the thorax and lungs - dr. pedro...

The Thorax and Lungs

C H A P T E R

The Thorax and Lungs 66

C H A P T E R 6 ! T H E T H O R A X A N D L U N G S 209

ANATOMY AND PHYSIOLOGY

Study the anatomy of the chest wall, identifying the structures illustrated.Note that an interspace between two ribs is numbered by the rib above it.

Manubrium of sternum

Body of sternum

Xyphoid process

Costal angle

Costochondraljunctions

Suprasternal notch

Sternal angle

2nd costalcartilage

Cardiac notchof left lung

2nd rib

2nd ribinterspace


210 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

Suprasternal notchSternal angle

2nd rib

2

3

4

5

6

7

8

9

1011

12

2

3

4

5

6

7

8

9

11

Note that the costal cartilages of the first seven ribs articulate with the ster-num; the cartilages of the 8th, 9th, and 10th ribs articulate with the costalcartilages just above them. The 11th and 12th ribs, the “floating ribs,” haveno anterior attachments. The cartilaginous tip of the 11th rib can usually befelt laterally, and the 12th rib may be felt posteriorly. On palpation, costalcartilages and ribs feel identical.

Locating Findings on the Chest. Describe abnormalities of the chest intwo dimensions: along the vertical axis and around the circumference of the chest.

To make vertical locations, you must be able to count the ribs and interspaces.The sternal angle, also termed the angle of Louis, is the best guide: place yourfinger in the hollow curve of the suprasternal notch, then move your fingerdown about 5 cm to the horizontal bony ridge joining the manubrium to thebody of the sternum. Then move your finger laterally and find the adjacent 2ndrib and costal cartilage. From here, using two fingers, you can “walk down theinterspaces,” one space at a time, on an oblique line illustrated by the red num-bers below. Do not try to count interspaces along the lower edge of the ster-num; the ribs there are too close together. In a woman, to find the interspaceseither displace the breast laterally or palpate a little more medially than illus-trated. Avoid pressing too hard on tender breast tissue.

Posteriorly, the 12th rib is another possible starting point for countingribs and interspaces: it helps locate findings on the lower posterior chestand provides an option when the anterior approach is unsatisfactory. Withthe fingers of one hand, press in and up against the lower border of the12th rib, then “walk up” the interspaces numbered in red below, or fol-low a more oblique line up and around to the front of the chest.

The inferior tip of the scapula is another useful bony marker—it usually liesat the level of the 7th rib or interspace.



2

3

4

5

6

7

8

9

101011

12

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Spinous process of C7 Spinous process of T1

Inferior angleof scapula

7th rib

The spinous processes of the vertebrae are also useful anatomic landmarks.When the neck is flexed forward, the most protruding process is usually thevertebra of C7. If two processes are equally prominent, they are C7 and T1.You can often palpate and count the processes below them, especially whenthe spine is flexed.

To locate findings around the circumference of the chest, use a series of verti-cal lines, shown in the next three illustrations. The midsternal and vertebrallines are precise; the others are estimated. The midclavicular line drops ver-tically from the midpoint of the clavicle. To find it, you must identify bothends of the clavicle accurately (see p. 469). The anterior and posterior axil-lary lines drop vertically from the anterior and posterior axillary folds, themuscle masses that border the axilla. The midaxillary line drops from theapex of the axilla.



Anterioraxillaryline

Posterioraxillaryline

Midaxillaryline

Midsternalline

Midclavicularline

Anterioraxillaryline

ANTERIOR VIEW RIGHT ANTERIOR OBLIQUE VIEW

Lungs, Fissures, and Lobes. The lungs and their fissures and lobes canbe mentally pictured on the chest wall. Anteriorly, the apex of each lung risesabout 2 cm to 4 cm above the inner third of the clavicle. The lower border ofthe lung crosses the 6th rib at the midclavicular line and the 8th rib at the mid-axillary line. (Because ribs slant, a fairly horizontal line can drop a rib or moreas it passes across the chest.) Posteriorly, the lower border of the lung lies atabout the level of the T10 spinous process. On inspiration, it descends farther.

Each lung is divided roughly in half by an oblique (major) fissure. This fis-sure may be approximated by a string that runs from the T3 spinous process

Scapular line

Vertebralline

POSTERIOR VIEW

Posteriorly, the verte-bral line overlies thespinous processes ofthe vertebrae. Thescapular line dropsfrom the inferior angleof the scapula.

obliquely down and around the chest to the 6th rib at the midclavicular line.The right lung is further divided by the horizontal (minor) fissure. Anteri-orly, this fissure runs close to the 4th rib and meets the oblique fissure in themidaxillary line near the 5th rib.



Apex of lung

Horizontalfissure

Obliquefissure

RUL

RML

RLL

LUL

LLL

LUL

LLL

RUL

RLL

Spinousprocessof T3

Inspiratorydescent

POSTERIOR VIEWANTERIOR VIEW

The right lung is thus divided into upper, middle, and lower lobes. The leftlung has only two lobes, upper and lower.

Left obliquefissure

LUL

LLL

RUL

RLL

RML

RIGHT AND LEFT LATERAL VIEWS



Locations on the Chest. Be familiar with general anatomic terms usedto locate chest findings, such as:

Supraclavicular—above the claviclesInfraclavicular—below the claviclesInterscapular—between the scapulaeInfrascapular—below the scapulaBases of the lungs—the lowermost portionsUpper, middle, and lower lung fields

You may then infer what part(s) of the lung(s) are affected by an abnormalprocess. Signs in the right upper lung field, for example, almost certainlyoriginate in the right upper lobe. Signs in the right middle lung field later-ally, however, could come from any of three different lobes.

The Trachea and Major Bronchi. Breath sounds over the tracheaand bronchi have a different quality than breath sounds over the lungparenchyma. Be sure you know the location of these structures. The tra-chea bifurcates into its mainstem bronchi at the levels of the sternal angleanteriorly and the T4 spinous process posteriorly.

The Pleurae. The pleurae are serous membranes that cover the outersurface of each lung, the visceral pleura, and also line the inner rib cage andupper surface of the diaphragm, the parietal pleura. Their smooth opposingsurfaces, lubricated by pleural fluid, allow the lungs to move easily within therib cage during inspiration and expiration. The pleural space is the potentialspace between visceral and parietal pleurae.

POSTERIOR VIEWANTERIOR VIEW

Trachea

Left mainbronchus

Right mainbronchus

Sternalhead

Clavicularhead

of thesternomastoidmuscle

Breathing. Breathing is largely an automatic act, controlled in the brain-stem and mediated by the muscles of respiration. The dome-shaped di-aphragm is the primary muscle of inspiration. When it contracts, it descendsin the chest and enlarges the thoracic cavity. At the same time it compressesthe abdominal contents, pushing the abdominal wall outward. Muscles inthe rib cage and neck expand the thorax during inspiration, especially theparasternals, which run obliquely from sternum to ribs, and the scalenes,which run from the cervical vertebrae to the first two ribs.

During inspiration, as these muscles contract, the thorax expands. Intra-thoracic pressure decreases, drawing air through the tracheobronchial treeinto the alveoli, or distal air sacs, and expanding the lungs. Oxygen diffusesinto the blood of adjacent pulmonary capillaries, and carbon dioxide diffusesfrom the blood into the alveoli.

After inspiratory effort stops, the expiratory phase begins. The chest wall andlungs recoil, the diaphragm relaxes and rises passively, air flows outward, andthe chest and abdomen return to their resting positions.

Normal breathing is quiet and easy—barely audible near the open mouth asa faint whish. When a healthy person lies supine, the breathing movementsof the thorax are relatively slight. In contrast, the abdominal movements areusually easy to see. In the sitting position, movements of the thorax becomemore prominent.

During exercise and in certain diseases, extra work is required to breathe,and accessory muscles join the inspiratory effort. The sternomastoids are themost important of these, and the scalenes may become visible. Abdominalmuscles assist in expiration.



Changes With Aging

As people age, their capacity for exercise decreases. The chest wall becomesstiffer and harder to move, respiratory muscles may weaken, and the lungslose some of their elastic recoil. The speed of breathing out with maximaleffort gradually diminishes. Skeletal changes associated with aging may ac-centuate the dorsal curve of the thoracic spine, producing kyphosis and in-creasing the anteroposterior diameter of the chest. The resulting “barrelchest,” however, has little effect on function.

THE HEALTH HISTORY


See Table 6-1. Chest Pain, pp. 234–235.

Angina pectoris, myocardial infarction

Pericarditis

Dissecting aortic aneurysm

Bronchitis

Pericarditis, pneumonia

Costochondritis, herpes zoster

Reflux esophagitis, esophagealspasm

Cervical arthritis, biliary colic, gastritis

Complaints of chest pain or chest discomfort raise the specter of heart disease,but often arise from structures in the thorax and lung as well. To assess thissymptom, you must pursue a dual investigation of both thoracic and cardiaccauses. Sources of chest pain are listed below. For this important symptom,you must keep all of these in mind.

