Inspection and Draping

<% Option Explicit %> Inspection and Draping

Inspection and Draping:

Draping- the patient should be exposed to the waist so both the anterior and posterior aspects can be inspected. A complete inspection of the entire chest needs to be completed, so the patient must be uncovered to the waist. Female patients can be uncovered intermittently, as needed during the course of the examination.

Inspection - Peripheral

Clubbing- Loss of 160 degree normal angle between nail base and finger nail. Sponginess of nail base. Increased curvature of finger nail.
Cyanosis- A bluish discolouration of skin and mucous membranes due to excessive concentration of reduced haemoglobin in the blood.
peripheral cyanosis (ex. fingers tips, lips)
central cyanosis (in buccal muscosa, i.e. look under the tongue)
Intercostal Indrawing- indrawing of the intercostal spaces from abnormally high negative pressure generated during inspiration (associated with airway obstruction or obstructive lung disease)?
Abdominal paradox- an indrawing of the abdomen, because of extremely high negative thoracic pressure generated during inspiration (associated with airway obstruction or obstructive lung disease)?

Palpation (Posterior)

Tactile fremitus- palpable vibrations transmitted through the bronchopulmonary system to the chest wall when the patient speaks. Each lung field should be palpated (see lung field figures) while the patient says a phrase that causes a palpable resonance in the chest (i.e. “boy o boy” or “ninety nine”).

Percussion (Posterior)

Percussion of lung fields: one must avoid percussing too close to the vertebrae and the scapulae. See Figure 2.

Diaphragmatic excursion: A test used to measure the movement of the diaphragm. The level of the diaphragm is first estimated during tidal breathing. From this initial level, the diaphragm level at expiration and inspiration should be found, by percussing the patient after asking them to breathe appropriately. See figure 3.

Auscultation (Posterior)

Table 1. Differential diagnosis of conditions using respiratory examination results.

Disorder	Mediastinal Displacement	Chest Wall Movement	Vocal Fremitus	Percussion Note	Breath Sounds	Added Sounds	Voice Sounds
Pleural Effusion	Heart displaced to opposite side	Reduced over affected area	Affected area markedly decreased	dull	Absent over fluid; bronchial at upper border	Absent; pleural rub may be found above effusion	Absent over effusion; incr. with egophony over upper border
Consolidation	none	Reduced over affected area	Incr. or normal	dull	bronchial	crackles	Incr. with egophony and whispering pectroiloquy
Pneumo-thorax	Tracheal deviation to opposite if under tension	Decr. over affected side	Absent	Resonant	Absent or decr.	Absent	Absent
Atelectasis	Ipsilateral shift	Decr. over affected area	Variable	Dull	Absent or diminished	Crackles may be heard	Absent
Broncho-spasm	None	Decr. symmetrically	Normal or Decr.	Normal or Decr.	Broncho-vesicular	Wheeze	Normal or Decr.
Interstitial fibrosis	None	Decr. symmetrically	Normal or Incr.	Normal	Broncho-vesicular	End-inspiratory crackles unaffected by cough or pressure

Palpation (Anterior)

Tactile fremitus- palpable vibrations transmitted through the bronchopulmonary system to the chest wall when the patient speaks. Each lung field should be palpated (see lung field figures) while the patient says a phrase that causes a palpable resonance in the chest (i.e. “boy o boy” or “ninety nine”).

Percussion (Anterior)

Percussion of lung fields: the regions to be percussed are diagrammed in Figure 5.

Auscultation (Anterior)

Auscultation of Anterior lung fields: the anterior lung fields that can be auscultated include the right upper lobe (RUL), right middle lobe (RML), right lower lobe (RLL), left upper lobe (LUL), and the left lower lobe (LLL). See figure 6.