Mosby's Guide to Physical Examination, 7Th Edition

http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 CHAPTER Chest and Lungs 13

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The chest and lungs allow for respiration. The purpose of ELSEVIERrespiration is to keep the body adequately supplied with oxygen and protected from excess accumulation of carbon dioxide. It involves the movement of air back and forth from the alveoli to the outside environment, gas exchange across the alveolar-pulmonary capillary membranes, and circulatory system transport of oxygen to, and carbon dioxide from,OF the peripheral tissues.

Physical Examination Preview

Here is a preview of the steps involved inCONTENT conducting } Bh\\Tcah physical examination of the chest and lungs. These pro- } DbT ^U PRRTbb^ah \dbR[Tb cedures are explained in detail in this chapter and are 4. Note any audible sounds with respiration (i.e., stridor or available on at http://evolve.elsevier.com/Seidel in fWTTiTb bTT _ }} printable PDFs or downloadable formats for PDA, iPod, or $ ?P[_PcT cWT RWTbc U^a cWT U^[[^fX]V bTT _ }}) smartphone use.The following steps are performed with the } Bh\\Tcah patient sitting. } CW^aPRXR Tg_P]bX^] 1. Inspect the chest; front and back, noting thoracic landmarks, } BT]bPcX^]b bdRW Pb RaT_Xcdb VaPcX]V eXQaPcX^]b U^a cWTPROPERTY U^[[^fX]V bTT _ }}) } CPRcX[T UaT\Xcdb } BXiT P]S bWP_T P]cTa^_^bcTaX^a J0?L SXP\TcTa R^\_PaTS 6. Perform direct or indirect percussion on the chest, compar- fXcW cWT [PcTaP[ SXP\TcTa X]V bXSTb U^a cWT U^[[^fX]V bTT _ }}) } Bh\\Tcah SAMPLE } 3XP_WaPV\PcXR TgRdabX^] } 2^[^a } ?TaRdbbX^] c^]T X]cT]bXch _XcRW SdaPcX^] P]S `dP[Xch } Bd_Ta RXP[ eT]^db _PccTa]b 7. Auscultate the chest with the stethoscope diaphragm, from } ?a^\X]T]RT ^U aXQb P_Tg c^ QPbT* R^\_PaX]V bXSTb U^a cWT U^[[^fX]V bTT _ }}) ! 4eP[dPcT aTb_XaPcX^]b U^a cWT U^[[^fX]V bTT _ }}) } 8]cT]bXch _XcRW SdaPcX^] P]S `dP[Xch ^U QaTPcW b^d]Sb } APcT } D]Tg_TRcTS QaTPcW b^d]Sb RaPRZ[Tb aW^]RWX fWTTiTb } AWhcW\ ^a _PccTa] UaXRcX^] adQb 3. Inspect chest movement with breathing for the following } E^RP[ aTb^]P]RT bTT _ }})

