways by secretions
                                                                                                       .
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    Characteristic   Intensity    Pitch     Description                                  Location



                                            musical wheeze that suggests obstructed
                                                                                         heard loudest over trachea
    stridor          .       inspiratory          trachea or larynx; medical
                                                  emergency
                                                                                                in inspiration




                             insp. &        creaking or brushing sounds; continuous or   usually can be localized to
    pleural rub      .                             discontinuous; assoc. w/ pleural             particular place on
                             exp.                  effusion or pneumothorax                     chest wall




                             Not
    mediastinal              synchronised   crackles synchronized w/ heart beat;         best heard w/ patient in
                     .                             medical emerg.; assoc. w/                    left lateral
    crunch                   with                  pneumomediatstinum                           decubitus position


                             respiration
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    End of examination

     Thank    patient at the end of examination

     Tell   patient to redress

     Wash    hands

     Report/record     findings as appropriate
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    Quiz

   http://solutions.3m.com/wps/portal/3M/en_US/Littman
    n/stethoscope/education/heart-lung-sounds/

   http://www.cvmbs.colostate.edu/clinsci/callan/breath_
    sounds.htm

   http://www.mediscuss.org/respiratory-auscultation-
    tips-audio-mp3-examples-71.html

				
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posted:10/12/2011
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