! The myocardium

! The pericardium

! The aorta

! The trachea and large bronchi

! The parietal pleura

! The chest wall, including the musculoskeletal system and skin

! The esophagus

! Extrathoracic structures such as the neck, gallbladder, and stomach.

This section focuses on pulmonary complaints, including general questionsabout chest symptoms, dyspnea, wheezing, cough, and hemoptysis. For

EXAMPLES OF ABNORMALITIES

Common or Concerning Symptoms

! Chest pain! Dyspnea! Wheezing! Cough! Blood-streaked sputum (hemoptysis)

THE HEALTH HISTORY

health history questions about exertional chest pain, palpitations, orthop-nea, paroxysmal nocturnal dyspnea, and edema, see Chapter 7, The Cardio-vascular System.

Your initial questions should be as broad as possible. “Do you have any dis-comfort or unpleasant feelings in your chest?” As you proceed to the full his-tory, ask the patient to point to where the pain is in the chest. Watch for anygestures as the patient describes the pain. You should elicit all seven attri-butes of this symptom (see p. 27) to distinguish among the various causesof chest pain.

Lung tissue itself has no pain fibers. Pain in lung conditions such as pneu-monia or pulmonary infarction usually arises from inflammation of the ad-jacent parietal pleura. Muscle strain from prolonged recurrent coughing mayalso be responsible. The pericardium also has few pain fibers—the pain ofpericarditis stems from inflammation of the adjacent parietal pleura. (Chestpain is commonly associated with anxiety, too, but the mechanism remainsobscure.)

Dyspnea is a nonpainful but uncomfortable awareness of breathing that is in-appropriate to the level of exertion. This serious symptom warrants a full ex-planation and assessment, since dyspnea commonly results from cardiac orpulmonary disease.

Ask “Have you had any difficulty breathing?” Find out when the symptomoccurs, at rest or with exercise, and how much effort produces onset. Be-cause of variations in age, body weight, and physical fitness, there is no ab-solute scale for quantifying dyspnea. Instead, make every effort to determineits severity based on the patient’s daily activities. How many steps or flights ofstairs can the patient climb before pausing for breath? What about work suchas carrying bags of groceries, mopping the floor, or making the bed? Hasdyspnea altered the patient’s lifestyle and daily activities? How? Carefullyelicit the timing and setting of dyspnea, any associated symptoms, and re-lieving or aggravating factors.

Most patients with dyspnea relate shortness of breath to their level of activ-ity. Anxious patients present a different picture. They may describe difficultytaking a deep enough breath, or a smothering sensation with inability to getenough air, along with paresthesias, or sensations of tingling or “pins andneedles” around the lips or in the extremities.

Wheezes are musical respiratory sounds that may be audible both to the pa-tient and to others.

Cough is a common symptom that ranges in significance from trivial toominous. Typically, cough is a reflex response to stimuli that irritate re-

THE HEALTH HISTORY


A clenched fist over the sternumsuggests angina pectoris; a fingerpointing to a tender area on thechest wall suggests musculoskele-tal pain; a hand moving fromneck to epigastrum suggestsheartburn.

Anxiety is the most frequent cause of chest pain in children;costochondritis is also common.

See Table 6-2, Dyspnea, pp. 236–237.

Anxious patients may haveepisodic dyspnea during both restand exercise, and hyperventilation,or rapid, shallow breathing. At other times they may have frequent sighs.

Wheezing suggests partial airway obstruction from secre-tions, tissue inflammation, or aforeign body.

See Table 6-3, Cough and Hemoptysis, p. 238.


ceptors in the larynx, trachea, or large bronchi. These stimuli includemucus, pus, and blood, as well as external agents such as dusts, foreignbodies, or even extremely hot or cold air. Other causes include inflamma-tion of the respiratory mucosa and pressure or tension in the air passagesfrom a tumor or enlarged peribronchial lymph nodes. Although coughtypically signals a problem in the respiratory tract, it may also be cardio-vascular in origin.

For complaints of cough, a thorough assessment is in order. Ask whether thecough is dry or produces sputum, or phlegm. Ask the patient to describe thevolume of any sputum and its color, odor, and consistency.

To help patients quantify volume, a multiple-choice question may behelpful . . . “How much do you think you cough up in 24 hours; a tea-spoon, tablespoon, a quarter cup, half cup, cupful?” If possible, ask thepatient to cough into a tissue; inspect the phlegm and note its character-istics. The symptoms associated with a cough often lead you to its cause.

Hemoptysis is the coughing up of blood from the lungs; it may vary fromblood-streaked phlegm to frank blood. For patients reporting hemoptysis,assess the volume of blood produced as well as the other sputum attributes;ask about the related setting and activity and any associated symptoms.

Before using the term “hemoptysis,” try to confirm the source of the bleed-ing by both history and physical examination. Blood or blood-streaked ma-terial may originate in the mouth, pharynx, or gastrointestinal tract and iseasily mislabeled. When vomited, it probably originates in the gastrointesti-nal tract. Occasionally, however, blood from the nasopharynx or the gastro-intestinal tract is aspirated and then coughed out.

HEALTH PROMOTION AND COUNSELING


Cough is an important symptom ofleft-sided heart failure.

Dry hacking cough in Mycoplasmalpneumonia; productive cough in bronchitis, viral or bacterialpneumonia

Mucoid sputum is translucent,white, or gray; purulent sputum isyellowish or greenish.

Foul-smelling sputum in anaerobiclung abscess; tenacious sputum incystic fibrosis

Large volumes of purulent sputumin bronchiectasis or lung abscess

Diagnostically helpful symptomsinclude fever, chest pain, dyspnea,orthopnea, and wheezing.

See Table 6-3, Cough and Hemop-tysis, p. 238. Hemoptysis is rare ininfants, children, and adolescents; itis seen most often in cystic fibrosis.

Blood originating in the stomach isusually darker than blood from therespiratory tract and may be mixedwith food particles.



Important Topics for Health Promotion and Counseling

! Tobacco cessation

Despite declines in smoking over the past several decades, more than 27% ofAmericans age 12 and older still smoke.* All adults, pregnant women, par-ents, and adolescents who smoke should be counseled regularly to stopsmoking. Smoking has been definitively linked to significant pulmonary,cardiovascular, and neoplastic disease, and accounts for one out of every fivedeaths in the United States.† It is considered the leading cause of preventabledeath. Nonsmokers exposed to smoke are also at increased risk for lung can-cer, ear and respiratory infection, asthma, low birthweight, and residentialfires. Smoking exposes patients not only to carcinogens, but also to nicotine,an addictive drug. Be especially alert to smoking by teenagers, the age groupwhen tobacco use often begins, and by pregnant women, who may continuesmoking during pregnancy.

The disease risks of smoking drop significantly within a year of smoking ces-sation. Effective interventions include targeted messages by clinicians, groupcounseling, and use of nicotine-replacement therapies. Clinicians are advisedto adopt the four “As”:

! Ask about smoking at each visit.

! Advise patients regularly to stop smoking in a clear personalized message.

! Assist patients to set stop dates and provide educational materials for self-help.

! Arrange for follow-up visits to monitor and support progress.



Preview: Recording the Physical Examination—The Thorax and Lungs

Note that initially you may use sentences to describe your findings; lateryou will use phrases. The style below contains phrases appropriate formost write-ups. Unfamiliar terms are explained in the next section, Techniques of Examination.

“Thorax is symmetric with good expansion. Lungs resonant. Breathsounds vesicular; no rales, wheezes, or rhonchi. Diaphragms descend 4 cm bilaterally.”

OR

“Thorax symmetric with moderate kyphosis and increased anteroposterior(AP) diameter, decreased expansion. Lungs are hyperresonant. Breathsounds distant with delayed expiratory phase and scattered expiratorywheezes. Fremitus decreased; no bronchophony, egophony, or whis-pered pectoriloquy. Diaphragms descend 2 cm bilaterally.”

* Substance Abuse and Mental Health Services Administration, 1999 National Household Survey.www.samhsa.gov/hhsurvey/content/1999. Accessed 8/13/01.† Centers for Disease Control and Prevention. Cigarette Smoking: Attributable Mortality and Years ofPotential Life Cost—United States. MMWR 42: 645–649, 1993.


Suggests chronic obstructive lungdisease

TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES


See Table 3-12, Abnormalities inRate and Rhythm of Breathing (p. 93). Prolonged expiration sug-gests narrowed lower airways.

TECHNIQUES OF EXAMINATION

It is helpful to examine the posterior thorax and lungs while the patient issitting, and the anterior thorax and lungs with the patient supine. Proceedin an orderly fashion: inspect, palpate, percuss, and auscultate. Try to visu-alize the underlying lobes, and compare one side with the other, so the pa-tient serves as his or her own control. Arrange the patient’s gown so that youcan see the chest fully. For women, drape the gown over each half of the an-terior chest as you examine the other half. Cover the woman’s anterior chestwhen you examine the back.

With the patient sitting, examine the posterior thorax and lungs. The pa-tient’s arms should be folded across the chest with hands resting, if possible,on the opposite shoulders. This position moves the scapulae partly out ofthe way and increases your access to the lung fields. Then ask the patient tolie down.