1 ANATOMY AND PHYSIOLOGY view. heart. and lungs the around cage expandable protective a form chest the of structures bony The 13-1 FIGURE 2 Thompson and Wilson, 1996.) Wilson, and Thompson Posterior view. Posterior B, Chest and Lungs and Chest 13 CHAPTER PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 Anterior A, SAMPLE (From diaphragm, the dominant muscle, contracts and moves downward during inspiration, lower- AP the exceeds generally adults. chest in diameter the of diameter lateral The anteriorly. not but posteriorly costal cartilages just above them. Ribs 11 and 12, sometimes referred are to as floating ribs, attach seven upper the vertebrae; the thoracic with join 10 and 9, 8, ribs and cartilages, costal the by the sternum the to anteriorly attached to connected are ribs the All 13-2). and 13-1 (Figs. vertebrae thoracic 12 the of posteriorly, and ribs; of pairs 12 the of laterally, cartilages; the as movement costal and process, xiphoid of manubrium, sternum, the of anteriorly capable consists It expand. lungs muscle and cartilage, bone, of cage a is thorax, or chest, The Acromion Ribs B A lung Ribs Right Left process Scapula lung The primary muscles of respiration are the diaphragm and the intercostal muscles. The muscles. intercostal the and diaphragm the are respiration of muscles primary The Acromion process Clavicle ANATOMY AND PHYSIOLOGY AND ANATOMY Clavicle CONTENTOF ELSEVIER Larynx - Trachea vertebrae Thoracic NOT Manubrium Sternum Scapula lung Right lung Left Xiphoid FINAL supplying blood to the lung parenchyma and stroma. The bronchial vein is formed at the at formed is vein bronchial The stroma. and parenchyma lung the to blood supplying bronchioles. respiratory into ultimately and bronchioles terminal into subdivide to begin then branches The lungs. the of are bronchi main The bodies). foreign lobe one supplying branch each left, the on two and right the on branches three into divided of aspiration to susceptible more therefore (and main left and right 13-1). (Box the joint manubriosternal the below just into and T5 or T4 of divides level the about at trachea bronchi The thyroid. the of isthmus the to The posterior alveoli. the to airway upper the and esophagus the to anterior lies It diameter. in cm 2 about and long cm 11 to from 10 is trachea moves it as warmed and humidified, filtered, heart. the for cradle a providing concave, extent some to are lung the of surfaces medial The diaphragm. the of surface convex the on resting concave, and broad is lung each of base The borders descendondeepinspirationtoaboutT12andriseforcedexpirationT9. of base the into the neck in adults. Posteriorly, the apexes of the rib lungs rise to about the level of T1. The lower first the above cm 4 about anteriorly extends and rounded is apex the chyma isshapedbyanelasticsubpleuraltissuethatlimitsitsexpansion.Eachlungconical; duct connecting with the alveoli (as many as 300 million in an adult). The entire lung paren- the alveolar an and and nerves, lymphatics, vessels, blood axilla of consists lobe Each anteriorly. the rib fourth in rib fifth the of level the at lobes middle and upper the into lung right the of portion upper the divides fissure horizontal lesser a addition, In portions. lower and upper the divides oblique—that fissure—the major a has lung Each lobe. middle right the of counterpart a is which lingula, the projection, tonguelike inferior an has lobe upper left The 13-4). (Fig. two having left the and lobes three having right the symmetric, not but paired are lungs elastic highly and spongy The lungs. the enclose that membranes serous pleurae, visceral and parietal the with lined are cavities pleural The lungs. the except viscera thoracic the of all contains lungs, the between situated mediastinum, The mediastinum. the and ties 13-3). (Fig. compromise pulmonary is there when or exercise during trapezius and sternocleidomastoid used are muscles “accessory” The These movements. respiratory to contribute also expiration. may muscles during intercostals diameter internal the lateral and the inspiration, decrease during intercostal diameter external chest The AP space. the intrathoracic increase the muscles increase to contents abdominal the ing The bronchial arteries branch from the anterior thoracic aorta and the intercostal arteries, bronchus left the than placed vertically more and shorter, wider, is bronchus right The is air which along pathway a provides that system tubular a is tree tracheobronchial The cavi- pleural left and right the spaces: major three into divided is chest the of interior The pleura Parietal pleura Visceral lung Right and vein artery coronary Right http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 PROPERTY bronchus mainstem Right Tr achea SAMPLE Cricoid cartilage Thyroid cartilage vein Hepatic Esophagus

CONTENTOF aorta Abdominal ELSEVIERDiaphragm Arch ofaorta bronchus mainstem Left Pericardium artery andvein Left coronary Left lung recess diaphragmatic Costo-

- Lungs and Chest 13 CHAPTER NOT anatomic structures. anatomic related and cavity Chest 13-2 FIGURE FINAL 3

