practical guide clinical medicine (pneumo).doc

7/23/2019 practical guide clinical medicine (Pneumo).doc

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History of Present Illness (HPI)

Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem. A

large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The

value of the history, of course, will depend on your ability to elicit relevant information. Your sense of

what constitutes important data will grow exponentially in the coming years as you gain a greater

understanding of the pathophysiology of disease through increased exposure to patients and illness.

owever, you are already in possession of the tools that will enable you to obtain a good history. That is,

an ability to listen and ask common!sense "uestions that help define the nature of a particular problem. #tdoes not take a vast, sophisticated fund of knowledge to successfully interview a patient. #n fact seasoned

physicians often lose site of this important point, placing too much emphasis on the use of testing while

failing to take the time to listen to their patients. $uccessful interviewing is for the most part dependent

upon your already well developed communication skills.

%hat follows is a framework for approaching patient complaints in a problem oriented fashion. The

patient initiates this process by describing a symptom. #t falls to you to take that information and use it as

a springboard for additional "uestioning that will help to identify the root cause of the problem. &ote that

this is different from trying to identify disease states which might exist yet do not generate overt

symptoms. To uncover these issues re"uires an extensive (eview Of $ystems )a.k.a. (O$*. +enerally,

this consists of a list of "uestions grouped according to organ system and designed to identify disease

within that area. or example, a review of systems for respiratory illnesses would include- o you have acough/ #f so, is it productive of sputum/ o you feel short of breath when you walk/ etc. #n a practical

sense, it is not necessary to memori0e an extensive (O$ "uestion list. (ather, you will have an

opportunity to learn the relevant "uestions that uncover organ dysfunction when you review the physical

exam for each system individually. #n this way, the (O$ will be given some context, increasing the

likelihood that you will actually remember the relevant "uestions.

The patient's reason for presenting to the clinician is usually referred to as the 1hief 1omplaint. 2erhaps

a less pe3orative4more accurate nomenclature would be to identify this as their area of 1hief 1oncern.

Getting Started:

Always introduce yourself to the patient. Then try to make the environment as private and free of

distractions as possible. This may be difficult depending on where the interview is taking place. The

emergency room or a non!private patient room are notoriously difficult spots. o the best that you can

and feel free to be creative. #f the room is crowded, it's O5 to try and find alternate sites for the interview.

#t's also acceptable to politely ask visitors to leave so that you can have some privacy.

#f possible, sit down next to the patient while conducting the interview. (emove any physical barriers that

stand between yourself and the interviewee )e.g. put down the side rail so that your view of one another is

unimpeded... though make sure to put it back up at the conclusion of the interview*. These simple

maneuvers help to put you and the patient on e"ual footing. urthermore, they enhance the notion that

you are completely focused on them. You can either disarm or build walls through the speech, posture and

body languarge that you adopt. (ecogni0e the power of these cues and the impact that they can have on

the interview. %hile there is no way of creating instant intimacy and rapport, paying attention to what

may seem like rather small details as well as always showing kindness and respect can go a long waytowards creating an environment that will facilitate the exchange of useful information.

#f the interview is being conducted in an outpatient setting, it is probably better to allow the patient to

wear their own clothing while you chat with them. At the conclusion of your discussion, provide them

with a gown and leave the room while they undress in preparation for the physical exam.

Initial Question(s):

#deally, you would like to hear the patient describe the problem in their own words. Open ended "uestions

are a good way to get the ball rolling. These include- %hat brings your here/ ow can # help you/ %hat

seems to be the problem/ 2ush them to be as descriptive as possible. %hile it's simplest to focus on a

single, dominant problem, patients occasionally identify more then one issue that they wish to address.

%hen this occurs, explore each one individually using the strategy described below.

Follow-up Questions:There is no single best way to "uestion a patient. $uccessful interviewing re"uires that you avoid medical

terminology and make use of a descriptive language that is familiar to them. There are several broad

"uestions which are applicable to any complaint. These include-

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6. Duration:ow long has this condition lasted/ #s it similar to a past problem/ #f so, what was

done at that time/

7. Severity/!ara"ter:ow bothersome is this problem/ oes it interfere with your daily

activities/ oes it keep you up at night/ Try to have them ob3ectively rate the problem. #f they are

describing pain, ask them to rate it from 6 to 68 with 68 being the worse pain of their life, though

first find out what that was so you know what they are using for comparison )e.g. childbirth, a

broken limb, etc.*. urthermore, ask them to describe the symptom in terms with which they are

already familiar. %hen describing pain, ask if it's like anything else that they've felt in the past.

5nife!like/ A sensation of pressure/ A toothache/ #f it affects their activity level, determine towhat degree this occurs. or example, if they complain of shortness of breath with walking, how

many blocks can they walk/ ow does this compare with 9 months ago/

:. #o"ation/$adiation:#s the symptom )e.g. pain* located in a specific place/ as this changed over

time/ #f the symptom is not focal, does it radiate to a specific area of the body/

;. Have t!ey tried any t!erapeuti" %aneuvers&:#f so, what's made it better )or worse*/

. !y today&:This is particularly relevant when a patient chooses to make mention ofsymptoms4complaints that appear to be long standing. #s there something new4different today as

opposed to every other day when this problem has been present/ oes this relate to a gradual

worsening of the symptom itself/ as the patient developed a new perception of its relative

importance )e.g. a friend told them they should get it checked out*/ o they have a specific

agenda for the patient!provider encounter/

or those who favor mnemonics, the > dimensions of a medical problem can be easily recalled using

O? 1A(T$ )+nset, #ocation4radiation, Duration, haracter, 'ggrevating factors, $eliving factors,

,iming and Severity*.

The content of subse"uent "uestions will depend both on what you uncover and your knowledge

base4understanding of patients and their illnesses. #f, for example, the patient's initial complaint was chestpain you might have uncovered the following by using the above "uestions-

The pain began 6 month ago and only occurs with activity. #t rapidly goes away with rest.

