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Position-Dependent Pleural Friction Rub Thomas L Henry Ford Hospital Medical Journal Volume 22 | Number 1 Article 7 3-1974 Position-Dependent Pleural Friction Rub Thomas L. Connolly Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Connolly, Thomas L. (1974) "Position-Dependent Pleural Friction Rub," Henry Ford Hospital Medical Journal : Vol. 22 : No. 1 , 31-34. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol22/iss1/7 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford FHosp. Med. Journal Vol. 22, No. 1, 1974 Position-Dependent Pleural Friction Rub Thomas L. Connolly, MD* JINCE we live in an age in which increas­ ing reliance is paid to ever more refined laboratory and radiological techniques, it may seem anacronistic to describe a sim­ ple method in bedside diagnosis. How­ ever, the detection of pleural inflamma­ tion from whatever cause may initially depend upon the history obtained from the patient and the findings on physical The art of physical examination is often for­ gotten by clinicians in their haste to depend on examination. It is well known that a laboratory tests. This paper described a helpful pleural friction rub, the hallmark of way to diagnose pleurisy in someone who pleuritis, may be heard in the absence of should have it according to the history. Auscul­ laboratory or radiological abnormalities. tation of the chest in the supine and lateral decubitus positions will occasionally facilitate Thus, hearing a pleural friction rub may the detection of a pleural friction rub when be critically important in the diagnosis of conventional examinations may not do so. conditions involving the pleura primarily Two patients are described in whom this or as an extension of lung processes. method was used. Most physicians examine the patient's chest only in the sitting position, or in the sitting and supine positions. Auscultation of the chest in the right and left lateral decubitus positions, with the patient breathing deeply, will occasionally reveal the presence of a pleural friction rub not heard in the sitting or supine positions. This simple technique has been neg­ lected in classic teaching. The claim that a pericardial friction rub •Formerly, Department of Medicine, Henry may be heard only in one position, Ford Hospital. Currently, Division of Infec­ tious Disease of the Department of Medicine, namely, the sitting position, with the pa­ Creighton University School of Medicine, tient leaning forward, is stressed in most Omaha, Nebraska. textbooks of physical diagnosis. Address reprint requests to Dr. Connolly at 527 Medical Arts Building, Omaha, Nebraska It is also emphasized in most treatises 68102. on physical diagnosis that application of 31 Connolly pressure with the diaphragm of the The patient continued to have left-sided stethoscope over the affected area may chest pain after admission, particularly with deep breathing. Two days after admission he facilitate the detection of a pleural fric­ stated that his pain was particularly severe tion rub. However, the fact that a pleural when he lay on his left side. He noted practi­ friction rub may be heard only in the right cally no pain after he shifted from his left side or left lateral decubitus position is not to some other position. Fine rales were occa­ mentioned in the standard works on sionally noted in both bases, but no other ab­ normality was detected. On the fourth hospi­ physical diagnosis,medicine,^^'^^ or tal day, the patient was examined in the sitting, chest disease."'" Cabot" did point out supine and both right and left lateral decubitus that if the patient with pleuritic pain is positions. A prominent pleural friction rub, made to lie on the affected side for a short confirmed by several observers, was heard over the left lateral thorax when he was in the time, a friction rub previously notaudible left lateral decubitus position. The friction rub may be heard when he sits up and could not be heard in other positions despite breathes deeply. However, Cabot did not the fact that increased pressure was applied to mention the value of auscultation of the the patient's chest with the diaphragm of the chest with the patient in the supine or stethoscope. lateral decubitus positions. The patient was given tetracycline. Over the next three days his condition improved, The following two case reports illus­ the pleural friction rub disappeared, and the trate the occasional importance of posi­ pulmonary infiltrate cleared. Cold agglutinin titer, five days after admission, was 1:32, and tion of the patient in the detection of a Eaton Agent complement fixation titer, six pleural friction rub. days after admission, was 1:32. Convalescent sera were not tested. A diagnosis of pneumonitis and pleuritis of unknown cause Case Reports was made. Case 1. A