ANATOMY AND PHYSIOLOGY ANATOMY AND PHYSIOLOGY Wilson and Thompson, 1990.) Thompson, and Wilson lungs. the of lobes The 13-4 FIGURE view. view. Anterior A, ventilation. of Muscles 13-3 FIGURE 4 Chest and Lungs and Chest 13 CHAPTER PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703

SAMPLE Posterior B, (From Right middlelobe Transverse B A Diaphragm Intercostal Right lowerlobe Intercostal muscles thoracis muscles Right bronchi Right upperlobe Scalenus CONTENTOF muscles Right hilum ELSEVIER Cardiac depression Sternocleidomastoid

Trachea - posterior superior Serratus posterior inferior Serratus NOT abdominus Rectus anterior Serratus minor Pectoralis Left hilum Left upperlobe Left lowerlobe

Left bronchi FINAL

oblique fissure Spinous process during the respiratory cycle. respiratory the during T12 or T10 to T3 about from extends which lobe, lower the primarily is view posterior the apices, the for Except Posteriorly c^ PgX[[P cWT Pc aXQ UcW line. midclavicular the at cWT sixth the Ua^\ bcaTcRWX]V bbdaT SXPV^]P[ a by off set UcW is lobe lower the right, cWT the on as left the PQ^dc Pc on sternum; the at bbdaT fourth the about to midaxilla W^aXi^]cP[ the in rib cWT Qh bT_PaPcTS [^QTb middle and upper the primarily is right the on view anterior the triangle, lateral inferior an for Except liver. the of dome the of fullness the of because higher ride may lung right The Anteriorly V 13-1 BOX midclavicular midaxillary line ISUALIZING midaxillary Sixth rib Fifth ribat Fifth rib http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 Horizontal PROPERTY Right line line of T3 fissure

SAMPLE THE orhrb Fourth r L UNGS RLL Right lateral F RUL RLL RML RUL ROM Anterior

RML THE LUL S LLL CONTENT URFACE line midclavicular Sixth ribat fissure Horizontal Fourth rib fissure Right oblique OF

ELSEVIERfissure oblique Left XcP[ XTcSQ W QXd bdTU^ Qd W [TeT[ cWT PQ^dc Ua^\ anteriorly. rib sixth bbdaT the to medially rib third the ^Q[X`dT of cWT Qh QXbTRcTS eXacdP[[h is expanse entire The rib. eighth or seventh the to axilla the of peak the from extending area the underlies lung The Lateral Left cWT X] aXQ UcW cWT ^U anteriorly. more rib sixth the [TeT[ and line midaxillary cWT PQ^dc Pc ST\PaRPcTS is lobe upper The rib. eighth or seventh the to axilla the of peak the from extending area the underlies lung The Lateral Right midclavicular Sixth ribat oblique fissure Left line

- Lungs and Chest 13 CHAPTER LLL

NOTLUL Posterior Left lateral RUL RLL LUL LLL FINAL of T3 process Spinous T12 T10 fissure Oblique T3 5

ANATOMY AND PHYSIOLOGY ANATOMY AND PHYSIOLOGY Wilson, 1996.) Wilson, chest. the of landmarks Topographic 13-6 FIGURE 1990.) Thompson, and Wilson circulation. Pulmonary 13-5 FIGURE 6 (From Thompson and Thompson (From Chest and Lungs and Chest 13 CHAPTER PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 SAMPLE (From 3. The suprasternal notch. A depression, easily palpable and most often visible at the base the at visible often most and palpable easily depression, A notch. suprasternal The 3. the of angulation palpable and visible A Louis). of (angle junction manubriosternal The 2. nipples The 1. 13-6): (Fig. findings describe to used are chest the on markers topographic following The LANDMARKS ANATOMIC by 13-5). (Fig. returned veins pulmonary is the arteries bronchial the by supplied blood the of most but lung, the of hilum inferior pulmonaryveins Nipple sternum Body of Second of the ventral aspect of the neck, just superior to the manubriosternal junction. manubriosternal the to superior just neck, the of aspect ventral the of it. above immediately rib the of that to responds cor- space intercostal each of number The point. this from spaces intercostal and ribs the sternum and the point at which the second rib articulates with the sternum. One can count Clavicle Right superiorand Superior venacava rib Right pulmonaryartery