With the patient supine, examine the anterior thorax and lungs. The supineposition makes it easier to examine women because the breasts can be gen-tly displaced. Furthermore, wheezes, if present, are more likely to be heard.(Some authorities, however, prefer to examine both the back and the frontof the chest with the patient sitting. This technique is also satisfactory).

For patients unable to sit up without aid, try to get help so that you can ex-amine the posterior chest in the sitting position. If this is impossible, roll thepatient to one side and then to the other. Percuss the upper lung, and aus-cultate both lungs in each position. Because ventilation is relatively greaterin the dependent lung, your chances of hearing wheezes or crackles aregreater on the dependent side.

Initial Survey of Respiration and the Thorax

Even though you may have already recorded the respiratory rate when youtook the vital signs, it is wise to again observe the rate, rhythm, depth, and ef-fort of breathing. A normal resting adult breathes quietly and regularly about

Combining clinician and group counseling with nicotine replacement ther-apy is especially effective for highly addicted patients.

Relapses are common and should be expected. Nicotine withdrawal, weightgain, stress, social pressure, and use of alcohol are often cited as explanations.Help patients to learn from these experiences: work with the patient to pin-point the precipitating circumstances and develop strategies for alternativeresponses and health-promoting behaviors.


14 to 20 times a minute. An occasional sigh is to be expected. Note whetherexpiration lasts longer than usual.

Always inspect the patient for any signs of respiratory difficulty.

! Assess the patient’s color for cyanosis. Recall any relevant findings from ear-lier parts of your examination, such as the shape of the fingernails.

! Listen to the patient’s breathing. Is there any audible wheezing? If so, wheredoes it fall in the respiratory cycle?

! Inspect the neck. During inspiration, is there contraction of the sterno-mastoid or other accessory muscles, or supraclavicular retraction? Is thetrachea midline?

Also observe the shape of the chest. The anteroposterior (AP) diameter may in-crease with aging.

Examination of the Posterior Chest

INSPECTIONFrom a midline position behind the patient, note the shape of the chest andthe way in which it moves, including:

! Deformities or asymmetry

! Abnormal retraction of the interspaces during inspiration. Retraction ismost apparent in the lower interspaces. Supraclavicular retraction is oftenassociated.

! Impaired respiratory movement on one or both sides or a unilateral lag(or delay) in movement.

PALPATIONAs you palpate the chest, focus on areas of tenderness and abnormalities inthe overlying skin, respiratory expansion, and fremitus.

Identify tender areas. Carefully palpate any area where pain has been re-ported or where lesions or bruises are evident.



Cyanosis signals hypoxia. Club-bing of the nails (see p. 110) inchronic obstructive pulmonarydisease (COPD) or congenitalheart disease

Audible stridor, a high-pitchedwheeze, is an ominous sign of airway obstruction in the larynx ortrachea.

Inspiratory contraction of the sternomastoids at rest signals severe difficulty breathing. Lateraldisplacement of the trachea inpneumothorax, pleural effusion, or atelectasis

The AP diameter also may increasein COPD.

See Table 6-4, Deformities of theThorax (p. 239).

Retraction in severe asthma, COPD,or upper airway obstruction.

Unilateral impairment or lagging of respiratory movement suggestsdisease of the underlying lung orpleura.

Intercostal tenderness over in-flamed pleura

Bruises over a fractured rib



Test chest expansion. Place your thumbs at about the level of the 10th ribs,with your fingers loosely grasping and parallel to the lateral rib cage. As youposition your hands, slide them medially just enough to raise a loose fold ofskin on each side between your thumb and the spine.

Ask the patient to inhale deeply. Watch the distance between your thumbsas they move apart during inspiration, and feel for the range and symmetryof the rib cage as it expands and contracts.

Feel for tactile fremitus. Fremitus refers to the palpable vibrations transmit-ted through the bronchopulmonary tree to the chest wall when the patientspeaks. To detect fremitus, use either the ball (the bony part of the palm atthe base of the fingers) or the ulnar surface of your hand to optimize the vi-bratory sensitivity of the bones in your hand. Ask the patient to repeat thewords “ninety-nine” or “one-one-one.” If fremitus is faint, ask the patientto speak more loudly or in a deeper voice.

Use one hand until you have learned the feel of fremitus. Some cliniciansfind using one hand more accurate. The simultaneous use of both hands tocompare sides, however, increases your speed and may facilitate detection ofdifferences.

Causes of unilateral decrease ordelay in chest expansion includechronic fibrotic disease of the underlying lung or pleura, pleuraleffusion, lobar pneumonia, pleuralpain with associated splinting, andunilateral bronchial obstruction.

Fremitus is decreased or absentwhen the voice is soft or whenthe transmission of vibrationsfrom the larynx to the surface ofthe chest is impeded. Causes in-clude an obstructed bronchus;COPD; separation of the pleuralsurfaces by fluid (pleural effusion),fibrosis (pleural thickening), air (pneumothorax), or an infil-trating tumor; and also a verythick chest wall.

Assess any observed abnormalities such as masses or sinus tracts (blind, in-flammatory, tubelike structures opening onto the skin)

Although rare, sinus tracts usuallyindicate infection of the underlyingpleura and lung (as in tuberculosis,actinomycosis).

Palpate and compare symmetric areasof the lungs in the pattern shown inthe photograph. Identify and locateany areas of increased, decreased, orabsent fremitus. Fremitus is typicallymore prominent in the interscapulararea than in the lower lung fields,and is often more prominent on theright side than on the left. It dis-appears below the diaphragm.

Tactile fremitus is a relatively roughassessment tool, but as a scoutingtechnique it directs your attentionto possible abnormalities. Later inthe examination you will check anysuggested findings by listening forbreath sounds, voice sounds, andwhispered voice sounds. All theseattributes tend to increase or de-crease together.

PERCUSSIONPercussion is one of the most important techniques of physical examination.Percussion of the chest sets the chest wall and underlying tissues into mo-tion, producing audible sound and palpable vibrations. Percussion helps youestablish whether the underlying tissues are air-filled, fluid-filled, or solid. Itpenetrates only about 5 cm to 7 cm into the chest, however, and thereforewill not help you to detect deep-seated lesions.

The technique of percussion can be practiced on any surface. As you prac-tice, listen for changes in percussion notes over different types of materialsor different parts of the body. The key points for good technique, describedfor a right-handed person, are as follows:

! Hyperextend the middle fingerof your left hand, known as thepleximeter finger. Press its distalinterphalangeal joint firmly onthe surface to be percussed. Avoidsurface contact by any other partof the hand, because this dampensout vibrations. Note that thethumb, 2nd, 4th, and 5th fingersare not touching the chest.

! Position your right forearm quiteclose to the surface, with the handcocked upward. The middle fingershould be partially flexed, relaxed,and poised to strike.



1 1

2

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2

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4 4

LOCATIONS FOR FEELING FREMITUS

! With a quick sharp but relaxedwrist motion, strike the pleximeterfinger with the right middle fin-ger, or plexor finger. Aim at yourdistal interphalangeal joint. Youare trying to transmit vibrationsthrough the bones of this joint tothe underlying chest wall.

Strike using the tip of the plexorfinger, not the finger pad. Yourfinger should be almost at rightangles to the pleximeter. A shortfingernail is recommended toavoid self-injury.

! Withdraw your striking fingerquickly to avoid damping the vi-brations you have created.

In summary, the movement is at thewrist. It is directed, brisk yet relaxed,and a bit bouncy.



Percussion Notes. With your plexor or tapping finger, use the lightestpercussion that produces a clear note. A thick chest wall requires heavier per-cussion than a thin one. However, if a louder note is needed, apply morepressure with the pleximeter finger (this is more effective for increasing per-cussion note volume than tapping harder with the plexor finger).

When percussing the lower posterior chest, stand somewhat to the side ratherthan directly behind the patient. This allows you to place your pleximeterfinger more firmly on the chest and your plexor is more effective, making abetter percussion note.

When comparing two areas, use the same percussion technique in both areas.Percuss or strike twice in each location. It is easier to detect differences inpercussion notes by comparing one area with another than by striking repet-itively in one place.


Learn to identify five percussion notes. You can practice four of them on your-self. These notes differ in their basic qualities of sound: intensity, pitch, andduration. Train your ear to distinguish these differences by concentrating onone quality at a time as you percuss first in one location, then in another. Re-view the table below. Normal lungs are resonant.



While the patient keeps both arms crossed in front of the chest, percuss thethorax in symmetric locations from the apices to the lung bases.

Percuss one side of the chest and then the other at each level, as shown by thenumbers below. Omit the areas over the scapulae—the thickness of muscleand bone alters the percussion notes over the lungs. Identify and locate thearea and quality of any abnormal percussion note.

Relative Relative RelativeIntensity Pitch Duration Example of Location

Percussion Notes and Their Characteristics

* Distinguished mainly by its musical timbre.