forty-eight-year-old man was ad­ mitted to Henry Ford Hospital on August 14, Case 2. A forty-six-year-old man was admit­ 1966. He complained of sharp and dull pain, ted to Henry Ford Hospital on September 23, not related to respiration, in the left anterior 1966. He had noted generalized myalgia for chest during the preceding 24 hours. The pain seven days. For five days he had noted recur­ occasionally radiated to the neck and to the rent vomiting, adull frontal headache, shaking left arm and hand. Initially, it was associated chills and fever. He complained of having a with shortness of breath and sweating. The cough which produced three to four tea­ patient had not noted chills, fever or cough. spoons of thick, yellow sputum daily, for four days. He had had visual hallucinations for Physical examination revealed a well- three days. nourished man in moderate distress from chest pain. Blood pressure was 140 systolic, Physical examination revealed a well- and 80 diastolic. Temperature and pulse were nourished, well-oriented man in no acute dis­ normal. Respirations were 24 per minute and tress. The blood pressure was 130 systolic and shallow. No significant abnormalities were 90 diastolic. The temperature was 101.8F, the noted on examination of the chest and lungs, pulse 90 per minute and the respirations 24 per and the rest ofthe examination was unremark­ minute. There was moderate inflammation of able. the pharynx. Examination ofthe chest revealed normal expansion. Increased tactile fremitus Urinalysis, complete blood count, urea ni­ and dullness to percussion were detected at trogen and serum glutamic oxalacetic trans­ the left base, posteriorly. Coarse inspiratory aminase (SGOT) and lactic dehydrogenase rales, bronchial breath sounds, and whisper­ (LDH) determinations and electrocardiograms ing pectoriloquy were heard over the same were normal. Sputum cultures revealed nor­ area. A friction rub was confirmed by several mal flora. Smears and cultures of the sputum examiners over the left posterolateral lung for acid fast bacilli were negative. Radiologic base, while the patient was in the supine and films of the chest showed an infiltrate consist­ left lateral decubitus positions. It was absent ing of nodular and linear densities in the right when the patient was in the sitting position, lower lobe, the opposite side from which the despite the application of increased pressure friction rub was later heard. with the diaphragm of the stethoscope over .32 Position-Dependent Pleural Friction Rub the affected area. No other significant abnor­ was in the left lateral decubitus position. malities were noted on physical examination. The mechanism of these findings is not readily apparent. A possible explanation Hemoglobin was 14.5 grams; white cell count was 24,900, with 78% neutrophils. is that when the patient was on his left Sputum cultures revealed normal flora. side, the weight of his lung brought the Radiologic films of the chest revealed a patchy visceral and perietal pleura into closer infiltrate in the left base posteriorly. and more forceful apposition. The pres­ sure exerted externally on the chest wall Following diagnosis of left lower lobe pneumonia with toxic psychosis, the patient in this position might also have brought was treated with cephaloridine, 0.5 gm, in­ the pleural surfaces closer together. tramuscularly, every 12 hours for seven days. He made an uneventful recovery with resolu­ In this position, breathing might cause tion of the pneumonia and prompt disappear­ the inflamed and roughened pleural sur­ ance of his psychotic symptoms. faces to rub together and cause pleuritic pain. Discussion It is suggested that examination of the The first case report is of interest in that chest include auscultation in the supine the patient's pleuritic symptoms corre­ and lateral decubitus positions in all pa­ lated with the physical findings. He noted tients suspected of having pleurisy, but in pain in his left lateral chest with breathing whom conventional examination does when he was in the left lateral decubitus not reveal a pleural friction rub. This sim­ position, and he obtained relief by shift­ ple method will occasionally facilitate the ing to a different position. A pleural fric­ detection of a pleural friction rub which tion rub was heard only when the patient otherwise would not be appreciated. References 1. Adams FD: Physical Diagnosis, ed 14. Bal­ 8. Kraetzer AF: Procedure in Examination of timore, Williams & Wilkins, 1958 the Lungs, ed 3. Revised and with a preface by J Segal. New York, Oxford University 2. Majors RH and Delp MH: Majors Physical Press, 1947 Diagnosis, ed 7. Edited by MH Delp and RT Manning. Philadelphia, Saunders, 1968 9. Guttmann P: Handbook of Physical Diag­ nosis, Comprising Throat, Thorax and Ab­ domen.
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