Round notes “first week”

Lessons:
1-History
2-Palpation
3-Inspection
4-Percussion
5-Auscultation
6-General examination
 History

-In covid-19, we do investigations such as “ESR, CRT, D-dimer”

-The normal range of CRT is 0-7
-The normal range of D-dimer is 0-500
-A case diagnosed with covid-19 is quarantined for 14-21 days
-A case diagnosed with covid-19 is not considered to be fully
healed unless the fever is gone “the most important symptom”
-PCR is the only diagnostic test for COVID-19

-Extrinsic asthma is the most common type of asthma

-The Arabic translation of COPD is ‫سدة رئوية مزمنة‬
"‫"فى حالة لو الدكتور سأل السؤال ده‬

-We consider the patient to be an EX smoker if the case has

stopped smoking for more than 6 consecutive months
-We have three types of smoking, “first hand” which is the
person directly smoking, “second hand” which is the person
exposed to the smoking indirectly, and “third hand”, which can
be a fetus that is intrauterine while being exposed to smoking
effects from a smoking mother
-Pack year index “in packs” = Number of packs smoked in a day
X Number of years of smoking
-According to the value of pack year index, the smoker is
labeled as “Mild < 10-30 < Heavy” while “10-30” is considered
as a moderate smoker
-If the patient can’t recall the number of packs smoked in a day
but can remember the number of separate cigarettes, then the
index is = Number of cigarettes smoked in a day / 20 X Number
of years, because one pack of cigarettes contains 20 individual
cigarettes
-If the patient smokes hookah ‫ شيشة‬then the smoking index is
= “Number of stones smoked in a day X 7.5” / 20 X Number of
years
As smoking one stone is equivalent to smoking 7.5 cigarettes

-Being exposed to pets with long hair such as cats or dogs can
cause bronchial asthma

-Interstitial lung fibrosis can occur due to involvement with

birds or chicken because of their feathers, causing a disease
called “Pigeon’s breeders lung”
-Heroine and Opium can cause ARDS “adult respiratory distress
syndrome” in drug abusers
-Opium causes euphoria which may lead to aspiration causing
pneumonia
-IV addicts can contract infections mainly viral, such as hepatitis
C, B, and HIV

-Negative data is always mentioned in past history

-The Arabic translation of IHD “ischemic heart disease” is

‫قصور فى الشريان التاجى‬

-Tuberculosis is treated by taking the treatment for 6 months,

Rifampicin, which is one of the drugs taken, changes the colour
of urine, which is a normal finding

-Fibrothorax is fibrosis around the lung due to neglected “blood

or pus or TB”
-Being on immunosuppressive medication may cause repeated
chest infections

-In the history, we also ask about the “sleep history” of the
patient, we ask about items such as “sleep disturbances,
insomnia, obstructive sleep apnea, and nocturnal apnea”

-The occupation of the patient is important as well, we ask the

patient if he/she has an improvement in symptoms during
breaks of work, or if symptoms get worse during work

-The most common respiratory disease in occupations is

occupational asthma

-We also ask about the vaccination history, such as “BCG for
Tb” and “Pneumococcal polysaccharide vaccine”

-Hemoptysis can cause death due to aspiration or choking

 Palpation

1- Position of mediastinum

-We check for trachea and heart “apex” positions

-Fibrothorax changes the position of trachea to the ipsilateral
side “on the same side of the pathology”
-Pleural effusion and pneumothorax change the position of
trachea to the opposite side of the pathology

2- Chest expansion

-Chest expansion can be limited on both sides by obstructive

diseases such as: COPD, Bronchial asthma, and bronchiectasis
-Chest expansion can be limited on both sides by destructive
diseases such as: Interstitial lung fibrosis

-Chest expansion can be limited on one side “unilateral” by:

effusion, pneumothorax, fibrothorax, atelectasis, and
pneumonectomy
-Chest expansion can be limited in one ZONE by: Lobectomy,
encysted effusion, encysted pneumothorax, Focal atelectasis,
emphysema, bronchogenic carcinoma, Lung abscess

3- Palpable fremitus

-Tactile vocal fremitus “patient saying 44 in Arabic” is increased

in consolidation as in pneumonia, because air inside the lung is
replaced by fluid or tissue in alveoli
-Rhoncus fremitus is felt as ‫شخللة فى الصدر‬
 Inspection

1-shape and symmetry of the chest

2-Pulsations “epigastric” if present
3-Respiratory movement of the chest
4-Costal margin “movement”
5-Intercostal spaces “movement and width”
6-Subcostal angle “wide or narrow”
7-Abdominal recti muscles “movement during breathing”
8-Vertebral column “kyphosis of scoliosis”
9-Skin “colour, scars”

