the thorax and lungs- bates

7/31/2019 The Thorax and Lungs- BATES

1/4

The Thorax and Lungs

1. 2nd intercostal space for needle insertion for tension pneumothorax; 4th intercostalspace for chest tube insertion; T4 for lower margin of endotracheal tube on chest x-

ray. 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 atender 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 alsocommon.

5. Anxious patients may have episodic dyspnea during both rest and exercise, andhyperventilation, or rapid, shallow breathing. At other times, they may sigh

frequently.

6. Wheezing suggests partial airway obstruction from secretions, tissue inflammation, ora 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 orgreenish.

10.Foul-smelling sputum in anaerobic lung abscess; tenacious(Sticking together) sputumin 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'Si. Ask about tobacco use.

ii. Advise to quit through clear, personalized messages.iii. Assess willingness to quit.iv. Assist to quit.v. Arrange follow-up and support.

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


2/4

15.Audible stridor, a high-pitched wheeze, is an ominous sign of airway obstruction inthe larynx or trachea.

16.Inspiratory contraction of the sternomastoids and scalenes at rest signals severedifficulty 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.1518.Retraction in severe asthma, COPD, or upper airway obstruction19.Unilateral impairment or lagging of respiratory movement suggests disease of the

underlying lung or pleura.

20.Intercostal tenderness over inflamed pleura21.Bruises over a fractured rib22.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 ofthe 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 pleuraleffusion, pneumothorax, neoplasm from decreased transmission of low frequency

sounds; asymmetric increased fremitus in unilateral pneumonia from increased

transmission.15

26.Percussion Notes and Their CharacteristicsRelative

Intensity

Relative

Pitch

Relative

Duration

Example of

Location

Pathologic

Examples

Flatness Soft High Short Thigh Large pleural

effusion

Dullness Medium Medium Medium Liver Lobar pneumonia

Resonance Loud Low Long Healthy lung Simple chronic

bronchitis

Hyperresonance Very loud Lower Longer Usually none COPD,

pneumothorax

Tympany Loud High*

*

Gastric air bubbleor puffed-out

cheek

Largepneumothorax

*Distinguished mainly by its musical timbre.

27.Dullness replaces resonance when fluid or solid tissue replaces air-containing lung oroccupies 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.


3/4

28.Generalized hyperresonance may be heard over the hyperinflated lungs of COPD orasthma, 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 inatelectasis or diaphragmatic paralysis.

30.Sounds from bedclothes, paper gowns, and the chest itself can generate confusion inauscultation. Hair on the chest may cause crackling sounds. Either press harder or wetthe 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 lungdisease or muscular weakness) or when the transmission of sound is poor (as in

pleural effusion, pneumothorax, or COPD).

32.Characteristics of Breath SoundsDuration ofSounds

Intensity of

ExpiratorySound

Pitch of

ExpiratorySound

Locations Where

Heard Normally

Vesicular*

Inspiratory sounds

last longer than

expiratory ones.

Soft Relatively low Over most of both

lungs

BronchovesicularInspiratory and

expiratory sounds

are about equal.

Intermediate Intermediate Often in the 1st and

2nd interspaces

anteriorly and between

the scapulae

Bronchial Expiratory sounds

last longer than

inspiratory ones.

Loud Relatively high Over the manubrium, if

heard at all

Tracheal Inspiratory and

expiratory sounds

are about equal.

Very loud Relatively high Over the trachea in the

neck

*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 fromthose 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, earlycongestive 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, especiallywheezing by self-report or examination, plus history of smoking, age, and decreased

breath sounds. Diagnosis requires pulmonary function tests such as spirometry.


4/4

41.Adventitious or Added Breath Sounds16Crackles (or Rales) Wheezes and Rhonchi

Discontinuous ContinuousIntermittent, 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

brief (5-10 msec)

Wheezes: relatively high-pitched (400 Hz) with

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 becomeairless.

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 chestpain has a musculoskeletal origin.

48.Dullness replaces resonance when fluid or solid tissue replaces air-containing lung oroccupies 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 bedetected 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. Italso lowers the level of diaphragmatic dullness posteriorly.

52.The walk test (Time an 8-foot walk at the patient's normal pace): Nondisabled older adultstaking 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 twiceas likely to have COPD.

54.An increase in the local pain (distant from your hands) suggests rib fracture ratherthan just soft-tissue injury.

Recording the Physical Examinationthe Thorax and Lungs

a. Thorax is symmetric with good expansion. Lungs resonant. Breath soundsvesicular; 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.

the thorax and lungs- bates

Documents