# Chest Exam
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![PEx QR Code](https://i.imgur.com/f50WqKLm.jpg)
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### You're going to treat a lot of chest problems
- **7+%** of inpatient stays have **pulmonary pathology** (PNA, COPD, AHRF)
![](https://i.imgur.com/xkWU5wul.jpg)
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### How I think about Physical Exam (PEx) components
| Tier I Exam | Tier II Exam |
|:----------------------:|:----------------------------------:|
| Screening | Focused |
| Every pt, every time | DDx driven |
| Catch common things | :arrow_up: or :arrow_down: Dx prob |
| e.g. Work of breathing | e.g. percussion or egophany |
You won't do a **full** pulmonary exam on every patient every day but you are required to assess them every day. That daily assessment should be practical, efficient, and high-yield. OnlineMedEd refers to this as a "tier 1 exam", which I've adopted. You'll develop your own based on what works for you. I've included mine as an example if you want something to start with, but its not dogma.
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### My Tier-1 pulm exam
| :eye: Inspect | :ear: Auscultate |
|:-----------------:|:----------------:|
| Work of breathing | Breath sounds |
| Accessory muscles | Wheezes |
| x-word dypsnea | Crackles(Rales) |
| | I:E ratio |
> **x-word dypsnea** is the number of words a person can say before needing to take a breath
>
> **I:E Ratio** is the ratio of inspiration time to expiratory time (high in obstructive lung disease)
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### Additional (Tier II) PEx findings
- Inspection
- Chest (A)Symmetry
- Auscultation
- Egophony
- Percussion
- Dull vs nml vs hyperresonant
- Palpation
- Crepitus
- Tactile fremitus
- step-offs
- masses
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### Lung sounds and pathophys
**Crackles(rales)**
- Normally, alveoli stay open during expiration because surfactant prevents collapse
- Excess fluid around or in the alveoli from edema abrogates this causing collapse
- Rales, is the sound of these collapsed alveoli "snapping" open during inspiration
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**Rhonchi**
- Obstruction or excess secretions in bronchioles causes turbulent airflow and vibration
- Can be heard on inspiration or expiration
**Wheezes**
- Airway constriction causes normally laminar airflow to be turbulent and vibratory
- Frequently expiratory
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[PEx finding -> Pathology](https://empendium.com/mcmtextbook/chapter/B31.I.1.31.)
[JAMA Rational Clinical Exam: CAP](https://pubmed.ncbi.nlm.nih.gov/9356004/)
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