CONTENT Suprasternal process Xiphoid OF notch ELSEVIER Inferior venacava Aorta - NOT Clavicle Arch ofaorta of Louis) junction (angle Manubriosternal Left pulmonaryartery Manubrium Costal angle inferior pulmonaryveins Left superiorand Pulmonary trunk

Nipple FINAL increase in the lateral diameter of about 2 cm and an increase in the circumference of 5 to 5 of circumference the in increase an and an cm 2 include about flare of diameter ribs lateral the lower in increase the as chest the in occur that changes Anatomic woman. nant preg- the of function respiratory the in changes create to interact progesterone, circulating of level increased an and uterus enlarged the including factors, biochemical and Mechanical movable. more and prominent more often is process xiphoid the and yielding, and cartilaginous more is It adult. the in than prominent diameter. AP the exceeding lateral diameter the with proportions, adult assumes chest the growth, With 13-7). (Fig. old years 2 postnatal about is child the until head for the of that to equal roughly is circumference the and diameter, integrated fully are lungs the and function. configurations, mature their adopt the circulations systemic and and pulmonary The ovale readily.) so close foramen always not do The arteriosus ductus (Reminder: arteriosus. ductus the of closure and contraction within ovale foramen the of stimulates usually blood arterial the in tension oxygen increased the and closure birth, after minutes to leads often most pressure pulmonary in decrease relative This circulation. systemic the than resistance less much offering relax, and expand through the placenta, blood flows through the lungs more vigorously. The pulmonary arteries the lungs fill with air for the first time; this first respiratory effort is great. No longer coursing placenta. the by mediated respiratory is exchange neurologic gas Fetal stimuli. and chemical postnatal to respond to infant term the prepare they Rather, fields. lung the move or alveoli the open not do they gestation; of much throughout lungs The spaces. and tubules of occur movements respiratory structure passive Relatively collapsed. are alveoli the and air, no contain involuted an to sac simple a from ultimately evolves It gut. the of wall ventral the on groove a is lung the gestation, of weeks 4 about At clavicles The 6. with felt and seen readily more be can It C7. of process spinous The prominens. Vertebra 5. the at margins costal the of together blending the by formed angle The angle. Costal 4. PREGNANT WOMEN PREGNANT The relatively thin chest wall of the infant and young child makes the bony structure more lateral the approximating diameter AP the round, generally is newborn the of chest The cut, is cord the After dramatic. and rapid is function respiratory in change the birth At CHILDREN AND INFANTS vertebra. its of number the below rib the overlying thus obliquely, project down T4 from processes spinous the because posteriorly ribs the counting to guide a of as this that use to difficult is is It T1. upper of that is the lower the felt, and C7, of are process spinous prominences two If forward. bent head patient’s the approximately angles. at 45-degree inserted ribs the with degrees, 90 than more no usually is It sternum.

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CONTENTOF ELSEVIER

- Lungs and Chest 13 CHAPTER NOT same as the lateral diameter. lateral the as same the approximately is diameter anteroposterior the that Note infant. healthy of Chest 13-7 FIGURE years. 8 of age the by down ! slows This abc life. of years cWT X] aPcT aP_XS very a at increases alveoli of number The birth. at grown fully not is lung The Development Lung F;7HB 9B?D?97B FINAL 7