%hen it does occur, it is a steady pressure focused on the center of the chest that is roughly

a < )on a scale of 6 to 68*. Over the last week, it has happened 9 times while in the first

week it happened only once. The patient has never experienced anything like this

previously and has not mentioned this problem to anyone else prior to meeting with you.

As yet, they have employed no specific therapy.

This is "uite a lot of information. owever, if you were not aware that coronary!based ischemia causes asymptom complex identical to what the patient is describing, you would have no idea what further

"uestions to ask. That's O5. %ith additional experience, exposure, and knowledge you will learn the

appropriate settings for particular lines of "uestioning. %hen clinicians obtain a history, they are

continually generating differential diagnoses in their minds, allowing the patient's answers to direct the

logical use of additional "uestions. %ith each step, the list of probable diagnoses is pared down until a

few likely choices are left from what was once a long list of possibilities. 2erhaps an easy way to

understand this would be to think of the patient problem as a %indows!@ased computer program. The

patient tells you a symptom. You click on this symptom and a list of general "uestions appears. The

patient then responds to these "uestions. You click on these responses and... blank screen. &o problem. As

yet, you do not have the clinical knowledge base to know what "uestions to ask next. %ith time and

experience you will be able to click on the patient's response and generate a list of additional appropriate"uestions. #n the previous patient with chest pain, you will learn that this patient's story is very consistent

with significant, symptomatic coronary artery disease. As such, you would ask follow!up "uestions that

help to define a cardiac basis for this complaint )e.g. history of past myocardial infarctions, risk factors

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for coronary disease, etc.*. You'd also be aware that other disease states )e.g. emphysema* might cause

similar symptoms and would therefore ask "uestions that could lend support to these possible diagnoses

)e.g. history of smoking or whee0ing*. At the completion of the 2#, you should have a pretty good idea

as to the likely cause of a patient's problem. You may then focus your exam on the search for physical

signs that would lend support to your working diagnosis and help direct you in the rational use of

ad3uvant testing.

(ecogni0ing symptoms4responses that demand an urgent assessment )e.g. crushing chest pain* vs. those

that can be handled in a more leisurely fashion )e.g. fatigue* will come with time and experience. All

patient complaints merit careful consideration. $ome, however, re"uire time to play out, allowing them toeither become a something )a recogni0able clinical entity* or a nothing, and simply fade away.

1linicians are constantly on the look!out for markers of underlying illness, historical points which might

increase their suspicion for the existence of an underlying disease process. or example, a patient who

does not usually seek medical attention yet presents with a new, specific complaint merits a particularly

careful evaluation. ore often, however, the challenge lies in having the discipline to continually re!

consider the diagnostic possibilities in a patient with multiple, chronic complaints who presents with a

variation of his4her usual symptom complex.

You will undoubtedly forget to ask certain "uestions, re"uiring a return visit to the patient's bedside to

ask, Bust one more thing. on't worry, this happens to everyoneC You'll get more efficient with practice.

Dealing it! our +wn Dis"o%fort:

any of you will feel uncomfortable with the patient interview. This process is, by its very nature, highlyintrusive. The patient has been stripped, both literally and figuratively, of the layers that protect them

from the physical and psychological probes of the outside world. urthermore, in order to be successful,

you must ask in!depth, intimate "uestions of a person with whom you essentially have no relationship.

This is completely at odds with your normal day to day interactions. There is no way to proceed without

asking "uestions, peering into the life of an otherwise complete stranger. This can, however, be done in a

way that maintains respect for the patient's dignity and privacy. #n fact, at this stage of your careers, you

perhaps have an advantage over more experienced providers as you are hyper!aware that this is not a

natural environment. any physicians become immune to the sense that they are violating a patient's

personal space and can thoughtlessly over step boundaries. Avoiding this is not an easy task. ?isten and

respond appropriately to the internal warnings that help to sculpt your normal interactions.

.ital Signs

Dital signs include the measurement of- temperature, respiratory rate, pulse, blood pressure and, where

appropriate, blood oxygen saturation. These numbers provide critical information )hence the name

vital* about a patient's state of health. #n particular, they-

6. 1an identify the existence of an acute medical problem.

7. Are a means of rapidly "uantifying the magnitude of an illness and how well the body is coping

with the resultant physiologic stress. The more deranged the vitals, the sicker the patient.

:. Are a marker of chronic disease states )e.g. hypertension is defined as chronically elevated blood

pressure*.

ost patients will have had their vital signs measured by an (& or health care assistant before you have a

chance to see them. owever, these values are of such great importance that you should get in the habit of

repeating them yourself, particularly if you are going to use these values as the basis for management

decisions. This not only allows you to practice obtaining vital signs but provides an opportunity to verify

their accuracy. As noted below, there is significant potential for measurement error, so repeat

determinations can provide critical information.

Getting Started:The examination room should be "uiet, warm and well lit. After you have finished

interviewing the patient, provide them with a gown )a.k.a. Bohnny* and leave the room )or draw a

separating curtain* while they change. #nstruct them to remove all of their clothing )except for briefs* and

put on the gown so that the opening is in the rear. Occasionally, patient's will end up using them asponchos, capes or in other creative ways. %hile this may make for a more attractive ensemble it will also,

unfortunately, interfere with your ability to perform an examinationC 2rior to measuring vital signs, the

patient should have had the opportunity to sit for approximately five minutes so that the values are not

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affected by the exertion re"uired to walk to the exam room. All measurements are made while the patient

is seated.

+*servation:@efore diving in, take a minute or so to look at the patient in their entirety, making your

observations, if possible, from an out!of!the way perch. oes the patient seem anxious, in pain, upset/

%hat about their dress and hygiene/ (emember, the exam begins as soon as you lay eyes on the patient.

,e%perature:This is generally obtained using an oral thermometer that provides a digital reading when

the sensor is placed under the patient's tongue. As most exam rooms do not have thermometers, it is not

necessary to repeat this measurement unless, of course, the recorded value seems discordant with the

patient's clinical condition )e.g. they feel hot but reportedly have no fever or vice versa*. epending onthe bias of a particular institution, temperature is measured in either 1elcius or arenheit, with a fever

defined as greater than :>!:>.< 1 or 686!686.< . (ectal temperatures, which most closely reflect internal

or core values, are approximately 6 degree higher than those obtained orally.

