physical examinatio+cxr

Respiratory system 1In The name of God

Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

http://www.novapdf.com


Physical Examination of the Chest

معاینھ فیزیکی سیستم تنفس




Diagram of Thoracic Area




Chest Topography: Anterior Chest




Chest Topography:Lateral Chest




Chest Topography:Posterior Chest




8

Respiratory tract anatomy

fig 13-1




Lung Anatomy• Right Lung

– Superior lobe– Middle lobe– Inferior lobe

• Left Lung– Superior lobe– Inferior lobe




Fissures:




Location of Lobes




Lung Anterior




Lung Posterior




Lung Left Side




Lung Right Side




Physical Exam Techniques

• Observation• Palpation• Percussion• Auscultation




Observation:Breathing Patterns

• Apnea• Tachypnea/Bradypnea• Biot’s• Cheynes-Stokes• Kussmaul




Observation:Thoracic Contour




Observation: Thoracic Contour(cont.)

• Pectus Excavatum• Pectus Carinatum• Kyphosis• Scoliosis• Kyphoscoliosis• Symmetry of chest movement




Barrel Chest




Scoliosis




Kyphosis

Slide 18-22




Observation: Clubbing




Palpation: Tracheal Alignment




Tracheal Alignment Abnormalities

• Pneumothorax – shifts to unaffected side• Pleural Effusion – shifts to unaffected side• Fibrosis or Atelectasis – shifts towards

affected side• Pulmonary consolidation – no shift




Palpation : Chest Excursion




Palpation: Vocal Fremitus

• BILATERAL comparison of vocal vibrations

• Increased with alveolar consolidation

• Decreased with increased distance between lung and chest wall– Pneumothorax, Pleural

effusion




Percussion

• Assess density of underlying tissue




Percussion Notes

• Resonance – normal• Dullness – increased density

– Atelectasis, alveolar filling/consolidation, pleural effusion, fibrosis

• Hyperresonance – decreased density– Hyperinflation (COPD), Pneumothorax




Lets all listen in




Auscultation: Listening to breath sounds with a stethoscope




Normal Breath Sounds and Their Locations




Abnormal Breath Sounds: Diminished or Absent

• Increased distance between aerated lung and chest wall:– Pneumothorax, Pleural effusion, Atelectasis,

Obesity around thorax• Decreased or absent airflow

– Airflow obstruction (eg asthma), Hyperinflation (COPD), Malpositioned ET Tube




Abnormal Breath Sounds: Bronchial or Bronchovesicular

in abnormal part of the lung

• Lung has become more solid and less aerated in these areas

• Consolidation, eg, pneumonia, or Atelectasis




Abnormal Breath Sounds: Adventitious Sounds

• Wheeze – continuous musical sounds heard mostly during expiration – May be also heard on inspiration

• Caused by a sudden change in airway caliber– Edema, spasm, secretions, foreign body




Abnormal Breath Sounds: Adventitious Sounds

• Crackles – discontinuous sound heard mostly on inspiration

• Caused by small airways and alveoli popping open or from secretions in very large airways




Condition Chest Excursion

Fremitus Percussion BreathSounds

Atelectasis

Pneumothorax

Pleural Effusion

COPD

Pulmonary Consolidation

Fibrosis

Pulmonary Edema




Techniques - Projection

•P-A (relation of x-ray beam to patient)




Techniques - Projection (continued)•Lateral




Techniques - Projection (continued)

•Lateral Decubitus




Techniques - Projection (continued)

•Oblique




The Normal Chest X-ray• PA View:

1. Aortic arch2. Pulmonary trunk3. Left atrial appendage4. Left ventricle5. Right ventricle6. Superior vena cava7. Right hemidiaphragm8. Left hemidiaphragm9. Horizontal fissure




Lung Anatomy• Trachea• Carina• Right and Left Pulmonary

Bronchi• Secondary Bronchi• Tertiary Bronchi• Bronchioles• Alveolar Duct• Alveoli




Anatomy




Rotation




Rotation (continued)




Penetration




Inspiration/Expiration




Technical Details

•Type•Rotation •Inspiration/expiration•Penetration




Summary of Density • Air• Water• Bone• Tissue

Tissue




DensitiesThe big two densities are:

(1) WHITE - Bone(2) BLACK - Air

The others are:

(3) DARK GREY- Fat (4) GREY- Soft tissue/water

And if anything Man-made is on the film, it is:

(5) BRIGHT WHITE - Man-made




Pitfalls to Chest X-ray Interpretation

• Poor inspiration• Over or under penetration• Rotation• Forgetting the path of the x-ray beam




Systematic Approach• Soft Tissues

– Breast shadows– Supraclavicular areas– Axillae– Tissues along side of

breasts




Systematic Approach• Diaphragm and

Pleural Surfaces– Diaphragm

• Dome-shaped• Costophrenic angles

– Normal pleural is not visible

– Interlobar fissures




Mediastinum




Hilum




Hilum

Made of:

1. Pulmonary Art.+Veins2. The Bronchi

Left Hilus higher (max 1-2,5 cm)

Identical: size, shape, density




Ribs




Lung Anatomy on Chest X-ray• The right upper lobe

(RUL) occupies the upper 1/3 of the right lung.

• Posteriorly, the RUL is adjacent to the first three to five ribs.

• Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib




Lung Anatomy on Chest X-ray• The right middle lobe

is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum




Lung Anatomy on Chest X-ray• The right lower lobe is the

largest of all three lobes, separated from the others by the major fissure.

• Posteriorly, the RLL extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm.

• Review of the lateral plain film surprisingly shows the superior extent of the RLL.




Lung Anatomy on Chest X-ray• These lobes can be separated

from one another by two fissures.

• The minor fissure separates the RUL from the RML, and thus represents the visceral pleural surfaces of both of these lobes.

• Oriented obliquely, the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body.




Lung Anatomy on Chest X-ray• The lobar architecture

of the left lung is slightly different than the right.

• Because there is no defined left minor fissure, there are only two lobes on the left; the left upper




Lung Anatomy on Chest X-ray• These two lobes are

separated by a major fissure, identical to that seen on the right side, although often slightly more inferior in location.

• The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe.




The Silhouette Sign• An intra-thoracic radio-

opacity, if in anatomic contact with a border of heart or aorta, will obscure that border. An intra-thoracic lesion not anatomically contiguous with a border or a normal structure will not obliterate that border.




Pathology




RUL pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



RML pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



RLL pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



LUL pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



LLL pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



Consolidation on CTCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



Hilar m lCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



The Enlarged Hila

Causes:

1. Adenopathies (neoplasia, infection)

2. Primary Tumor

3. Vascular

4. Sarcoidosis




Multiple MassesCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



Hilar Lymphadenopathy - BLCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



Pleural EffusionCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



Pulmonary FibrosisCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



Heart failureCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



PneumothoraxCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



RUL collapseCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



EmphysemaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



Cervical RibCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



Cavitating lesionCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



Hiatus herniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



Chest Tube, NG Tube, Pulm. artery cathCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)



physical examinatio+cxr

Technology