You're going to treat a lot of chest problems
- 7+% of inpatient stays have pulmonary pathology (PNA, COPD, AHRF)
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 |  or  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.
My Tier-1 pulm exam
 Inspect |
 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)
Additional (Tier II) PEx findings
- Inspection
- Chest (A)Symmetry
- Auscultation
- Egophony
- Percussion
- Dull vs nml vs hyperresonant
- Palpation
- Crepitus
- Tactile fremitus
- step-offs
- masses
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
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
Chest Exam slides: hackmd.io/@elijahc/PEx-chest
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