$espiratory $ate:(espirations are recorded as breaths per minute. They should be counted for at least

:8 seconds as the total number of breaths in a 6< second period is rather small and any miscounting can

result in rather large errors when multiplied by ;. Try to do this as surreptitiously as possible so that the

patient does not consciously alter their rate of breathing. This can be done by observing the rise and fall

of the patient's hospital gown while you appear to be taking their pulse. &ormal is between 67 and 78. #n

general, this measurement offers no relevant information for the routine examination. owever,

particularly in the setting of cardio!pulmonary illness, it can be a very reliable marker of disease activity.

Pulse:This can be measured at any place where there is a large artery )e.g. carotid, femoral, or simply bylistening over the heart*, though for the sake of convenience it is generally done by palpating the radial

impulse. You may find it helpful to feel both radial arteries simultaneously, doubling the sensory input

and helping to insure the accuracy of your measurements. 2lace the tips of your index and middle fingers

3ust proximal to the patients wrist on the thumb side, orienting them so that they are both over the length

of the vessel.

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.as"ular 'nato%y

,e"!niue for 0easuring t!e $adial Pulse

The pictures below demonstrate the location of the radial artery )surface anatomy on the left, gross

anatomy on the right*.


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re"uently, you can see transmitted pulsations on careful visual inspection of this region, which may help

in locating this artery. Epper extremity peripheral vascular disease is relatively uncommon, so the radial

artery should be readily palpable in most patients. 2ush lightly at first, adding pressure if there is a lot of

subcutaneous fat or you are unable to detect a pulse. #f you push too hard, you might occlude the vessel

and mistake your own pulse for that of the patient. uring palpation, note the following-

6. Fuantity- easure the rate of the pulse )recorded in beats per minute*. 1ount for :8 seconds andmultiply by 7 )or 6< seconds x ;*. #f the rate is particularly slow or fast, it is probably best to

measure for a full 98 seconds in order to minimi0e the impact of any error in recording over

shorter periods of time. &ormal is between 98 and 688.

7. (egularity- #s the time between beats constant/ #n the normal setting, the heart rate should appear

metronomic. #rregular rhythms, however, are "uite common. #f the pattern is entirely chaotic with

no discernable pattern, it is referred to as irregularly irregular and likely represents atrial

fibrillation. Gxtra beats can also be added into the normal pattern, in which case the rhythm is

described as regularly irregular. This may occur, for example, when impulses originating from the

ventricle are interposed at regular 3unctures on the normal rhythm. #f the pulse is irregular, it's a

good idea to verify the rate by listening over the heart )see cardiac exam section*. This is because

certain rhythm disturbances do not allow ade"uate ventricular filling with each beat. The resultant

systole may generate a rather small stroke volume whose impulse is not palpable in the periphery.

:. Dolume- oes the pulse volume )i.e. the sub3ective sense of fullness* feel normal/ This reflects

changes in stroke volume. #n the setting of hypovolemia, for example, the pulse volume is

relatively low )aka weak or thready*. There may even be beat to beat variation in the volume,

occurring occasionally with systolic heart failure.

(hythm $imulator

1lood Pressure:@lood pressure )@2* is measured using mercury based manometers, with readings

reported in millimeters of mercury )mm g*. The si0e of the @2 cuff will affect the accuracy of these

readings. The inflatable bladder, which can be felt through the vinyl covering of the cuff, should reachroughly >8H around the circumference of the arm while its width should cover roughly ;8H. #f it is too

small, the readings will be artificially elevated. The opposite occurs if the cuff is too large. 1linics should

have at least 7 cuff si0es available, normal and large. Try to use the one that is most appropriate,

recogni0ing that there will rarely be a perfect fit.

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1lood Pressure uffs

#n order to measure the @2, proceed as follows-

6. %rap the cuff around the patient's upper arm so that the line marked artery is roughly over the

brachial artery, located towards the medial aspect of the antecubital fossa )i.e. the crook on theinside of their elbow*. The placement does not have to be exact nor do you actually need to

identify this artery by palpation.

'nte"u*ital Fossa

The pictures below demonstrate the antecubital fossa anatomy )surface anatomy on the left, gross

anatomy on the right*.

7. 2ut on your stethescope so that the ear pieces are angled away from your head. Twist the head

piece so that the bell is engaged. This can be verified by gently tapping on the end, which should

produce a sound. %ith your left hand, place the bell over the area of the brachial artery. %hile

most practitioners use the diaphragm of the stethescope, the bell is actually be superior for picking

up the low pitched sounds used for measuring @2. #t's worth mentioning that a number of different

models of stethescops are available on the market, each with its own variation on the structure of

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the diaphragm and bell. (ead the instruction manual accompanying your stethoscope in order to

determine how your device works.

:. +rasp the patient's right elbow with your right hand and raise their arm so that the brachial artery

is roughly at the same height as the heart. The arm should remain somewhat bent and completely

relaxed. You can provide additional support by gently trapping their hand and forearm between

your body and right elbow. #f the arm is held too high, the reading will be artifactually lowered,

and vice versa.

;. Turn the valve on the pumping bulb clockwise )may be counter clockwise in some cuffs* until it

no longer moves. This is the position which allows air to enter and remain in the bladder.


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=. (epeat the measurement on the patient's other arm, reversing the position of your hands. The two

readings should be within 68!6< mm g of each other. ifferences greater then this imply that

there is differential blood flow to each arm, which most fre"uently occurs in the setting of

subclavian artery atherosclerosis.

>. Occasionally you will be unsure as to the point where systole or diastole occurred and wish torepeat the measurement. #deally, you should allow the cuff to completely deflate, permit any

venous congestion in the arm to resolve )which otherwise may lead to inaccurate measurements*,

and then repeat a minute or so later. urthermore, while no one has ever lost a limb secondary to

@2 cuff induced ischemia, repeated measurement can be uncomfortable for the patient, another

good reason for giving the arm a break.