ANATOMY AND PHYSIOLOGY REVIEW OF RELATED HISTORY 8 Chest and Lungs and Chest 13 CHAPTER PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 SAMPLE adult to respiratory infection. respiratory to adult themselves of mucus. Retained mucus encourages bacterial growth and predisposes the older volume. residual in increase an and capacity vital in decrease a is changes these of result net The exertion. for tolerance decreased a and fields lung lower the in alveoli the of underventilation in result respiration of muscles the in strength tensile some of loss the and This exchange. gas for available surface alveolar the decreases folds interalveolar the wall. chest the of expansion decreased and stiffening be also may There diameter. chest AP increased an in resulting spine, thoracic the of curve dorsal the emphasize to tend aging of changes skeletal addition, In resiliency. lung of loss the with coupled 13-9), Fig. (see diaphragm and thorax the in strength muscle of loss from results adults older many in seen is that chest barrel The unchanged. remains rate respiratory the is done by the diaphragm. Minute ventilation increases due to increased tidal volume, though breathing of work major the that so increases movement diaphragmatic yet position, resting 103.5 degrees in later pregnancy. The diaphragm at rest rises as much as 4 cm above its usual approximately to degrees 68.5 about from increases progressively angle subcostal The cm. 7 V V ILLNESS PRESENT OF HISTORY for relevant each. are over-the- therapies alternative and and complementary (prescription as well as use preparations) counter medication regarding Questions evaluation. diagnostic topics these about questions appropriate an of to development the and examination Responses physical the focusing for listed. clues provide are illness present the of history the in include to topics targeted section, this in discussed conditions or symptoms the of each For Shortness of breath (Box 13-2) (Box breath of Shortness Coughing gn mcu mmrns ed o eoe re ad le aut ae es be o rid to able less are adults older and drier become to tend membranes mucous Aging of some of loss associated The fibrous. more relatively and elastic less become alveoli The ADULTS OLDER V V V V V V V V V V V V V V Severity: extent of activity limitation, fatigue with breathing, anxiety about getting air getting about anxiety breathing, with fatigue limitation, activity of extent Severity: exhale or inhale to Harder eating day, of time activities, certain exercise, of extent to Related used pillows of number comfortable, most Position Pattern onset before event choking or gagging duration; gradual; or sudden Onset: effectiveness vaporizers; drugs, nonprescription or prescription treat: to Efforts Associated symptoms: shortness of breath, chest pain or tightness with breathing, fever, pain chest causes conversation, or sleep disrupts patient, tires Severity: Pattern: occasional, regular, paroxysmal; related to time of day, weather, activities (e.g., mostly blood-tinged, purulent, mucoid, (clear, color amount, characteristics: Sputum day of times certain at activity, with frequency, duration, production: Sputum pro- bubbling, whooping, barking, hoarse, hacking, wet, moist, dry, cough: of Nature duration gradual; sudden, Onset: coryza, stuffy nose, noisy respirations, hoarseness, gagging, choking, stress choking, gagging, hoarseness, respirations, noisy nose, stuffy coryza, time over change breaths; deep talking, exercise), odor foul blood), nonproductive ductive, REVIEW OF RELATED HISTORY RELATED OF REVIEW CONTENTOF ELSEVIER

