med 18

 

..... Physical Examination

A patient's visual appearance reveals much about their

degree of respiratory distress. This assessment can be done

concurrently with the history. Patients sit in the tripod

position (hands on knees with chest propped forward,

neck extended) to open their airways while in severe dis ­

tress. Look for retractions, intercostal tugging, or even

paradoxical breathing (sucking in the abdomen when

breathing), which indicates mechanical breathing insufficiency. Patients in extremis can look groggy or lethargic

due to respiratory fatigue/collapse.

Next guide your physical exam by mentally walking

down the anatomy required for oxygenation and

ventilation. The radiographic studies mentioned in this

section are adjuncts meant to confirm the findings on your

physical exam.

Upper airway. Dyspnea caused by partial upper airway

obstruction is typically associated with sonorous respirations if it originates in the oropharynx (ie, the tongue), or

stridor and voice change if anatomically related to the trachea or vocal cords. Causes of dyspnea in the upper airway

are typically visible on exam or by nasopharyngeal scope.

Use radiographs or a contrast computed tomography (CT)

of the neck to evaluate soft tissue swellings near the pharynx.

Bronchi. When dyspnea is caused by bronchial

pathology-whether by foreign body, inflammation,

infection, or bronchospasm-it is typically associated

with wheezing (most commonly expiratory, but may be

inspiratory, or both). Chest x-ray ( CXR) may reveal

bronchial cuffing.

Alveolar. Alveoli function by maximizing contact between

air pockets and capillary beds. Dyspnea occurs if alveoli are

filled with fluid (ie, blood, pus, or water), collapsed (ie, atelectasis), or destroyed (eg, emphysema). Alveolar pathology is

typically associated with crackles or r ales on exam and CXR

will show "socked in" solid consolidations.

Interstitial space. Fluid or inflammation in the interstitial space inhibits oxygen transfer to blood cells. This

unusual and potentially illusive cause of dyspnea will

manifest with dry crackles on exam and be seen on CXR as

a "hazy but spongy" density.

Diaphragm. The diaphragm is responsible for active

inspiration. If the diaphragm is restricted (ie, increased

intra-abdominal pressure from mass, pregnancy, or

CHAPTER 20