I. Avoid moving your hands or the head of the stethescope while you are taking readings as this may

produce noise that can obscure the $ounds of 5oratkoff.

68. You can verify the $@2 by palpation. To do this, position the patient's right arm as described

above. 2lace the index and middle fingers of your right hand over the radial artery. #nflate the cuff

until you can no longer feel the pulse, or simply to a value 68 points above the $@2 as determined

by auscultation. $lowly deflate the cuff until you can again detect a radial pulse and note the

reading on the manometer. This is the $@2 and should be the same as the value determined with

the use of your stethescope.

Ohio $tate Eniversity, @lood 2ressure $imulator

&ormal is between 688498 and 6;84I8. ypertension is thus defined as either $@2 greater then 6;8 or

@2 greater than I8. #t is important to recogni0e that blood pressure is rarely elevated to a level that

causes acute symptoms. That is, while hypertension in general is common, emergencies resulting from

extremely high values and subse"uent acute end organ dysfunction are "uite rare. (ather, it is the

chronically elevated values which lead to target organ damage, though in a slow and relatively silent

fashion. At the other end of the spectrum, the minimal $@2 re"uired to maintain perfusion varies with theindividual. Therefore, interpretation of low values must take into account the clinical situation. Those

with poorly functioning hearts, for example, can ad3ust to a chronically low $@2 )e.g. >8!I8* and live

without symptoms of hypoperfusion. owever others, used to higher baseline values, might become "uite

ill if their $@2s were suddenly decreased to these same levels.

any things can alter the accuracy of your readings. #n order to limit their impact, remember the

following-

6. o not place the blood pressure cuff over a patients clothing or roll a tight fitting sleeve above

their biceps when determining blood pressure as either can cause elevated readings.

7. ake sure the patient has had an opportunity to rest before measuring their @2. Try the following

experiment to assess the impact that this can have. Take a patient's @2 after they've rested. Then

repeat after they've walked briskly in place for several minutes. 2atients who are not toophysically active )i.e. relatively deconditioned* will develop an elevation in both their $@2 and

@2. Also, see what effect raising or lowering the arm, and thus the position of the brachial artery

relative to the heart, has on @2. #f you have a chance, obtain measurements on the same patient

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with both a large and small cuff. These exercises should give you an appreciation for the

magnitude of error that can be introduced when improper techni"ue is utili0ed.

:. #f the reading is surprisingly high or low, repeat the measurement towards the end of your exam.

;. #nstruct your patients to avoid coffee, smoking or any other unprescribed drug with

sympathomimetic activity on the day of the measurement.


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affect adherence )e.g. A1G!# NcoughM 1TN mild increase in urination, erectile dysfunctionM

all anti!htn medsN hypotension*

;. T& is directly related to weight, inactivity, GTO consumption, K salt intake. As such, life style

interventions are absolutely worth addressing, though they are relatively ineffective as sole

treatments )due to the inability of patients K clinicians to achieve sustained and meaningful

changes*. That said, you'll never know the impact until you try to address ! and readdress ! and

readdress P each visit.

. 1ertain conditions favor particular meds ! for example- iabetes N A1G!# or Angiotensin

(eceptor @lockers )A(@s*M 1oronary artery disease N @ blockers.

I. The use of : or more meds for refractory T& isn't uncommon ! in particular w4very obesepatients.

68. Acute interventions to immediately lower @2 are largely reserved for those times when there is

clear evidence of acute symptoms from acute TO )e.g. 1, coronary ischemia, increased intra!

cranial pressure* secondary to very high values.

B&1 = Gxpress !! $ummary of +uidelines for treatment T&

&ew Gngland Bournal of edicine ! @2 easurement

oser , et al. (esistant or difficult to control hypertension.&GB 7889M :+2ygen Saturation:Over the past decade, this non!invasive measurement of gas exchange and red blood

cell oxygen carrying capacity has become available in all hospitals and many clinics. %hile imperfect, it

can provide important information about cardio!pulmonary dysfunction and is considered by many to be a

fifth vital sign. #n particular, for those suffering from either acute or chronic cardio!pulmonary disorders,

it can help "uantify the degree of impairment.

Pulse +2y%eter

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,!e #ung 32a%

The ; ma3or components of the lung exam )inspection, palpation, percussion and auscultation* are also

used to examine the heart and abdomen. ?earning the appropriate techni"ues at this 3uncture will

therefore enhance your ability to perform these other examinations as well. Dital signs, an important

source of information, are discussed elsewhere.

Inspe"tion/+*servation:A great deal of information can be gathered from simply watching a patientbreathe. 2ay particular attention to-

6. +eneral comfort and breathing pattern of the patient. o they appear distressed, diaphoretic,

labored/ Are the breaths regular and deep/

7. Ese of accessory muscles of breathing )e.g. scalenes, sternocleidomastoids*. Their use signifies

some element of respiratory difficulty.

:. 1olor of the patient, in particular around the lips and nail beds. Obviously, blue is badC

yanosis of nail *eds

;. The position of the patient. Those with extreme pulmonary dysfunction will often sit up!right. #n

cases of real distress, they will lean forward, resting their hands on their knees in what is known as

the tri!pod position.

Patient wit! e%p!yse%a *ending over in ,ri-Pod Position

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. The direction of abdominal wall movement during inspiration. &ormally, the descent of the

diaphragm pushes intra!abdominal contents down and the wall outward. #n cases of severe

diaphragmatic flattening )e.g. emphysema* or paralysis, the abdominal wall may move inward

during inspiration, referred to as paradoxical breathing. #f you suspect this to be the case, place

your hand on the patient's abdomen as they breathe, which should accentuate its movement.