- NOT

FINAL V V V V V V V V HISTORY FAMILY V V V V V V HISTORY MEDICAL PAST V Clotting disorders (risk of pulmonary embolism) pulmonary of (risk disorders Clotting Bronchitis Bronchiectasis Malignancy dermatitis atopic asthma, Allergy, Emphysema fibrosis Cystic Tuberculosis against Immunization imaging chest tests, skin fungal and tuberculin tests, function pulmonary allergy, Testing: disorders clotting blood cancer, cardiac, disorders: chronic Other bronchitis, compliance), treatment, (date, tuberculosis diseases: pulmonary Chronic positive bilevel or continuous including devices ventilation-assisting or oxygen of Use pulmo- for hospitalizations surgery, or trauma pharyngotracheal and/or nasal, Thoracic, pain Chest V V V V V V emphysema, bronchiectasis, asthma, cystic fibrosis cystic asthma, bronchiectasis, emphysema, respectively) BiPAP, or (CPAP machines pressure airway dates disorders, nary } } _WhbXRP[ ^U [TeT[ U^[[^fX]V) fWPc cWT FXcW X]R[dST QTVX]. SXU Rd[ch } Shb_]TP aTb_XaPc^ah S^Tb ^U [XUT \P]XUTbcPcX^]b bcPXab. SPX[h >cWTa R[X\QX]V ^U fWT] PRcXeXcXTb aTbc ^cWTa P]S fWPc bc^_ FXcW D_bcPXab. c^ bdaUPRT. ]TRTbbPah [TeT[ } Xc aTbcX]V. P 8b Xb >] _PcXT]c fP[ZX]V. cWT } \dRW fWT] 7^f TeT] _aTbT]c } Xc 8b } dyspnea: produces that effort of kind and amount the establish to important is It condition. underlying the of severity the with increases dyspnea general, In person. well otherwise an in it cause can obesity and lifestyle sedentary A compromise. cardiac or pulmonary with Dyspnea, D 13-2 BOX Other medications: recreational drugs (e.g., cocaine) (e.g., drugs recreational medications: Other medication pain splinting, heat, treat: to Efforts air, getting about anxiety coughing, fever, breathing, shallow symptoms: Associated infection, respiratory lower coughing, trauma, with associated duration; and Onset use oxygen treat: to Efforts respiratory in point specific to (relationship discomfort or pain symptoms: Associated radiation of pain to neck or arms or neck to pain of radiation thrombophlebitis of history anesthesia, recent edema ankle diaphoresis, cough, location), exertion, ESCRIPTORS a—dyspnea increases in the upright posture. upright the in increases Platypnea—dyspnea helpful. is upright sitting sleep; of period a after breath of shortness of onset sudden dyspnea—a nocturnal Paroxysmal helps. that whether and pillow one than more on sleep to needs patient the whether ask down; lies patient the when increases or begins that breath of Orthopnea—shortness ST\P]S.

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SAMPLE OF R ESPIRATION , influenza pneumoniae , Streptococcus

CONTENTOF ELSEVIER

- Lungs and Chest 13 CHAPTER NOT and its environs. its and chest the in possibilities other of circumstances, such in also, importantly, but, heart the of Think cWT X] bXcdPcTS Xb 8c } ]TTS[T TTcX]V P Xb 8c } Qh f^abT \PST Xb 8c aPSXPcT ]^c } S^Tb 8c } R^]bcP]c P Xb CWTaT } when heart the in originate generally not does pain Chest Pain Chest F;7HB 9B?D?97B

the back. the in blades shoulder the between or shoulders two. or second a only lasts that jab like precordium. the on pressing day. all lasts that achiness FINAL 9

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- age day), per smoked packs of Number s NOT

FINAL %%&/+(0,FC +0(/0&, /%/%(&&/ [Zb+&U^f[ )c_$dZ'' ')UcW_d$_dZZ I[_Z[bU+-&)U9^Wfj[h EQUIPMENT chronic asthma, emphysema, or cystic fibrosis. The ribs are more horizontal, the spine is spine the horizontal, more are ribs The fibrosis. cystic or emphysema, asthma, chronic 13-8). (Fig. half as other. the much as by times at diameter, for lateral the than less ordinarily is chest the comparison of diameter AP The a as used be can side one but symmetric, absolutely be not will chest The findings.) record you as use to landmarks thoracic lists 13-3 (Box tissue. overlying of abundance an of free and flat rather usually sternum the superiorly, prominent clavicles the obvious, is framework bony The spaces. intercostal the and ribs, the of angle the angle, you as bed limited, the lower is and raise mobility needed. to hesitate not and Do bed. bed the of in sides both is to access patient have should deformity the of If presence excavatum). the or pectus retractions, minimal or (e.g., pulsations minimal as such detect, to source dif- otherwise ficult light and subtle the more are that that findings so accentuate may patient angles different the at comes Positioning movement. chest highlight to needed is light tangential bright a and warm, comfortably be should stethoscope and neces- room The not sary. is exposure full when patient the cover should drape A barrier. a is kind Clothing any waist. of the to unclothed support, without possible if upright, sit patient the Have INSPECTION V V V V Fg 1-) eut fo cmrmsd eprto a i, o example, for in, as respiration compromised from results 13-9) (Fig. chest Barrel costal the front, the and back the both from chest the of symmetry and shape the Note TcQP P W]Q ^]T ^]U^ Wc_XcX" 5XV _^X]c cWPc Ua^\ S^f] R^d]cTS QT cWT] RP] eTacTQaPT thoracic The palpated. readily is vertebra cervical seventh the of process spinous The 7. 6. 5. 4. 3. " ) 5XV TgP\X]PcX^] _WhbXRP[ 2. ^] ]SX]Vb cWT [^RP[XiT 1. WT[_ fX[[ bdaUPRT cWT on lines imaginary following the chest, the of landmarks anatomic the with conjunction In T 13-3 BOX Drapes stethoscope) smaller a need you infants, (for diaphragm and bell with Stethoscope measure tape and ruler Centimeter pen Marking