-We check the transverse and AP diameters

-The normal range of ratios of AP diameter to the transverse
diameter is “½ to 5/7”
-AP diameter is increased in hyperinflation as in COPD
-AP diameter is decreased in atelectasis
-Barrel shaped chest is hyperinflated chest + Kyphosis
-Flat shaped chest occurs due to atelectasis
-If a picture shows pectus excavatum “inward indentation of
chest” and asks about the name of deformity, then the answer
is Funnel shaped chest
-Pectus excavatum is commonly harmless unless very severe,
then it causes cardiopulmonary compression

-Pectus carinatum “outward protrusion of chest” causes a

deformity called Pigeon’s chest
-Pectus carinatum is also harmless, and might occur due to
rickets “Vitamin D deficiency”

-A bulge on one side of the chest can be caused by: effusion of

pneumothorax
-A depression on one side can be caused by: Atelectasis,
fibrothorax, or pneumonectomy

-The diseased side of the chest moves poorly or doesn’t move

at all
-Wide hemi angle can occur due to effusion, hemithorax, or
unilateral hyperinflation
-Narrow hemi angle can occur due to atelectasis or fibrothorax

-Bilateral Abdominal paradox can occur due to severe

respiratory distress, diaphragmatic weakness, or fatigue
-Paradoxical movement of recti “suction during inspiration” can
occur due to unilateral diaphragmatic paralysis

-We check the skin for possible scars such as suprasternal scars
which may be due to mediastinoscopy
-Other scars such as scars in 2nd intercostal space of the
midclavicular line can be due to tube insertion in
pneumothorax
-Other scars such as scars in 4th or 5th intercostal space in
midaxillary line can be due to tube insertion for effusion or due
to thoracoscopy for undiagnosed exudative pleural effusion
-Other scars such as large AnteroPosterior scars can be due to
pneumonectomy or lobectomy or decortication
-Other scars such as parasternal scars can be due to heart
surgeries

-We also check the lymph nodes for enlargement

 Percussion

-Diaphragmatic lung paresis may occur due left phrenic nerve

injury in open heart surgery
-Diseases that cause dullness in normally resonant areas are:
atelectasis, consolidation “pneumonia”
-Traub’s area can be normally dull if the patient has just eaten
before the examination
-Traub’s area is normally tympanetic
-Traub’s area is dull in diseases such as: pleural effusion,
splenomegaly, or hepatomegaly
-Traub’s area is hyperresonant in COPD
-Kronig’s isthmus is percussed while the patient is sitting, it
contains the apex of the lung, and it is normally resonant; it can
be dull due to pancoast tumor or massive effusion or pleural
cap

-In percussion, the name of the finger tapping is called Plexor,

while the name of the finger being put on the chest of the
patient and getting tapped on is called pleximeter
 Auscultation

1-Air entry “intensity of breathing sound”

2-Type of breathing
3-Vocal resonance
4-Added sounds “Normally there are NO added sounds”
-What causes an increased sound of air entry normally?
NOTHING
-D’espine sign causes bronchial breathing, it occurs due to
existence of Subcarinal lymph nodes under the bifurcation of
the trachea located next to the paravertebral line at the level of
4th thoracic vertebra, those lymph nodes are normally non-
existent

General examination

1-General look “appearance”

2-Vital signs “Bp, Temperature, HR, RR”
3-Colours “cyanosis, jaundice, pallor, plethoric face”
4-Head and neck examination
5-Upper and lower extremities examination
-In appearance we check for consciousness
-If the patient is agitated and sympathetically stimulated, then
the patient might by hypoxemic
-If the patient is sleepy or narcotic, he might by hypercapnic

-We also examine the sitting position of the patient such as

Tripod position “due to unilateral lung obstruction” or leaning
forward “due to abdominal pain” or in orthopnic position “due
to stimulation of J-receptors”

-The patient may by breathing rapidly and deeply as in kausmaul

breathing to compensate the metabolic acidosis that he has

-We check for cyanosis by arterial blood gases

-Jaundice occurs when bilirubin level is >2
-Plethoric face or plethora is “flushed” face due to SVC
obstruction “mediastinum syndrome” or carbon-monoxide
toxicity
-Pallor occurs due to anemia
-We examine the head and neck for puffiness of eyes, congestion
of mouth or tongue, acting ala nasi, or saddle nose
-We examine the upper extremities for clubbing and the lower
limbs for DCT and erythema nodosum