I. Any obvious chest or spine deformities. These may arise as a result of chronic lung disease )e.g.

emphysema*, occur congenitally, or be otherwise ac"uired. #n any case, they can impair a patient's

ability to breathe normally. A few common variants include-o 2ectus excavatum- 1ongenital posterior displacement of lower aspect of sternum. This

gives the chest a somewhat hollowed!out appearance. The x!ray shows a subtle concave

appearance of the lower sternum.

o @arrel chest- Associated with emphysema and lung hyperinflation. Accompanying xray

also demonstrates

increased anterior!posterior diameter as well as diaphragmatic flattening.

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o $pine abnormalities-

5yphosis- 1auses the patient to be bent forward. Accompanying R!(ay of same

patient clearly demonstrates extreme curvature of the spine.

$coliosis- 1ondition where the spine is curved to either the left or right. #n the

pictures below, scoliosis of the spine causes right shoulder area to appear somewhat

higher than the left. 1urvature is more pronounced on x!ray.

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10. $eview of #ung 'nato%y:Enderstanding the pulmonary exam is greatly enhanced by

recogni0ing the relationships between surface structures, the skeleton, and the main lobes of the

lung. (eali0e that this can be difficult as some surface landmarks )eg nipples of the breast* do not

always maintain their precise relationship to underlying structures. &evertheless, surface markers

will give you a rough guide to what lies beneath the skin. The pictures below demonstrate these

relationships. The multi!colored areas of the lung model identify precise anatomic segments of the

various lobes, which cannot be appreciated on examination. ain lobes are outlined in black. The

following abbreviations are used- (E? L (ight Epper ?obeM ?E? L ?eft Epper ?obeM (? L(ight iddle ?obeM (?? L (ight ?ower ?obeM ??? L ?eft ?ower ?obe.

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'nterior .iew

Posterior .iew

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$ig!t #ateral .iew

6=


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#eft

#ateral

.iew

6>.

6I.

20. Palpation:2alpation plays a relatively minor role in the examination of the normal chest

as the structure of interest )the lung* is covered by the ribs and therefore not palpable. $pecific

situations where it may be helpful include-

1. Accentuating normal chest excursion- 2lace your hands on the patient's back with thumbs

pointed towards the spine. (emember to first rub your hands together so that they are not

too cold prior to touching the patient. Your hands should lift symmetrically outward when

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the patient takes a deep breath. 2rocesses that lead to asymmetric lung expansion, as might

occur when anything fills the pleural space )e.g. air or fluid*, may then be detected as the

hand on the affected side will move outward to a lesser degree. There has to be a lot of

plerual disease before this asymmetry can be identified on exam.

Dete"ting !est 32"ursion

2. Tactile remitus- &ormal lung transmits a palpable vibratory sensation to the chest wall.

This is referred to as fremitus and can be detected by placing the ulnar aspects of both

hands firmly against either side of the chest while the patient says the words &inety!

&ine. This maneuver is repeated until the entire posterior thorax is covered. The bony

aspects of the hands are used as they are particularly sensitive for detecting thesevibrations.

'ssessing Fre%itus

2athologic conditions will alter fremitus. #n particular-

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AA ?ung consolidation- 1onsolidation occurs when the normally air filled lung

parenchyma becomes engorged with fluid or tissue, most commonly in the setting

of pneumonia. #f a large enough segment of parenchyma is involved, it can alter the

transmission of air and sound. #n the presence of consolidation, fremitus becomes

more pronounced.

AA 2leural fluid- luid, known as a pleural effusion, can collect in the potential space

that exists between the lung and the chest wall, displacing the lung upwards.

remitus over an effusion will be decreased.

#n general, fremitus is a pretty subtle finding and should not be thought of as the primary

means of identifying either consolidation or pleural fluid. #t can, however, lend supporting

evidence if other findings )see below* suggest the presence of either of these processes.

Gffusions and

infiltrates can perhaps

be more easilyunderstood using a

sponge to represent the

lung. #n this model, an

infiltrate is depicted by

the blue coloration that

has invaded the sponge

itself )sponge on left*.

An effusion is depicted

by the blue fluid upon

which the lung is

floating )sponge onright*.

2. #nvestigating painful areas- #f the patient complains of pain at a particular site it is

obviously important to carefully palpate around that area. #n addition, special situations

)e.g. trauma* mandate careful palpation to look for evidence of rib fracture, subcutaneous

air )feels like your pushing on (ice 5rispies or bubble paper*, etc.

Per"ussion:This techni"ue makes use of the fact that striking a surface which covers an air!filledstructure )e.g. normal lung* will produce a resonant note while repeating the same maneuver over

a fluid or tissue filled cavity generates a relatively dull sound. #f the normal, air!filled tissue has

been displaced by fluid )e.g. pleural effusion* or infiltrated with white cells and bacteria )e.g.

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pneumonia*, percussion will generate a deadened tone. Alternatively, processes that lead to

chronic )e.g. emphysema* or acute )e.g. pneumothorax* air trapping in the lung or pleural space,

respectively, will produce hyper!resonant )i.e. more drum!like* notes on percussion. #nitially, you

will find that this skill is a bit awkward to perform. Allow your hand to swing freely at the wrist,

hammering your finger onto the target at the bottom of the down stroke. A stiff wrist forces you to

push your finger into the target which will not elicit the correct sound. #n addition, it takes a while

to develop an ear for what is resonant and what is not. A few things to remember-

3. #f you're percussing with your right hand, stand a bit to the left side of the patient's back.

4. Ask the patient to cross their hands in front of their chest, grasping the opposite shoulder

with each hand. This will help to pull the scapulae laterally, away from the percussion

field.

5. %ork down the alley that exists between the scapula and vertebral column, which should

help you avoid percussing over bone.

6. Try to focus on striking the distal inter!phalangeal 3oint )i.e. the last 3oint* of your left

middle finger with the tip of the right middle finger. The impact should be crisp so you

may want to cut your nails to keep blood!letting to a minimumC

7. The last 7 phalanges of your left middle finger should rest firmly on the patient's back. Try

to keep the remainder of your fingers from touching the patient, or rest only the tips onthem if this is otherwise too awkward, in order to minimi0e any dampening of the

perucssion notes.