PROPERTYHORACIC EXAMINATION AND FINDINGS AND EXAMINATION the scapula when the patient is erect is patient the when scapula the of angle inferior the through line, vertebral the to parallel lines: scapular left and Right processes spinal the down vertically line: Vertebral folds axillary posterior the at beginning line, midsternal the to parallel lines: axillary posterior left and Right midaxilla the at beginning line, midsternal the to parallel lines: midaxillary left and Right folds axillary anterior the at beginning line, midsternal the to parallel lines: axillary anterior left and Right line midclavicular the at rib sixth the cross generally lungs the of borders inferior the midclavicle; at beginning line, midsternal the to parallel lines: midclavicular left and Right sternum the of midline the down vertically line: Midsternal SAMPLE http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 L ANDMARKS

CONTENTOF ELSEVIER

- Lungs and Chest 13 CHAPTER NOT diameter. lateral the than less is diameter anteroposterior the that Note male. adult healthy of Thorax 13-8 FIGURE FINAL 11 %%&/+(0.FC +0(/0&. /%/%(&&/

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Posterior view. Posterior B, cage. Rib 13-11 FIGURE PROPERTY diameter. anteroposterior the in increase Note chest. Barrel 13-9 FIGURE 12 Anterior view. Anterior A, Chest and Lungs and Chest 13 CHAPTER SAMPLE http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 A lobe lower Right lobe middle Right lobe upper Right Thoracic landmarks. Thoracic 13-10 FIGURE A 10 9 11 axillary line anterior Right 8 7 6 5

4 CONTENT 3

2 OF 12 1 lobe lower Left lobe upper Left C , Anterior thorax. Anterior A, line midclavicular Right line Midsternal ELSEVIERprocesses Spinal Trachea Thyroid cartilage Right lateral thorax. lateral Right B, space Intercostal line Vertebral First rib notch Suprasternal lobe lower Left Louis Angle of - lobe upper Left