Flatness

Dullness

Resonance

Hyperresonance

Tympany

Soft

Medium

Loud

Very loud

Loud

High

Medium

Low

Lower

High*

Short

Medium

Long

Longer

*

Thigh

Liver

Normal lung

None normally

Gastric air bubble orpuffed-out cheek

Pathologic Examples

Large pleural effusion

Lobar pneumonia

Simple chronic bronchitis

Emphysema, pneumothorax

Large pneumothorax

Dullness replaces resonance when fluid or solid tissue replacesair-containing lung or occupies the pleural space beneath yourpercussing fingers. Examples include: lobar pneumonia, in whichthe alveoli are filled with fluid andblood cells; and pleural accumula-tions of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor.

Generalized hyperresonance maybe heard over the hyperinflatedlungs of emphysema or asthma,but it is not a reliable sign. Unilat-eral hyperresonance suggests alarge pneumothorax or possibly alarge air-filled bulla in the lung.

1

2

3

4

5

1

2

3

4

5

6 6

7 7

LOCATIONS FOR PERCUSSION AND AUSCULTATION

An abnormally high level suggestspleural effusion, or a high diaphragm as in atelectasis or diaphragmatic paralysis.

Sounds from bedclothes, papergowns, and the chest itself cangenerate confusion in auscultation.Hair on the chest may cause crack-ling sounds. Either press harder orwet the hair. If the patient is coldor tense, you may hear musclecontraction sounds—muffled, low-pitched rumbling or roaring noises.A change in the patient’s positionmay eliminate this noise. You can



Identify the descent of the diaphragms, or diaphragmatic excursion. First, de-termine the level of diaphragmatic dullness during quiet respiration. Holdingthe pleximeter finger above and parallel to the expected level of dullness,percuss downward in progressive steps until dullness clearly replaces reso-nance. Confirm this level of change by percussion near the middle of the he-mothorax and also more laterally.

Resonant

Level ofdiaphragm

Dull

Locationand sequenceof percussion

Dull

Note that with this technique you are identifying the boundary between theresonant lung tissue and the duller structures below the diaphragm. You arenot percussing the diaphragm itself. You can infer the probable location ofthe diaphragm from the level of dullness.

Now, estimate the extent of diaphragmatic excursion by determining the dis-tance between the level of dullness on full expiration and the level of dull-ness on full inspiration, normally about 5 cm or 6 cm. This estimate doesnot correlate well, however, with radiologic assessment of diaphragmaticmovement.

AUSCULTATIONAuscultation of the lungs is the most important examining technique for as-sessing air flow through the tracheobronchial tree. Together with percus-sion, it also helps the clinician to assess the condition of the surroundinglungs and pleural space. Auscultation involves (1) listening to the soundsgenerated by breathing, (2) listening for any adventitious (added) sounds,and (3) if abnormalities are suspected, listening to the sounds of the patient’sspoken or whispered voice as they are transmitted through the chest wall.

Breath Sounds (Lung Sounds). You will learn to identify patterns ofbreath sounds by their intensity, their pitch, and the relative duration of theirinspiratory and expiratory phases. Normal breath sounds are:

EXAMPLES OF ABNORMALITIESTECHNIQUES OF EXAMINATION


! Vesicular, or soft and low pitched. They are heard through inspiration,continue without pause through expiration, and then fade away about onethird of the way through expiration.

! Bronchovesicular, with inspiratory and expiratory sounds about equal inlength, at times separated by a silent interval. Differences in pitch and in-tensity are often more easily detected during expiration.

! Bronchial, or louder and higher in pitch, with a short silence between in-spiratory and expiratory sounds. Expiratory sounds last longer than inspi-ratory sounds.

The characteristics of these three kinds of breath sounds are summarized inthe table below. Also shown are the tracheal breath sounds—very loud,harsh sounds that are heard by listening over the trachea in the neck.

reproduce this sound on yourselfby doing a Valsalva maneuver(straining down) as you listen toyour own chest.

If bronchovesicular or bronchialbreath sounds are heard in loca-tions distant from those listed, sus-pect that air-filled lung has beenreplaced by fluid-filled or solid lungtissue. See Table 6-5, Normal andAltered Breath and Voice Sounds(p. 240).

Intensity of Pitch of LocationsDuration of Expiratory Expiratory Where HeardSounds Sound Sound Normally

Characteristics of Breath Sounds

* The thickness of the bars indicates intensity; the steeper their incline, the higher the pitch.

Vesicular*

Broncho-vesicular

Bronchial

Tracheal

Inspiratory soundslast longer thanexpiratory ones.

Inspiratory andexpiratory soundsare about equal.

Expiratory soundslast longer thaninspiratory ones.

Inspiratory andexpiratory soundsare about equal.

Soft

Intermediate

Loud

Very loud

Relatively low

Intermediate

Relatively high

Relatively high

Over most ofboth lungs

Often in the 1st and 2ndinterspacesanteriorly andbetween thescapulae

Over the manu-brium, if heardat all

Over the tracheain the neck

Listen to the breath sounds with the diaphragm of a stethoscope after in-structing the patient to breathe deeply through an open mouth. Use the pat-tern suggested for percussion, moving from one side to the other and com-paring symmetric areas of the lungs. If you hear or suspect abnormal sounds,auscultate adjacent areas so that you can fully describe the extent of any ab-normality. Listen to at least one full breath in each location. Be alert for pa-tient discomfort due to hyperventilation (e.g., light headedness, faintness),and allow the patient to rest as needed.



Note the intensity of the breath sounds. Breath sounds are usually louderin the lower posterior lung fields and may also vary from area to area. If thebreath sounds seem faint, ask the patient to breathe more deeply. You maythen hear them easily. When patients do not breathe deeply enough orwhen they have a thick chest wall, as in obesity, breath sounds may remaindiminished.

Is there a silent gap between the inspiratory and expiratory sounds?

Listen for the pitch, intensity, and duration of the expiratory and inspiratorysounds. Are vesicular breath sounds distributed normally over the chest wall?Or are there bronchovesicular or bronchial breath sounds in unexpectedplaces? If so, where are they?

Adventitious (Added) Sounds. Listen for any added, or adventitious,sounds that are superimposed on the usual breath sounds. Detection of ad-ventitious sounds—crackles (sometimes called rales), wheezes, and rhonchi—is an important part of your examination, often leading to diagnosis of car-diac and pulmonary conditions. The most common kinds of these soundsare described below:

Breath sounds may be decreasedwhen air flow is decreased (as byobstructive lung disease or muscu-lar weakness) or when the trans-mission of sound is poor (as inpleural effusion, pneumothorax, oremphysema).

A gap suggests bronchial breathsounds.

For further discussion and otheradded sounds, see Table 6-6, Ad-ventitious (Added) Lung Sounds:Causes and Qualities (p. 241).

DISCONTINUOUS SOUNDS (CRACKLES OR RALES) are intermittent,nonmusical, and brief—like dots in time

Fine crackles ( ) are soft, high pitched, and very brief (5–10 msec).

Coarse crackles ( ) are somewhat louder, lower in pitch, and not quite so brief (20–30 msec).

CONTINUOUS SOUNDS are > 250 msec, notably longer than crackles—like dashesin time—but do not necessarily persist throughout the respiratory cycle. Unlikecrackles, they are musical.

Wheezes ( ) are relatively high pitched (around 400 Hz or higher) and have a hissing or shrill quality.

Rhonchi ( ) are relatively low pitched (around 200 Hz or lower) and have asnoring quality.

Adventitious Lung Sounds

Crackles may be due to abnormalities ofthe lungs (pneumonia, fibrosis, earlycongestive heart failure) or of the air-ways (bronchitis, bronchiectasis).

Wheezes suggest narrowed airways, as inasthma, COPD, or bronchitis.

Rhonchi suggest secretions in largeairways.

If you hear crackles, especially those that do not clear after cough, listencarefully for the following characteristics. These are clues to the underlyingcondition:

! Loudness, pitch, and duration (summarized as fine or coarse crackles)

! Number (few to many)

Fine late inspiratory crackles thatpersist from breath to breath suggest abnormal lung tissue.


! Timing in the respiratory cycle

! Location on the chest wall

! Persistence of their pattern from breath to breath

! Any change after a cough or a change in the patient’s position

In some normal people, crackles may be heard at the lung bases anteriorlyafter maximal expiration. Crackles in dependent portions of the lungs mayalso occur after prolonged recumbency.

If you hear wheezes or rhonchi, note their timing and location. Do theychange with deep breathing or coughing?

Transmitted Voice Sounds. If you hear abnormally located broncho-vesicular or bronchial breath sounds, continue on to assess transmitted voicesounds. With a stethoscope, listen in symmetric areas over the chest wall asyou:

! Ask the patient to say “ninety-nine.” Normally the sounds transmittedthrough the chest wall are muffled and indistinct.

! Ask the patient to say “ee.” You will normally hear a muffled long Esound.

! Ask the patient to whisper “ninety-nine” or “one-two-three.” The whis-pered voice is normally heard faintly and indistinctly, if at all.

Examination of the Anterior Chest

The patient, when examined in the supine position, should lie comfortablywith arms somewhat abducted. A patient who is having difficulty breathingshould be examined in the sitting position or with the head of the bed ele-vated to a comfortable level.



Clearing of crackles, wheezes, orrhonchi after cough suggests thatsecretions caused them, as inbronchitis or atelectasis.