8. %hen percussing any one spot, 7 or : sharp taps should suffice, though feel free to do

more if you'd like. Then move your hand down several inter!spaces and repeat the

maneuver. #n general, percussion in < or so different locations should cover one hemi!

thorax. After you have percussed the left chest, move yours hands across and repeat the

same procedure on the right side. #f you detect any abnormality on one side, it's a good

idea to slide your hands across to the other for comparison. #n this way, one thorax serves

as a control for the other. #n general, percussion is limited to the posterior lung fields.

owever, if auscultation )see below* reveals an abnormality in the anterior or lateral fields,percussion over these areas can help identify its cause.

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Per"ussion ,e"!niue

9. The goal is to recogni0e that at some point as you move down towards the base of the

lungs, the "uality of the sound changes. This normally occurs when you leave the thorax. #tis not particularly important to identify the exact location of the diaphragm, though if you

are able to note a difference in level between maximum inspiration and expiration, all the

better. Eltimately, you will develop a sense of where the normal lung should end by simply

looking at the chest. The exact vertebral level at which this occurs is not really relevant.

10. $peed percussion may help to accentuate the difference between dull and

resonant areas. uring this techni"ue, the examiner moves their left )i.e. the non!

percussing* hand at a constant rate down the patient's back, tapping on it continuously as it

progresses towards the bottom of the thorax. This tends to make the point of inflection )i.e.

change from resonant to dull* more pronounced.

2ractice percussionC Try finding your own stomach bubble, which should be around the left costal

margin. &ote that due to the location of the heart, tapping over your left chest will produce a

different sound then when performed over your right. 2ercuss your walls )if they're sheet rock*

and try to locate the studs. Tap on tupperware filled with various amounts of water. This not only

helps you develop a sense of the different tones that may be produced but also allows you to

practice the techni"ue.

'us"ultation:2rior to listening over any one area of the chest, remind yourself which lobe of the lung is

heard best in that region- lower lobes occupy the bottom :4; of the posterior fieldsM right middle lobe

heard in right axillaM lingula in left axillaM upper lobes in the anterior chest and at the top 64; of the

posterior fields. This can be "uite helpful in trying to pin down the location of pathologic processes thatmay be restricted by anatomic boundaries )e.g. pneumonia*. any disease processes )e.g. pulmonary

edema, bronchoconstriction* are diffuse, producing abnormal findings in multiple fields.

11. 2ut on your stethoscope so that the ear pieces are directed away from you. Ad3ust

the head of the scope so that the diaphragm is engaged. #f you're not sure, scratch lightly

on the diaphragm, which should produce a noise. #f not, twist the head and try again.

+ently rub the head of the stethoscope on your shirt so that it is not too cold prior to

placing it on the patient's skin.

12. The upper aspect of the posterior fields )i.e. towards the top of the patient's back*

are examined first. ?isten over one spot and then move the stethoscope to the same

position on the opposite side and repeat. This again makes use of one lung as a source of

comparison for the other. The entire posterior chest can be covered by listening in roughly; places on each side. Of course, if you hear something abnormal, you'll need to listen in

more places.

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#ung 'us"ultation

13. The lingula and right middle lobes can be examined while you are still standing

behind the patient.

14. Then, move around to the front and listen to the anterior fields in the same fashion.This is generally done while the patient is still sitting upright. Asking female patients to lie

down will allow their breasts to fall away laterally, which may make this part of the

examination easier.

,!oug!ts +n 4Gown 0anage%ent4 5 'ppropriately/$espe"tfully ,ou"!ing our Patients:

There are several sources of tension relating to the physical exam in general, which are really

brought to the fore during the chest examine. These include-

o Area to be examined must be reasonably exposed ! yet patient kept as covered as possible

o The need to 2alpate sensitive areas in order to perform accurate exam ! re"uires touching

people w4whom you've little ac"uaintance ! awkward, particularly if opposite gender

o As newcomers to medicine, you're particularly aware that this aspect of the exam isunnatural K hence very sensitive.. which is a good thingC

5eys to performing a sensitive yet thorough exam-

o Gxplain what you're doing ) why* before doing it N acknowledge elephant in the roomC

o Gxpose the minimum amount of skin necessary ! this re"uires artful use of gown K

drapes )males K females*

o Gxamining heart K lungs of female patients-

Ask pt to remove bra prior )you can't hear the heart well thru fabric*

Gxpose the chest only to the extent needed. or lung exam, you can listen to theanterior fields by exposing only the top part of the breasts )see picture below*.

Gnlist patient's assistance, asking them to raise their breast to a position that

enhances your ability to listen to the heart

o on't rush, act in a callous fashion, or cause pain

o 2?GA$G... don't examine body parts thru gown as-

#t reflects 2oor techni"ue

You'll miss things

You'll lose points on scored exams )O$1G, 12R, E$?G*C

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(emember ! on't examine thru clothing or snake stethoscope down shirts4gowns

+ood exam options

A few additional things worth noting.

o Ask the patient to take slow, deep breaths through their mouths while you are performing

your exam. This forces the patient to move greater volumes of air with each breath,

increasing the duration, intensity, and thus detectability of any abnormal breath sounds that

might be present.

o $ometimes it's helpful to have the patient cough a few times prior to beginning

auscultation. This clears airway secretions and opens small atelectatic )i.e. collapsed* areas

at the lung bases.

o #f the patient cannot sit up )e.g. in cases of neurologic disease, post!operative states, etc.*,

auscultation can be performed while the patient is lying on their side. +et help if the

patient is unable to move on their own. #n cases where even this cannot be accomplished, a

minimal examination can be performed by listening laterally4posteriorly as the patient

remains supine.

o (e"uesting that the patient exhale forcibly will occasionally help to accentuate abnormal

breath sounds )in particular, whee0ing* that might not be heard when they are breathing at

normal flow rates.

o A healthy individual breathing through their mouth at normal tidal volumes produces a softinspiratory sound as air rushes into the lungs, with little noise produced on expiration.

These are referred to as vessicular breath sounds.

