The Thorax and Lungs 1.

2nd intercostal space for needle insertion for tension pneumothorax; 4th intercostal space for chest tube insertion; T4 for lower margin of endotracheal tube on chest xray. T7-8 interspace as landmark for thoracentesis THE HEALTH HISTORY 2. Common or Concerning Symptoms Chest pain Shortness of breath (dyspnea) Wheezing Cough Blood-streaked sputum (hemoptysis)

3. A clenched fist over the sternum suggests angina pectoris; a finger pointing to a tender area on the chest wall suggests musculoskeletal pain; a hand moving from neck to epigastrum. suggests heartburn. 4. Anxiety is the most frequent cause of chest pain in children; costochondritis is also common. 5. Anxious patients may have episodic dyspnea during both rest and exercise, and hyperventilation, or rapid, shallow breathing. At other times, they may sigh frequently. 6. Wheezing suggests partial airway obstruction from secretions, tissue inflammation, or a foreign body.
7. Cough can be a symptom of left-sided heart failure. 8. Viral upper respiratory infections are the most common cause of acute cough; also consider acute bronchitis, pneumonia, left ventricular heart failure, asthma, foreign body. Postinfectious cough, bacterial sinusitis, asthma in subacute cough; postnasal drip, asthma, gastroesophageal reflux, chronic bronchitis, bronchiectasis in chronic cough.

9. Mucoid sputum is translucent, white, or gray; purulent sputum is yellowish or greenish. 10. Foul-smelling sputum in anaerobic lung abscess; tenacious(Sticking together) sputum in cystic fibrosis 11. Large volumes of purulent sputum in bronchiectasis or lung abscess. Diagnostically helpful symptoms include fever, chest pain, dyspnea, orthopnea, and wheezing. 12. Blood originating in the stomach is usually darker than blood from the respiratory tract and may be mixed with food particles. 13. ASSESSING READINESS TO QUIT SMOKING: THE 5 A'S i. ii. iii. iv. v. Ask about tobacco use. Advise to quit through clear, personalized messages. Assess willingness to quit. Assist to quit. Arrange follow-up and support.

14. Cyanosis signals hypoxia. Clubbing of the nails in lung abscesses, malignancy, congenital heart disease

15. Audible stridor, a high-pitched wheeze, is an ominous sign of airway obstruction in the larynx or trachea. 16. Inspiratory contraction of the sternomastoids and scalenes at rest signals severe difficulty in breathing. Lateral displacement of the trachea in pneumothorax, pleural effusion, or atelectasis 17. The AP diameter also may increase in chronic obstructive pulmonary disease (COPD), although evidence is not definitive.15 18. Retraction in severe asthma, COPD, or upper airway obstruction 19. Unilateral impairment or lagging of respiratory movement suggests disease of the underlying lung or pleura. 20. Intercostal tenderness over inflamed pleura 21. Bruises over a fractured rib 22. Although rare, sinus tracts usually indicate infection of the underlying pleura and lung (as in tuberculosis, actinomycosis). 23. Causes of unilateral decrease or delay in chest expansion include chronic fibrosis of the underlying lung or pleura, pleural effusion, lobar pneumonia, pleural pain with associated splinting, and unilateral bronchial obstruction. 24. Fremitus is decreased or absent when the voice is soft or when the transmission of vibrations from the larynx to the surface of the chest is impeded. Causes include a very thick chest wall; an obstructed bronchus; COPD; separation of the pleural surfaces by fluid (pleural effusion), fibrosis (pleural thickening), air (pneumothorax), or an infiltrating tumor. 25. Look for asymmetric fremitus: asymmetric decreased fremitus in unilateral pleural effusion, pneumothorax, neoplasm from decreased transmission of low frequency sounds; asymmetric increased fremitus in unilateral pneumonia from increased transmission.15 26. Percussion Notes and Their Characteristics Relative Relative Relative Example of Pathologic Intensity Pitch Duration Location Examples Flatness Dullness Resonance Hyperresonance Tympany Soft Medium Loud Very loud Loud High Short Thigh Large pleural effusion Liver Lobar pneumonia Healthy lung Simple chronic bronchitis Usually none COPD, pneumothorax Gastric air bubble Large or puffed-out pneumothorax cheek

Medium Medium Low Long Lower High* Longer

*

Distinguished mainly by its musical timbre. 27. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. Examples include: lobar pneumonia, in which the alveoli are filled with fluid and blood cells; and pleural accumulations of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor.