Increased transmission of voicesounds suggests that air-filled lunghas become airless. See Table 6-5,Normal and Altered Breath andVoice Sounds (p. 240).

Louder, clearer voice sounds arecalled bronchophony.

When “ee” is heard as “ay,” an E-to-A change (egophony) is present, as in lobar consolidationfrom pneumonia. The qualitysounds nasal.

Louder, clearer whispered sounds are called whispered pectoriloquy.

Persons with severe COPD mayprefer to sit leaning forward, withlips pursed during exhalation andarms supported on their knees ora table.



INSPECTIONObserve the shape of the patient’s chest and the movement of the chest wall.Note:

! Deformities or asymmetry

! Abnormal retraction of the lower interspaces during inspiration

! Local lag or impairment in respiratory movement

PALPATIONPalpation has four potential uses:

! Identification of tender areas

! Assessment of observed abnormalities

! Further assessment of chest expansion. Place your thumbs along each costalmargin, your hands along the lateral rib cage. As you position your hands,slide them medially a bit to raise loose skin folds between your thumbs.Ask the patient to inhale deeply. Observe how far your thumbs diverge asthe thorax expands, and feel for the extent and symmetry of respiratorymovement.

See Table 6-4, Deformities of theThorax (p. 239).

Severe asthma, COPD, or upperairway obstruction

Underlying disease of lung or pleura

Tender pectoral muscles or costalcartilages tend to corroborate, butdo not prove, that chest pain has amusculoskeletal origin.

! Assessment of tactile fremitus. Compare both sides of the chest, using theball or ulnar surface of your hand. Fremitus is usually decreased or absentover the precordium. When examining a woman, gently displace thebreasts as necessary.



PERCUSSIONPercuss the anterior and lateral chest, again comparing both sides. The heartnormally produces an area of dullness to the left of the sternum from the 3rdto the 5th interspaces. Percuss the left lung lateral to it.

Dullness replaces resonance when fluid or solid tissue replacesair-containing lung or occupies thepleural space. Because pleural fluidusually sinks to the lowest part ofthe pleural space (posteriorly in asupine patient), only a very largeeffusion can be detected anteriorly.

The hyperresonance of COPD maytotally replace cardiac dullness.

1 1

2 23 3

11

22

33

44 55

66

LOCATIONS FOR FEELING FREMITUS

LOCATIONS FOR PERCUSSION AND AUSCULTATION



In a woman, to enhance percussion, gently displace the breast with your lefthand while percussing with the right.

The dullness of right middle lobepneumonia typically occurs behindthe right breast. Unless you dis-place the breast, you may miss theabnormal percussion note.

A lung affected by COPD oftendisplaces the upper border of theliver downward. It also lowers thelevel of diaphragmatic dullnessposteriorly.

Alternatively, you may ask the patient to move her breast for you.

Identify and locate any area of abnormal percussion note.

With your pleximeter finger above and parallel to the expected upper bor-der of liver dullness, percuss in progressive steps downward in the right mid-clavicular line. Identify the upper border of liver dullness. Later, during theabdominal examination, you will use this method to estimate the size of theliver. As you percuss down the chest on the left, the resonance of normallung usually changes to the tympany of the gastric air bubble.



AUSCULTATIONListen to the chest anteriorly and laterally as the patient breathes with mouthopen, somewhat more deeply than normal. Compare symmetric areas of thelungs, using the pattern suggested for percussion and extending it to adja-cent areas as indicated.

Listen to the breath sounds, noting their intensity and identifying any varia-tions from normal vesicular breathing. Breath sounds are usually louder inthe upper anterior lung fields. Bronchovesicular breath sounds may be heardover the large airways, especially on the right.

Identify any adventitious sounds, time them in the respiratory cycle, andlocate them on the chest wall. Do they clear with deep breathing?

If indicated, listen for transmitted voice sounds.

Special Techniques

Clinical Assessment of Pulmonary Function. A simple but infor-mative way to assess the complaint of breathlessness in an ambulatory pa-tient is to walk with the patient down the hall or climb one flight of stairs.Observe the rate, effort, and sound of the patient’s breathing.

Forced Expiratory Time. This test assesses the expiratory phase ofbreathing, which is typically slowed in obstructive pulmonary disease. Askthe patient to take a deep breath in and then breathe out as quickly and com-pletely as possible with mouth open. Listen over the trachea with the di-aphragm of a stethoscope and time the audible expiration. Try to get threeconsistent readings, allowing a short rest between efforts if necessary.

Identification of a Fractured Rib. Local pain and tenderness of oneor more ribs raise the question of fracture. By anteroposterior compressionof the chest, you can help to distinguish a fracture from soft-tissue injury.With one hand on the sternum and the other on the thoracic spine, squeezethe chest. Is this painful, and where?

See Table 6-6, Adventitious(Added) Lung Sounds: Causes andQualities (p. 241), and Table 6-7,Physical Findings in Selected ChestDisorders (pp. 242–243).

If the patient understands and cooperates in performing the test,a forced expiration time of 6 ormore seconds suggests obstructivepulmonary disease.

An increase in the local pain (distant from your hands) suggestsrib fracture rather than just soft tissue injury.

TABLE 6-1 ! Chest Pain


Problem Process Location Quality Severity

CardiovascularAngina Pectoris

Myocardial Infarction

Pericarditis

Dissecting AorticAneurysm

PulmonaryTracheobronchitis

Pleural Pain

Gastrointestinal andother

Reflex EsophagitisDiffuse Esophageal SpasmChest Wall Pain

Anxiety

Temporary myocardialischemia, usually secondary tocoronary atherosclerosis

Prolonged myocardial ischemia,resulting in irreversible muscledamage or necrosis

! Irritation of parietal pleuraadjacent to the pericardium

! Mechanism unclear

A splitting within the layers ofthe aortic wall, allowing passageof blood to dissect a channel

Inflammation of trachea andlarge bronchi

Inflammation of the parietalpleura, as from pleurisy,pneumonia, pulmonaryinfarction, or neoplasm

Inflammation of the esophagealmucosa by reflux of gastric acid

Motor dysfunction of theesophageal muscle

Variable, often unclear

Unclear

Retrosternal or across theanterior chest, sometimesradiating to the shoulders,arms, neck, lower jaw, orupper abdomen

Same as in angina

Precordial, may radiate tothe tip of the shoulderand to the neck

Retrosternal

Anterior chest, radiatingto the neck, back, orabdomen

Upper sternal or on eitherside of the sternum

Chest wall overlying theprocess

Retrosternal, may radiateto the back

Retrosternal, may radiateto the back, arms, and jaw

Often below the leftbreast or along the costalcartilages; also elsewhere

Precordial, below the leftbreast, or across theanterior chest

Pressing, squeezing,tight, heavy,occasionallyburning

Same as in angina

Sharp, knifelike

Crushing

Ripping, tearing

Burning

Sharp, knifelike

Burning, may besqueezing

Usually squeezing

Stabbing, sticking,or dull, aching

Stabbing, sticking,or dull, aching

Mild to moderate,sometimes perceivedas discomfort ratherthan pain

Often but not alwaysa severe pain

Often severe

Severe

Very severe

Mild to moderate

Often severe

Mild to severe

Mild to severe

Variable

Variable

Note: Remember that chest pain may be referred from extrathoracic structures such as the neck (arthritis) and abdomen(biliary colic, acute cholecystitis). Pleural pain may be due to abdominal conditions such as subdiaphragmatic abscess.




AssociatedTiming Factors That Aggravate Factors That Relieve Symptoms

Usually 1–3 min but up to10 min. Prolonged episodesup to 20 min

20 min to several hr

Persistent

Persistent

Abrupt onset, early peak,persistent for hours or more

Variable

Persistent

Variable

Variable

Fleeting to hours or days

Fleeting to hours or day

Exertion, especially in the cold; meals;emotional stress. May occur at rest

Breathing, changing position,coughing, lying down, sometimesswallowing

Hypertension

Coughing

Breathing, coughing, movements ofthe trunk

Large meal; bending over, lying down

Swallowing of food or cold liquid;emotional stress

Movement of chest, trunk, arms

May follow effort, emotional stress

Rest, nitroglycerin

Sitting forward may relieve it.

Lying on the involved side mayrelieve it.

