Lung sounds: wheezing, rhonchi, crackles

[alisepeep]

I have a real hard time figuring out which is present with what pulmonary problems..can someone please help me interpret when you would have decreased/ increased fremitus, wheezing, rhonchi, breath sounds, etc?

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[step1april2013]

I have a real hard time figuring out which is present with what pulmonary problems..can someone please help me interpret when you would have decreased/ increased fremitus, wheezing, rhonchi, breath sounds, etc?

If you need a resource this is in First Aid in the lung section

The major pulm problem situations you should think of are lobar pneumonia vs. pleural effusion and tension pneumothorax vs. spontaneous pneumothorax.

General rules:
1) breath sounds decrease for all pathologies (except pneumonia where you hear bronchial breath sounds)
2) fremitus decreases for all pathologies (except pneumonia where it increases)
3) Tension pneumo = tracheal deviation away from the lesion
4) Spon pneumo = tracheal deviation toward the lesion

Wheezing= small airway inflammation (asthma)

Also apparently excertional dyspnea is code word for COPD

 

[preDoGuy24]

If you need a resource this is in First Aid in the lung section

The major pulm problem situations you should think of are lobar pneumonia vs. pleural effusion and tension pneumothorax vs. spontaneous pneumothorax.

General rules:
1) breath sounds decrease for all pathologies (except pneumonia where you hear bronchial breath sounds)
2) fremitus decreases for all pathologies (except pneumonia where it increases)
3) Tension pneumo = tracheal deviation away from the lesion
4) Spon pneumo = tracheal deviation toward the lesion

Wheezing= small airway inflammation (asthma)

Also apparently excertional dyspnea is code word for COPD

Be careful with the tracheal deviation business, I know that's the generally accepted review book difference between spontaneous and tension but I have been burned on a couple qbank questions where it was teacheal deviation away and spontaneous. Like everything go with the question stem first. Apparently trachea deviation is not even used clinically because you don't really get very much deviation in a spontaneous pnemo, if any at all.

Exertional dyspnea in a 30-50 year old woman, throw pulm htn on your differential.
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[step1april2013]

Be careful with the tracheal deviation business, I know that's the generally accepted review book difference between spontaneous and tension but I have been burned on a couple qbank questions where it was teacheal deviation away and spontaneous. Like everything go with the question stem first. Apparently trachea deviation is not even used clinically because you don't really get very much deviation in a spontaneous pnemo, if any at all.

Exertional dyspnea in a 30-50 year old woman, throw pulm htn on your differential.
Sent from my HTC One using Tapatalk

I've had questions like that too, where they described the pt. as tall and lanky and you had to determine it was spon pneumo from that even tho there was deviation away.

I wouldn't worry too much about that because NBME usually writes the question using a normality (typical presentation) unlike the qBanks. If they want to trick you they'll probably describe a patient with very general symptoms and show an X-ray that is totally unclear.

Also fibrodysplasia involving the pulm artery leading to Cor pulm is definitely high yield. Also high yield to note is that most COPD's will lead to cor pulm (there's only 4 COPD subtypes and they all have some kind of cardio manifestation-->Why does asthma even cause pulsus paradoxus??)

 

[MrBeauregard]

If you need a resource this is in First Aid in the lung section

The major pulm problem situations you should think of are lobar pneumonia vs. pleural effusion and tension pneumothorax vs. spontaneous pneumothorax.

General rules:
1) breath sounds decrease for all pathologies (except pneumonia where you hear bronchial breath sounds)
2) fremitus decreases for all pathologies (except pneumonia where it increases)
3) Tension pneumo = tracheal deviation away from the lesion
4) Spon pneumo = tracheal deviation toward the lesion

Wheezing= small airway inflammation (asthma)

Also apparently excertional dyspnea is code word for COPD

This is all pretty much correct. You also need to know breath sounds for obstructive pathology such as asthma and COPD, but that's pretty stinkin' easy.

For spontaneous pneumothorax versus tension pneumothorax, a very high index of suspicion is needed. A very helpful (and really the best clinical determinant between the two) is the presence of hemodynamic instability. Patients with tension pneumothoraces will have hemodynamic instability as a result of impingement upon the great vessels and obstruction to venous return. A spontaneous pneumothorax will never be presented this way. Also, the history of some sort of traumatic incident is helpful but certainly not always given in the question stem.

Tracheal deviation is classically taught but is seemingly less reliable (especially in a board question scenario).

As for exertional dyspnea, that isn't code for COPD by any means. COPD certainly causes exertional dyspnea, but so does pulmonary edema (cardiogenic and non-cardiogenic), mitral stenosis, aortic stenosis, interstitial lung disease (which may be due to environmental exposure, granulomas and autoimmunity, alveolar filling diseases, hypersensitivity, and other miscellaneous disease such as idiopathic pulmonary fibrosis). The best thing to do is read the entire stem; don't simply rely on the code phrase "exertional dyspnea" to give you the diagnosis of COPD.