28. Generalized hyperresonance may be heard over the hyperinflated lungs of COPD or asthma, but is not a reliable sign. Unilateral hyperresonance suggests a large pneumothorax or possibly a large air-filled bulla in the lung. 29. An abnormally high level suggests pleural effusion, or a high diaphragm as in atelectasis or diaphragmatic paralysis. 30. Sounds from bedclothes, paper gowns, and the chest itself can generate confusion in auscultation. Hair on the chest may cause crackling sounds. Either press harder or wet the hair. If the patient is cold or tense, you may hear muscle contraction sounds muffled, low-pitched rumbling or roaring noises. A change in the patient's position may eliminate this noise. You can reproduce this sound on yourself by doing a Valsalva maneuver (straining down) as you listen to your own chest. 31. Breath sounds may be decreased when air flow is decreased (as in obstructive lung disease or muscular weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or COPD). 32. Characteristics of Breath Sounds Intensity of Pitch of Locations Where Duration of Expiratory Expiratory Heard Normally Sounds Sound Sound Inspiratory sounds Soft Relatively low Over most of both Vesicular* last longer than lungs expiratory ones. Intermediate Intermediate Often in the 1st and BronchovesicularInspiratory and expiratory sounds 2nd interspaces are about equal. anteriorly and between the scapulae Expiratory sounds Loud Relatively high Over the manubrium, if Bronchial last longer than heard at all inspiratory ones. Inspiratory and Very loud Relatively high Over the trachea in the Tracheal expiratory sounds neck are about equal. * The thickness of the bars indicates intensity; the steeper their incline, the higher the pitch. 33. If bronchovesicular or bronchial breath sounds are heard in locations distant from those listed, suspect that air-filled lung has been replaced by fluid-filled or solid lung tissue. 34. A gap between inspiratory and expiratory sounds suggests bronchial breath sounds. 35. Fine late inspiratory crackles that persist from breath to breath suggest abnormal lung tissue.

36. Crackles may be from abnormalities of the lungs (pneumonia, fibrosis, early congestive heart failure) or of the airways (bronchitis, bronchiectasis). 37. Wheezes suggest narrowed airways, as in asthma, COPD, or bronchitis. 38. Rhonchi suggest secretions in large airways. 39. Clearing of crackles, wheezes, or rhonchi after coughing or position change suggests inspissated secretions, as in bronchitis or atelectasis. 40. Findings predictive of COPD include combinations of symptoms and signs, especially wheezing by self-report or examination, plus history of smoking, age, and decreased breath sounds. Diagnosis requires pulmonary function tests such as spirometry.

41. Adventitious or Added Breath Sounds16 Crackles (or Rales) Wheezes and Rhonchi Discontinuous Continuous Intermittent, nonmusical, and brief 250 msec, musical, prolonged (but not necessarily persisting throughout the respiratory cycle) Like dots in time Like dashes in time Fine crackles: soft, high-pitched, very Wheezes: relatively high-pitched (400 Hz) with brief (5-10 msec) hissing or shrill quality Coarse crackles: somewhat louder, lower in pitch, brief (20-30 msec) Rhonchi: relatively low-pitched (200 Hz) with snoring quality

42. Increased transmission of voice sounds suggests that air-filled lung has become airless. 43. Louder, clearer voice sounds are called bronchophony. 44. When ee is heard as ay, an E-to-A change (egophony) is present, as in lobar consolidation from pneumonia. The quality sounds nasal. 45. Louder, clearer whispered sounds are called whispered pectoriloquy. 46. Persons with severe COPD may prefer to sit leaning forward, with lips pursed during exhalation and arms supported on their knees or a table. 47. Tender pectoral muscles or costal cartilages corroborate, but do not prove, that chest pain has a musculoskeletal origin. 48. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space. Because pleural fluid usually sinks to the lowest part of the pleural space (posteriorly in a supine patient), only a very large effusion can be detected anteriorly. 49. The hyperresonance of COPD may totally replace cardiac dullness. 50. The dullness of right middle lobe pneumonia typically occurs behind the right breast. Unless you displace the breast, you may miss the abnormal percussion note. 51. A lung affected by COPD often displaces the upper border of the liver downward. It also lowers the level of diaphragmatic dullness posteriorly. 52. The walk test (Time an 8-foot walk at the patient's normal pace): Nondisabled older adults taking 5.6 seconds or longer are more likely to be disabled over time than those taking 3.1 seconds or fewer. Early intervention may prevent onset of subsequent disability.26 53. Patients older than 60 years with a forced expiratory time of 6 to 8 seconds are twice as likely to have COPD. 54. An increase in the local pain (distant from your hands) suggests rib fracture rather than just soft-tissue injury. Recording the Physical Examinationthe Thorax and Lungs a. Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or rhonchi. Diaphragms descend 4 cm bilaterally. OR b. Thorax symmetric with moderate kyphosis and increased anteroposterior (AP) diameter, decreased expansion. Lungs are hyperresonant. Breath sounds distant with delayed expiratory phase and scattered expiratory wheezes. Fremitus decreased; no bronchophony, egophony, or whispered pectoriloquy. Diaphragms descend 2 cm bilaterally.