Antacids, sometimes belching

Sometimes nitroglycerin

Sometimes dyspnea,nausea, sweating

Nausea, vomiting,sweating, weakness

Of the underlying illness


Syncope, hemiplegia,paraplegia

Cough


Sometimes regurgitation,dysphagia

Dysphagia

Often local tenderness

Breathlessness,palpitations, weakness,anxiety

TABLE 6-2 ! Dyspnea


TABLE 6-2 ! Dyspnea

Problem Process Timing

Left-Sided Heart Failure (left ventricular failure or mitral stenosis)

Chronic Bronchitis*

Chronic Obstructive PulmonaryDisease (COPD)*

Asthma

Diffuse Interstitial Lung Diseases(such as sarcoidosis, widespreadneoplasms, asbestosis, andidiopathic pulmonary fibrosis)Pneumonia

Spontaneous Pneumothorax

Acute Pulmonary Embolism

Anxiety With Hyperventilation

Elevated pressure in pulmonary capillarybed with transudation of fluid intointerstitial spaces and alveoli, decreasedcompliance (increased stiffness) of thelungs, increased work of breathing

Excessive mucus production in bronchi,followed by chronic obstruction ofairways

Overdistention of air spaces distal toterminal bronchioles, with destructionof alveolar septa and chronic obstructionof the airways

Bronchial hyperresponsiveness involvingrelease of inflammatory mediators,increased airway secretions, andbronchoconstriction

Abnormal and widespread infiltration ofcells, fluid, and collagen into interstitialspaces between alveoli. Many causes

Inflammation of lung parenchyma fromthe respiratory bronchioles to the alveoli

Leakage of air into pleural spacethrough blebs on visceral pleura, withresulting partial or complete collapse ofthe lung

Sudden occlusion of all or part ofpulmonary arterial tree by a blood clotthat usually originates in deep veins oflegs or pelvis

Overbreathing, with resultantrespiratory alkalosis and fall in thepartial pressure of carbon dioxide in the blood

Dyspnea may progress slowly, orsuddenly as in acute pulmonaryedema.

Chronic productive cough followedby slowly progressive dyspnea

Slowly progressive dyspnea; relativelymild cough later

Acute episodes, separated bysymptom-free periods. Nocturnalepisodes are common.

Progressive dyspnea, which varies inits rate of development with the cause

An acute illness, timing varies withthe causative agent

Sudden onset of dyspnea

Sudden onset of dyspnea

Episodic, often recurrent

*Chronic bronchitis and chronic obstructive pulmonary disease (COPD) may coexist.

TABLE 6-2 ! Dyspnea


Factors ThatAggravate Factors That Relieve Associated Symptoms Setting

Exertion, lying down

Exertion, inhaled irritants,respiratory infections

Exertion

Variable, includingallergens, irritants,respiratory infections,exercise, and emotion

Exertion

More often occurs at restthan after exercise. Anupsetting event may not be evident.

Rest, sitting up, though dyspneamay become persistent

Expectoration; rest, thoughdyspnea may become persistent

Rest, though dyspnea maybecome persistent

Separation from aggravatingfactors

Rest, though dyspnea maybecome persistent

Breathing in and out of a paperor plastic bag sometimes helpsthe associated symptoms.

Often cough, orthopnea,paroxysmal nocturnal dyspnea;sometimes wheezing

Chronic productive cough,recurrent respiratory infections;wheezing may develop

Cough, with scant mucoidsputum

Wheezing, cough, tightness inchest

Often weakness, fatigue. Coughless common than in other lungdiseases

Pleuritic pain, cough, sputum,fever, though not necessarilypresent

Pleuritic pain, cough

Often none. Retrosternaloppressive pain if the occlusionis massive. Pleuritic pain, cough,and hemoptysis may follow anembolism if pulmonaryinfarction ensues. Symptoms ofanxiety (see below).

Sighing, lightheadedness,numbness or tingling of thehands and feet, palpitations,chest pain

History of heart disease or itspredisposing factors

History of smoking, airpollutants, recurrentrespiratory infections

History of smoking, airpollutants, sometimes a familialdeficiency in alpha1-antitrypsin

Environmental and emotionalconditions

Varied. Exposure to one ofmany substances may becausative.

Varied

Often a previously healthyyoung adult

Postpartum or postoperativeperiods; prolonged bed rest;congestive heart failure,chronic lung disease, andfractures of hip or leg; deepvenous thrombosis (often notclinically apparent)

Other manifestations of anxietymay be present.

TABLE 6-3 ! Cough and Hemoptysis


TABLE 6-3 ! Cough and Hemoptysis*

Problem Cough and Sputum Associated Symptoms and Setting

Acute InflammationLaryngitis

Tracheobronchitis

Mycoplasma and ViralPneumoniasBacterial Pneumonias

Chronic InflammationPostnasal Drip

Chronic Bronchitis

Bronchiectasis

Pulmonary Tuberculosis

Lung Abscess

Asthma

Gastroesophageal Reflux

NeoplasmCancer of the Lung

Cardiovascular DisordersLeft Ventricular Failure or Mitral Stenosis

Pulmonary Emboli

Irritating Particles,Chemicals, or Gases

Dry cough (without sputum), may becomeproductive of variable amounts of sputum

Dry cough, may become productive (asabove)

Dry hacking cough, often becomingproductive of mucoid sputum

Pneumococcal: sputum mucoid orpurulent; may be blood-streaked, diffuselypinkish, or rusty

Klebsiella: similar; or sticky, red, and jellylike

Chronic cough; sputum mucoid ormucopurulent

Chronic cough; sputum mucoid topurulent, may be blood-streaked or evenbloody

Chronic cough; sputum purulent, oftencopious and foul-smelling; may be blood-streaked or bloody

Cough dry or sputum that is mucoid orpurulent; may be blood-streaked or bloody

Sputum purulent and foul-smelling; may bebloody

Cough, with thick mucoid sputum,especially near end of an attack

Chronic cough, especially at night or earlyin the morning

Cough dry to productive; sputum may beblood-streaked or bloody

Often dry, especially on exertion or at night;may progress to the pink frothy sputum ofpulmonary edema or to frank hemoptysis

Dry to productive; may be dark, bright red,or mixed with blood

Variable. There may be a latent periodbetween exposure and symptoms.

An acute, fairly minor illness with hoarseness.Often associated with viral nasopharyngitis

An acute, often viral illness, with burningretrosternal discomfort

An acute febrile illness, often with malaise,headache, and possibly dyspnea

An acute illness with chills, high fever,dyspnea, and chest pain. Often is preceded byacute upper respiratory infection.

Typically occurs in older alcoholic men

Repeated attempts to clear the throat.Postnasal discharge may be sensed by patientor seen in posterior pharynx. Associated withchronic rhinitis, with or without sinusitis

Often longstanding cigarette smoking.Recurrent superimposed infections. Wheezingand dyspnea may develop.

Recurrent bronchopulmonary infectionscommon; sinusitis may coexist

Early, no symptoms. Later, anorexia, weightloss, fatigue, fever, and night sweats

A febrile illness. Often poor dental hygieneand a prior episode of impaired consciousness

Episodic wheezing and dyspnea, but coughmay occur alone. Often a history of allergy

Wheezing, especially at night (often mistakenfor asthma), early morning hoarseness, andrepeated attempts to clear the throat. Often ahistory of heartburn and regurgitation

Usually a long history of cigarette smoking.Associated manifestations are numerous.

Dyspnea, orthopnea, paroxysmal nocturnaldyspnea

Dyspnea, anxiety, chest pain, fever; factorsthat predispose to deep venous thrombosis

Exposure to irritants. Eyes, nose, and throatmay be affected.

*Characteristics of hemoptysis are printed in red.

TABLE 6-4 ! Deformities of the Thorax


TABL

E 6-

4!

Def

orm

itie

s of

the

Tho

rax

Nor

mal

Adu

ltT

he th

orax

in th

e no

rmal

adu

lt is

wid

er th

an it

isde

ep. I

ts la

tera

l dia

met

er is

larg

er th

an it

san

tero

post

erio

r dia

met

er.

Barr

el C

hest

A b

arre

l che

st h

as a

n in

crea

sed

ante

ropo

ster

ior

diam

eter

. Thi

s sha

pe is

nor

mal

dur

ing

infa

ncy,

and

ofte

n ac

com

pani

es n

orm

al a

ging

and

chr

onic

obst

ruct

ive

pulm

onar

y di

seas

e.

Trau

mat

ic F

lail

Che

stIf

mul

tiple

ribs

are

frac

ture

d, p

arad

oxic

alm

ovem

ents

of t

he th

orax

may

be

seen

. As d

esce

ntof

the

diap

hrag

m d

ecre

ases

intr

atho

raci

c pr

essu

reon

insp

iratio

n, th

e in

jure

d ar

ea c

aves

inw

ard;

on

expi

ratio

n, it

mov

es o

utw

ard.

Exp

iratio

n

Insp

iratio

n

Cros

s Se

ctio

n of

Tho

rax

Cros

s Se

ctio

n of

Tho

rax

Cros

s Se

ctio

n of

Tho

rax

Funn

el C

hest

(Pe

ctus

Exc

avat

um)

A fu

nnel

che

st is

cha

ract

eriz

ed b

y a

depr

essio

n in

the

low

er p

ortio

n of

the

ster

num

. Com

pres

sion

of th

e he

art a

nd g

reat

ves

sels

may

cau

sem

urm

urs.

Pige

on C

hest

(Pe

ctus

Car

inat

um)

In a

pig

eon

ches

t, th

e st

ernu

m is

disp

lace

dan

terio

rly, i

ncre

asin

g th

e an

tero

post

erio

rdi

amet

er. T

he c

osta

l car

tilag

es a

djac

ent t

o th

epr

otru

ding

ster

num

are

dep

ress

ed.