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o %hee0es are whistling!type noises produced during expiration )and sometimes inspiration*

when air is forced through airways narrowed by bronchoconstriction, secretions, and4or

associated mucosal edema. As this most commonly occurs in association with diffuse

processes that affect all lobes of the lung )e.g. asthma and emphysema* it is fre"uently

audible in all fields. #n cases of significant bronchoconstriction, the expiratory phase of

respiration )relative to inspiration* becomes noticeably prolonged. 1linicians refer to this

as an increased # to G ratio. &ormal is approximatley 6-7 )i.e. expiration twice as long as

inspiration* though actual timed measurements are neither practical nor reliable. ocus

instead on simple observation, noting whether G seems JJ #. The greater the difference, theworse the obstruction. Occasionally, focal whee0ing can occur when airway narrowing if

restricted to a single anatomic area, as might occur with an obstructing tumor or

bronchoconstriction induced by pneumonia. %hee0ing heard only on inspiration is referred

to as stridor and is associated with mechanical obstruction at the level of the trachea4upper

airway. This may be best appreciated by placing your stethescope directly on top of the

trachea.

o (ales )a.k.a. crackles* are scratchy sounds that occur in association with processes that

cause fluid to accumulate within the alveolar and interstitial spaces. The sound is similar to

that produced by rubbing strands of hair together close to your ear. 2ulmonary edema is

probably the most common cause, at least in the older adult population, and results in

symmetric findings. This tends to occur first in the most dependent portions of the lowerlobes and extend from the bases towards the apices as disease progresses. 2neumonia, on

the other hand, can result in discrete areas of alveolar filling, and therefore produce

crackles restricted to a specific region of the lung. Dery distinct, diffuse, dry!sounding

crackles, similar to the noise produced when separating pieces of velcro, are caused by

pulmonary fibrosis, a relatively uncommon condition.

o ense consolidation of the lung parenchyma, as can occur with pneumonia, results in the

transmission of large airway noises )i.e. those normally heard on auscultation over the

trachea... known as tubular or bronchial breath sounds* to the periphery. #n this setting, the

consolidated lung acts as a terrific conducting medium, transferring central sounds directly

to the edges. #t's very similar to the noise produced when breathing through a snorkel.

urthermore, if you direct the patient to say the letter 'eee' it is detected during auscultation

over the involved lobe as a nasal!sounding 'aaa'. These 'eee' to 'aaa' changes are referred to

as egophony. The first time you detect it, you'll think that the patient is actually saying

'aaa'... have them repeat it several times to assure yourself that they are really following

your directionsC

o $ecretions that form4collect in larger airways, as might occur with bronchitis or other

mucous creating process, can produce a gurgling!type noise, similar to the sound produced

when you suck the last bits of a milk shake through a straw. These noises are referred to as

ronchi.

o Auscultation over a pleural effusion will produce a very muffled sound. #f, however, you

listen carefully to the region on top of the effusion, you may hear sounds suggestive ofconsolidation, originating from lung which is compressed by the fluid pushing up from

below. Asymmetric effusions are probably easier to detect as they will produce different

findings on examination of either side of the chest.

o Auscultation of patients with severe, stable emphysema will produce very little sound.

These patients suffer from significant lung destruction and air trapping, resulting in their

breathing at small tidal volumes that generate almost no noise. %hee0ing occurs when

there is a superimposed acute inflammatory process )see above*.

ost of the above techni"ues are complimentary. ullness detected on percussion, for example,

may represent either lung consolidation or a pleural effusion. Auscultation over the same region

should help to distinguish between these possibilities, as consolidation generates bronchial breathsounds while an effusion is associated with a relative absence of sound. $imilarly, fremitus will be

increased over consolidation and decreased over an effusion. As such, it may be necessary to

repeat certain aspects of the exam, using one finding to confirm the significance of another. ew

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findings are pathognomonic. They have their greatest meaning when used together to paint the

most informative picture.

,!e Dyna%i" #ung 32a%:

Pulse +2y%eter

Oftentimes, a patient will complain of a symptom that is induced by activity or movement.

$hortness of breath on exertion, one such example, can be a marker of significant cardiac or

pulmonary dysfunction. The initial examination may be relatively unrevealing. #n such cases,

consider observed ambulation )with the use of a pulse oxymeter, a device that continuously

measures heart rate and oxygen saturation, if available* as a dynamic extension of the cardiac and

pulmonary examinations. Fuantifying a patient's exercise tolerance in terms of distance and4or

time walked can provide information critical to the assessment of activity induced symptoms. #t

may also help unmask illness that would be inapparent unless the patient was asked to perform a

task that challenged their impaired reserves. 2ay particular attention to the rate at which thepatient walks, duration of activity, distance covered, development of dyspnea, changes in heart

rate and oxygen saturation, ability to talk during exercise and anything else that the patient

identifies as limiting their activity. The ob3ective data derived from this low tech test can aid you

in determining disease and symptom severity, helping to create a list of possible diagnoses and

assisting you in the rational use of additional tests to further delineate the nature of the problem.

This can be particularly helpful in providing ob3ective information when symptoms seem out of

proportion to findings. Or when patients report few complaints yet seem to have a cosiderable

amount of disease. #t will also generate a measurement that you can refer back to during

subse"uent evaluations in order to determine if there has been any real change in functional status.

,!e +ral Presentation

The purpose of the oral presentation is to provide other clinicians with patient information. This must be

done in such a way that it tells the patient's story in a logical, clear and complete fashion yet is neither

cumbersome nor too long. #t is a difficult skill to master and is made more complicated by the fact that

different clinical situations demand different types of presentations. or example, presentations given

during morning work rounds )the time when the medical team briefly visits with each patient to review

their clinical course and determine the plan for the day*, are not the same as those given at formal patient

management conferences. The first situation re"uires a focused presentation, with emphasis placed on

reviewing new facts and data )e.g. test results, vital signs, changes in clinical course, etc.* and outlining

the care plan. The second example calls for a much more detailed discussion. The presenter, then, musttake into account the environmental factors which determine the type of presentation that is re"uired.

