# Chest Exam <!-- Put the link to this slide here so people can follow --> slides: [hackmd.io/@elijahc/PEx-chest](/82sSByQQSj-DImrcT9nPXg)  --- ### 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 | :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. ---- ### 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) ---- ### 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 --- [PEx finding -> Pathology](https://empendium.com/mcmtextbook/chapter/B31.I.1.31.) [JAMA Rational Clinical Exam: CAP](https://pubmed.ncbi.nlm.nih.gov/9356004/)