Dep

ress

ed c

osta

l car

tilag

es

Ant

erio

rly d

ispl

aced

ste

rnum

Thor

acic

Kyp

hosc

olio

sis

In th

orac

ic k

ypho

scol

iosis

, abn

orm

al sp

inal

curv

atur

es a

nd v

erte

bral

rota

tion

defo

rm th

ech

est.

Dist

ortio

n of

the

unde

rlyin

g lu

ngs m

aym

ake

inte

rpre

tatio

n of

lung

find

ings

ver

y di

fficu

lt.

Cros

s Se

ctio

n of

Tho

rax

Cros

s Se

ctio

nof

Tho

rax

Cros

s Se

ctio

n of

Tho

rax

Rib

s w

idel

yse

para

ted

Spi

nal c

onve

xity

to th

e rig

ht(p

atie

nt b

endi

ng fo

rwar

d)

Rib

s cl

ose

toge

ther

TABLE 6-5 ! Normal and Altered Breath and Voice Sounds


TABL

E 6-

5!

Nor

mal

and

Alt

ered

Bre

ath

and

Voic

e So

unds

The

orig

ins o

f bre

ath

soun

ds a

re st

ill u

ncle

ar. A

ccor

ding

to le

adin

g th

eorie

s, tu

r-bu

lent

air

flow

in th

e ce

ntra

l airw

ays

prod

uces

the

trac

heal

and

bro

nchi

al b

reat

hso

unds

. As

thes

e so

unds

pas

s th

roug

h th

e lu

ngs

to th

e pe

riphe

ry, l

ung

tissu

e fil

-te

rs o

ut t

heir

high

er-p

itche

d co

mpo

nent

s an

d on

ly t

he s

oft

and

low

er-p

itche

dco

mpo

nent

s rea

ch th

e ch

est w

all,

whe

re th

ey a

re h

eard

as v

esic

ular

bre

ath

soun

ds.

Nor

mal

ly, t

rach

eal a

nd b

ronc

hial

soun

ds m

ay b

e he

ard

over

the

trac

hea

and

mai

n-st

em b

ronc

hi; v

esic

ular

bre

ath

soun

ds p

redo

min

ate

thro

ugho

ut m

ost o

f the

lung

s.

Whe

n lu

ng ti

ssue

lose

s its

air,

it tr

ansm

its h

igh-

pitc

hed

soun

ds m

uch

bett

er. I

f the

trac

heob

ronc

hial

tre

e is

open

, bro

nchi

al b

reat

h so

unds

may

rep

lace

the

nor

mal

vesic

ular

soun

ds o

ver a

irles

s are

as o

f the

lung

. Thi

s cha

nge

is se

en in

loba

r pne

u-m

onia

whe

n th

e al

veol

i fill

with

flui

d, r

ed c

ells,

and

whi

te c

ells—

a pr

oces

s ca

lled

cons

olid

atio

n.O

ther

cau

ses

incl

ude

pulm

onar

y ed

ema

or h

emor

rhag

e. B

ronc

hial

brea

th s

ound

s us

ually

cor

rela

te w

ith a

n in

crea

se in

tact

ile fr

emitu

s an

d tr

ansm

it-te

d vo

ice

soun

ds. T

hese

find

ings

are

sum

mar

ized

bel

ow.

Nor

mal

Air

-Fill

ed L

ung

Air

less

Lun

g, a

s in

Lob

ar P

neum

onia

Brea

th S

ound

sTr

ansm

itte

d V

oice

Sou

nds

Tact

ile F

rem

itus

Pred

omin

antly

ves

icul

ar

Spok

en w

ords

muf

fled

and

indi

stin

ctSp

oken

“ee

” he

ard

as “

ee”

Whi

sper

ed w

ords

fain

t and

indi

stin

ct, i

f hea

rd a

t all

Nor

mal

Bro

nchi

al o

r bro

ncho

vesic

ular

ove

r the

invo

lved

are

a

Spok

en w

ords

loud

er, c

lear

er (

bron

chop

hony

)Sp

oken

“ee

” he

ard

as “

ay”

(ego

phon

y)W

hisp

ered

wor

ds lo

uder

, cle

arer

(w

hisp

ered

pec

tori

loqu

y)

Incr

ease

d

TABLE 6-6 ! Adventitious (Added) Lung Sounds: Causes and Qualities


TABL

E 6-

6!

Adv

enti

tiou

s (A

dded

) Lu

ng S

ound

s: C

ause

s an

d Q

ualit

ies

Cra

ckle

sC

rack

les h

ave

two

lead

ing

expl

anat

ions

. (1)

The

y re

sult

from

a se

ries o

f tin

y ex

plos

ions

whe

n sm

all a

irway

s, de

flate

d du

ring

expi

ratio

n, p

op o

pen

durin

g in

spira

tion.

Thi

s mec

hani

sm p

roba

bly

expl

ains

the

late

insp

irato

ry c

rack

les o

f int

erst

itial

lung

dise

ase

and

early

con

gest

ive

hear

t fai

lure

. (2)

Cra

ckle

s res

ult f

rom

air

bubb

les

flow

ing

thro

ugh

secr

etio

ns o

r lig

htly

clo

sed

airw

ays d

urin

g re

spira

tion.

Thi

s mec

hani

sm p

roba

bly

expl

ains

at l

east

som

e co

arse

cra

ckle

s.

Whe

ezes

and

Rho

nchi

Stri

dor

Pleu

ral R

ub

Med

iast

inal

Cru

nch

(Ham

man

’s S

ign)

Insp

iratio

nE

xpira

tion

Late

insp

irat

ory c

rack

lesm

ay b

egin

in th

e fir

st h

alf o

f ins

pira

tion

but m

ust c

ontin

ue in

to la

te in

spira

tion.

The

y ar

eus

ually

fine

and

fairl

y pr

ofus

e, a

nd p

ersis

t fro

m b

reat

h to

bre

ath.

The

se c

rack

les a

ppea

r firs

t at t

he b

ases

of t

he lu

ngs,

spre

ad u

pwar

d as

the

cond

ition

wor

sens

, and

shift

to d

epen

dent

regi

ons w

ith c

hang

es in

pos

ture

. Cau

ses i

nclu

dein

ters

titia

l lun

g di

seas

e (s

uch

as fi

bros

is) a

nd e

arly

con

gest

ive

hear

t fai

lure

.

Earl

y ins

pira

tory

crac

kles

appe

ar so

on a

fter t

he st

art o

f ins

pira

tion

and

do n

ot c

ontin

ue in

to la

te in

spira

tion.

The

y ar

eof

ten

but n

ot a

lway

s coa

rse

and

are

rela

tivel

y fe

w in

num

ber.

Exp

irato

ry c

rack

les a

re so

met

imes

ass

ocia

ted.

Cau

ses

incl

ude

chro

nic

bron

chiti

s and

ast

hma.

Mid

insp

irat

ory a

nd ex

pira

tory

crac

kles

are

hear

d in

bro

nchi

ecta

sis b

ut a

re n

ot sp

ecifi

c fo

r thi

s dia

gnos

is. W

heez

es a

ndrh

onch

i may

be

asso

ciat

ed.

Whe

ezes

occ

ur w

hen

air fl

ows r

apid

ly th

roug

h br

onch

i tha

t are

nar

row

ed n

early

to th

e po

int o

f clo

sure

. The

y ar

e of

ten

audi

ble

at th

e m

outh

as w

ell a

s thr

ough

the

ches

t wal

l. C

ause

s of w

heez

es th

at a

re g

ener

aliz

ed th

roug

hout

the

ches

tin

clud

e as

thm

a, c

hron

ic b

ronc

hitis

, CO

PD, a

nd c

onge

stiv

e he

art f

ailu

re (

card

iac

asth

ma)

. In

asth

ma,

whe

ezes

may

be

hear

d on

ly in

exp

iratio

n or

in b

oth

phas

es o

f the

resp

irato

ry c

ycle

. Rho

nchi

sugg

est s

ecre

tions

in th

e la

rger

airw

ays.

Inch

roni

c br

onch

itis,

whe

ezes

and

rhon

chi o

ften

clea

r with

cou

ghin

g.

Occ

asio

nally

in se

vere

obs

truc

tive

pulm

onar

y di

seas

e, th

e pa

tient

is n

o lo

nger

abl

e to

forc

e en

ough

air

thro

ugh

the

narr

owed

bro

nchi

to p

rodu

ce w

heez

ing.

The

resu

lting

sile

nt ch

ests

houl

d ra

ise im

med

iate

con

cern

and

not

be

mist

aken

for i

mpr

ovem

ent.

A p

ersis

tent

loca

lized

whe

eze

sugg

ests

a p

artia

l obs

truc

tion

of a

bro

nchu

s, as

by

a tu

mor

or f

orei

gn b

ody.

It m

ay b

ein

spira

tory

, exp

irato

ry, o

r bot

h.

A w

heez

e th

at is

ent

irely

or p

redo

min

antly

insp

irato

ry is

cal

led

strid

or.I

t is o

ften

loud

er in

the

neck

than

ove

r the

ches

t wal

l. It

indi

cate

s a p

artia

l obs

truc

tion

of th

e la

rynx

or t

rach

ea, a

nd d

eman

ds im

med

iate

att

entio

n.