These include-

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6. The audience to which you are presenting. A group of cardiologists, for example, are going to be

most interested in the cardiac history.

7. The purpose of the presentation )e.g. is it for work rounds, teaching conference, clinic etc./*.

:. Time available to give the presentation. The longest, most complete presentation should take no

longer then

;. Your familiarity with the case as well as associated pathophysiology.

or the purposes of this discussion, we will focus on the formal4complete presentation as it is probably

the form which is most complicated and intimidating. You will find, however, that once you grasp thelogic and organi0ation of this process and have an opportunity to practice, your presentations will become

both more effective and less anxiety provoking. Tips for presenting during work rounds are provided in

the #npatient edicine section of the 1linical +uide.

#n the discussion that follows, illustrative examples are fre"uently included and have been set off from the

text by means of "uotation marks and italics.

,!e For%al Presentation

!ief o%plaint/!ief on"ern:

The presentation begins with a one sentence description of the patient and the reason prompting their

evaluation )i.e. the 1hief 1omplaint*. This is a teaser that sets the tone for the information to follow. #t

should not be too inclusive.

"Mr. H is a 50 year old male with AIDS who presents for the evaluation of fever, chills and

a couh over the past ! days."

History of Present Illness (HPI):

The 2# is presented in both a problem based and chronological fashion. That is, the dominant

problem4complaint serves as the centerpiece of the history. #f there is more then one problem, the

presenter may try to link them together when appropriate. #nformation related to this main theme is

presented in chronological order. This re"uires that the presenter go back far enough in time to cover any

historical data that is relevant to the patient's main complaint. Your ability as a presenter to know which

past information is important and which superfluous will be based on both your clinical experience and

understanding of pathophysiology. At the current time, this might be "uite limited. or the above patient,

a thorough description would include-

"Mr. H has een HI# $ since %&'() his *D+ count in une of -&(was %50 and viral load

approimately 50,000. /ast opportunistic infections have included /*/ pneumonia

%12&5) *M# retinitis %2&3) and 4aposi-s Sarcoma first noted on his sin %2&3. He currently

taes !6*, A76, and Indinavir, all of which he has een receivin for approimately one

year. He also taes 8actrim Sinle Strenth talets on a daily asis, alon with

9lucona:ole troches /;< for thrush. He claims to e %00= compliant with all of his

medication. He is homoseual thouh he is currently not seually active. He has neverused intravenous drus."

This information is not, in a strict sense, part of the present illness. owever, it providescritical

information that will have a direct bearing on the listener's interpretation of this patient's active problem.

Your ability to determine which background to incorporate into your 2# will improve with time and

exposure. The details of the patient's acute problem are then presented-

">ntil % wee ao, Mr. H had een ?uite active, walin up to 1 miles a day without

feelin short of reath. Approimately % wee ao, he ean to feel dyspneic with

moderate activity. 6his proressed to the point that, % day ao, he was reathless after

walin up a sinle fliht of stairs. ! days ao, he ean to develop su@ective fevers andchills alon with a couh productive of rustcolored sputum. 6here was associated nausea

ut no vomitin. He has spent most of the last 1+ hours in ed. He denies head ache,

photophoia, stiff nec, focal weaness, chest pain, hemoptysis, adominal pain, diarrhea

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or other complaints. 6here is no now history of asthma, *B/D or chronic pulmonary

condition. His current prolem seems different to him then his past episode of /*/."

This section documents the course of the patient's most active problem. #t concludes with a list of

pertinent negatives that are meant to exclude, on the basis of history, other possible diagnoses that are

known to have a similar symptom complex. #n a patient with an #D related illness, this review might

actually be much more extensive than that provided above due to the diffuse, multi!organ system

involvement that occurs with this disease. &ote that the patient's baseline functional status is described,

allowing the listener to gain some sense of the degree of impairment caused by the acute medicalproblem. #f a patient is a poor historian, confused or simply unaware of all the details related to their

illness, state this and move on. istorical information can be obtained from family, friends, etc. #f this is

the case, make sure that you note the source.

#f, for example, a patient complains of both chest pain and shortness of breath, they may well be

secondary to a single underlying process such as myocardial ischemia resulting in heart failure. %hen the

problems are completely unrelated, the dominant issue )as determined by the presenter* is treated first,

followed by a discussion of the secondary complaint. This can get "uite complicated when multiple

problems exist in parallel.

$eview of Syste%s:The critical positive and negative findings discovered during a review of systems are

generally incorporated at the end of the patient's history, as was done above. These "uestions are designed

to uncover illnesses which might travel with the main problem and attempt to identify commonlyoccurring complications )e.g. hemoptysis can be a se"uelae of pulmonary infection*. The listener needs

this information to help them put the remainder of the history in appropriate perspective. Any positive

responses to a more inclusive (O$ that covers all of the other various organ systems are then noted. The

extent to which this is repeated is left to the discretion of the presenter. #f it is completely negative, it is

generally acceptable to simply state, (O$ negative.

Past 0edi"al History:&ote is made of any other past medical problems which the patient has that are

not related to the current complaint. Those items mentioned above are not repeated.

"6he patient-s past medical history includes

%. Hypertension %0 years

1. Castrosophaeal ;eflu Disease

!. Deenerative oint Disease of the ;iht 4nee"

Past Surgi"al History:Any prior surgeries )along with the year in which they occurred* are noted.

"/ast surical history is remarale for

%. Status /ost *holycystectomy %&&0

1. Status /ost Appendectomy %&'5

!. Status /ost open repair and internal fiation of left femur fracture, %&'!"

0edi"ations/'llergies:All current medications )along with dose, route and fre"uency* are mentioned-

"6he patient taes the followin medications

A76 !00 m, % /B, 8ID

Indinavir (50 m, 1 /B, 6ID

!6* %50 m, % /B, 8ID

Eansopra:ole 10 m, % /B, 8ID

Eopressor 50 m, 1 /B, 8ID

*lotrima:ole 6roches %00 m, % /B 6ID /;

practical guide clinical medicine (pneumo).doc

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