Infla

med

and

roug

hene

d pl

eura

l sur

face

s gra

te a

gain

st e

ach

othe

r as t

hey

are

mom

enta

rily

and

repe

ated

ly d

elay

ed b

yin

crea

sed

fric

tion.

The

se m

ovem

ents

pro

duce

cre

akin

g so

unds

kno

wn

as a

ple

ural

rub

(or p

leur

al fr

ictio

n ru

b).

Pleu

ral r

ubs r

esem

ble

crac

kles

aco

ustic

ally

, alth

ough

they

are

pro

duce

d by

diff

eren

t pat

holo

gic

proc

esse

s. T

he so

unds

may

be

disc

rete

, but

som

etim

es a

re so

num

erou

s tha

t the

y m

erge

into

a se

emin

gly

cont

inuo

us so

und.

Aru

b is

usua

lly c

onfin

ed to

a re

lativ

ely

smal

l are

a of

the

ches

t wal

l, an

d ty

pica

lly is

hea

rd in

bot

h ph

ases

of r

espi

ratio

n.W

hen

infla

med

ple

ural

surf

aces

are

sepa

rate

d by

flui

d, th

e ru

b of

ten

disa

ppea

rs.

A m

edia

stina

l cru

nch

is a

serie

s of p

reco

rdia

l cra

ckle

s syn

chro

nous

with

the

hear

t bea

t, no

t with

resp

iratio

n. B

est

hear

d in

the

left

late

ral p

ositi

on, i

t is d

ue to

med

iast

inal

em

phys

ema

(pne

umom

edia

stin

um).

TABLE 6-7 ! Physical Findings in Selected Chest Disorders


TABL

E 6-

7!

Phys

ical

Fin

ding

s in

Sel

ecte

d C

hest

Dis

orde

rs

The

bla

ck b

oxes

in th

is ta

ble

sugg

est a

fram

ewor

k fo

r clin

ical

ass

essm

ent.

Star

t with

the

thre

e bo

xes

unde

r Pe

rcus

sion

Not

e: r

eson

ant,

dull,

and

hyp

erre

sona

nt. T

hen

mov

e fro

m e

ach

of th

ese

to o

ther

box

es th

at e

mph

asiz

e so

me

of th

e ke

y di

ffere

nces

amon

g va

rious

con

ditio

ns. T

he c

hang

es d

escr

ibed

var

y w

ith th

e ex

tent

and

seve

rity

of th

e di

sord

er. A

bnor

mal

ities

dee

p in

the

ches

t usu

ally

pro

duce

few

er si

gns t

han

supe

rfici

al o

nes,

and

may

cau

se n

o sig

ns a

t all.

Use

the

tabl

e fo

r th

e di

rect

ion

ofty

pica

l cha

nges

, not

for a

bsol

ute

dist

inct

ions

.

Tact

ile F

rem

itus

Perc

ussi

onA

dven

titi

ous

and

Tran

smit

ted

Con

diti

onN

ote

Trac

hea

Brea

th S

ound

sSo

unds

Voi

ce S

ound

s

Nor

mal

The

trac

heob

ronc

hial

tree

and

alve

oli a

re c

lear

; ple

urae

are

thin

and

clo

se to

geth

er;

mob

ility

of t

he c

hest

wal

lis

unim

paire

d.

Chr

onic

Bro

nchi

tis

The

bro

nchi

are

chr

onic

ally

infla

med

and

a p

rodu

ctiv

eco

ugh

is pr

esen

t. A

irway

obst

ruct

ion

may

dev

elop

.

Left

-Sid

ed H

eart

Fai

lure

(E

arly

)In

crea

sed

pres

sure

in th

epu

lmon

ary

vein

s cau

ses

cong

estio

n an

d in

ters

titia

led

ema

(aro

und

the

alve

oli);

bron

chia

l muc

osa

may

bec

ome

edem

atou

s.

Con

solid

atio

nA

lveo

li fil

l with

flui

d or

blo

odce

lls, a

s in

pneu

mon

ia,

pulm

onar

y ed

ema,

or

pulm

onar

y he

mor

rhag

e.

Res

onan

t

Res

onan

t

Res

onan

t

Dul

love

r the

airle

ss a

rea

Mid

line

Mid

line

Mid

line

Mid

line

Ves

icul

ar, e

xcep

t per

haps

bron

chov

esic

ular

and

bron

chia

l sou

nds o

ver

the

larg

e br

onch

i and

trac

hea

resp

ectiv

ely

Ves

icul

ar (

norm

al)

Ves

icul

ar

Bron

chia

l ove

r the

invo

lved

are

a

Non

e, e

xcep

t per

haps

a

few

tran

sient

insp

irato

rycr

ackl

es a

t the

bas

es o

f the

lung

s

Non

e; o

r sca

tter

ed c

oars

ecr

ackl

esin

ear

ly in

spira

tion

and

perh

aps e

xpira

tion;

or

whe

ezes

or r

honc

hi

Late

insp

irat

ory c

rack

les i

nth

e de

pend

ent p

ortio

ns o

fth

e lu

ngs;

poss

ibly

whe

ezes

Late

insp

irat

ory c

rack

les

over

the

invo

lved

are

a

Nor

mal

Nor

mal

Nor

mal

Incr

ease

dov

er th

ein

volv

ed a

rea,

with

bron

chop

hony

,eg

opho

ny, a

ndw

hisp

ered

pect

orilo

quy

TABLE 6-7 ! Physical Findings in Selected Chest Disorders


Ate

lect

asis

(L

obar

Obs

truc

tion)

Whe

n a

plug

in a

mai

nste

mbr

onch

us (

as fr

om m

ucus

or a

fore

ign

obje

ct)

obst

ruct

s air

flow

, affe

cted

lung

tiss

ueco

llaps

es in

to a

n ai

rless

stat

e.

Pleu

ral E

ffus

ion

Flui

d ac

cum

ulat

es in

the

pleu

ral s

pace

, sep

arat

es a

ir-fil

led

lung

from

the

ches

t wal

l,bl

ocki

ng th

e tr

ansm

issio

n of

soun

d.

Pneu

mot

hora

xW

hen

air l

eaks

into

the

pleu

ral

spac

e, u

sual

ly u

nila

tera

lly, t

helu

ng re

coils

from

the

ches

tw

all.

Pleu

ral a

ir bl

ocks

tran

smiss

ion

of so

und.

Chr

onic

Obs

truc

tive

Pulm

onar

y D

isea

se(C

OPD

)Sl

owly

pro

gres

sive

diso

rder

inw

hich

the

dist

al a

ir sp

aces

enla

rge

and

lung

s bec

ome

hype

rinfla

ted.

Chr

onic

bron

chiti

s is o

ften

asso

ciat

ed.

Ast

hma

Wid

espr

ead

narr

owin

g of

the

trac

heob

ronc

hial

tree

dim

inish

es a

irflow

to a

fluct

uatin

g de

gree

. Dur

ing

atta

cks,

airfl

ow d

ecre

ases

furt

her a

nd lu

ngs h

yper

infla

te.

Dul

love

r the

airle

ss a

rea

Dul

l to

flat

over

the

fluid

Hyp

erre

sona

ntor

tym

pani

ticov

er th

e pl

eura

lai

r

Diff

usel

yhy

perr

eson

ant

Res

onan

tto

diffu

sely

hype

rres

onan

t

Usu

ally

abs

entw

hen

bron

chia

l plu

g pe

rsist

s.E

xcep

tions

incl

ude

right

uppe

r lob

e at

elec

tasis

,w

here

adj

acen

t tra

chea

lso

unds

may

be

tran

smitt

ed.

Dec

reas

ed to

abs

ent,

but

bron

chia

l bre

ath

soun

dsm

ay b

e he

ard

near

top

ofla

rge

effu

sion.

Dec

reas

ed to

abs

ento

ver

the

pleu

ral a

ir

Dec

reas

ed to

abs

ent

Oft

en o

bscu

red

by w

heez

es

Usu

ally

abs

entw

hen

the

bron

chia

l plu

gpe

rsist

s. In

exce

ptio

ns, e

.g.,

right

upp

er lo

beat

elec

tasis

, may

be

incr

ease

d

Dec

reas

ed to

abs

ent,

but m

ay b

e inc

reas

edto

war

d th

e to

p of

ala

rge

effu

sion

Dec

reas

ed to

abs

ent

over

the

pleu

ral a

ir

Dec

reas

ed

Dec

reas

ed

May

be

shift

edto

war

d in

volv

edsid

e

Shift

ed to

war

dop

posit

e sid

e in

ala

rge

effu

sion

Shift

edto

war

dop

posit

e sid

eif

muc

h ai

r

Mid

line

Mid

line

Non

e

Non

e, e

xcep

t a p

ossib

lepl

eura

lrub

Non

e, e

xcep

t a p

ossib

lepl

eura

l rub

Non

e, o

r the

cra

ckle

s,w

heez

es, a

nd rh

onch

i of

asso

ciat

ed c

hron

icbr

onch

itis

Whe

ezes

, pos

sibly

crac

kles

the thorax and lungs - dr. pedro...

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