line Scapular NOT B Posterior thorax. Posterior C, B lobe upper Right line axillary Posterior lobe middle Right Scapula lobe lower Right FINAL T-12 T-10 T- T- T- T- T- T- T- T- T- T- L-2 L-1 11 9 8 7 6 5 4 3 2 1 line Anterior axillary line Midaxillary %%&/+(0*FC +0(/0'* /%/%(&&/ [Zb+&U^f[ )c_$dZ') ')UcW_d$_dZZ I[_Z[bU+-&)U9^Wfj[h neither too shallow nor too deep. Note any variations in respiratory rate. respiratory even, in variations any be Note deep. too should nor shallow too breathing neither of pattern The distress. apparent without and regularly, easily, breathe to patient the Expect symmetric. bilaterally be should chest the of Expansion 13-13). often is rate the to helpful. relative patient the of behavior the Noting exertion. of individual degree the the of and age the including factors, of number a on depends minute) per (breaths respirations of rate normal The states. sleep and waking different the in vary can rates ratory Respi- time. longer a for rate pulse the counting were you if as just pulse, the palpating after rate respiratory the Count rate. the varying from patient the prevent to pulse, the count to going 1 are approximately you is that heartbeats patient to : the respirations tell of not Do 4. Determine the respiratory rate. The rate should be 12 to 20 respirations per minute; the ratio Patterns Respiratory nutrition. general to clue some give ribs the of nence promi- relative and fat underlying The obstruction. vascular or disorders heart of sign a be congenital abnormalities. Look for any superficial venous patterns over the chest, which may other to clue a be may these nipples; supernumerary are there whether Note malodorous. it be clues to respiratory or cardiac disorder. Smell the breath; intrathoracic infection may make 13-12). (Fig. process xiphoid the above sternum lower the of indentation an is which excavatum), (pectus chest funnel and protrusion, sternal nent laterally or (kyphosis) 21-20, Figs. posteriorly (see (scoliosis) either deviated be may spine The sternum. or cage, rib condi- chronic a often most is there present. greater), tion even or equals 1.0 or of approaches ratio diameter (a AP diameter the lateral when the however, age; with increase does It 0.70 0.75. about to be to expected is and ratio” “thoracic the as expressed is relationship may The eter. diam- trachea lateral the The than less prominent. be should more diameter AP the is Ordinarily, displaced. angle posteriorly be sternal the and kyphotic, somewhat least at Note the pattern (or rhythm) of respiration and the way in which the chest moves (Fig. moves chest the which in way the and respiration of rhythm) (or pattern the Note PROPERTYmay These present. is pallor or cyanosis whether noting lips, and nails, skin, the Inspect Two common structural problems are pigeon chest (pectus carinatum), which is a promi- Other changesinchestwallcontourmaybetheresultofstructuralproblemsspine, A SAMPLE http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 and 21-77). and B, Cross section Posterior of thorax Anterior CONTENTOF B ELSEVIER Cross section Posterior of thorax Anterior - Lungs and Chest 13 CHAPTER NOT potbelly, and sunken chest. sunken and potbelly, =^cT RWX[S posture, poor child’s the h^d]V P X] RWTbc 'hTPa^[S (funnel excavatum Pectus B, P] X] RWTbc _XVT^] A, 13-12 FIGURE 1 ][ca[_Rd RPaX]Pcd\ _TRcdb D]X[PcTaP[ FINAL 13 %%&/+(0+FC +0(/0'+ /%/%(&&/ 2

EXAMINATION AND FINDINGS [Zb+&U^f[ )c_$dZ'* ')UcW_d$_dZZ I[_Z[bU+-&)U9^Wfj[h EXAMINATION AND FINDINGS

PROPERTY respiration. of depth relative the indicate lines the of swings vertical The patterns. these of rates relative cWT X]SXRPcTb PgXb W^aXi^]cP[ The respiration. of Patterns 13-13 FIGURE 14 Chest and Lungs and Chest 13 CHAPTER SAMPLE http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 Sighing (hyperpnea) Hyperventilation Tachypnea Bradypnea Normal unless they are quite obvious (Box 13-4). Hyperventilation can be due to breathing rapidly breathing to due be can Hyperventilation 13-4). (Box obvious quite are they unless fitness. cardiorespiratory of level splendid a indicate also may It ena. tion, or a sensible response to protect against the pain of pleurisy or other irritative phenom- infec- disturbance, electrolyte or neurologic indicate may minute, per respirations 12 than pattern. similar a produce and diaphragm the of descent prevent may ascites abdominal or enlargement liver Massive pleurisy. or rib broken a of pain from splinting protective of symptom a often is It observation. your to response self-conscious a as simply or hyperventilation during occur may breathing shallow Rapid, persistent. is rate respiratory the that sure be to check Double adult. an in this above rate respiratory sistent Note any variations in respiratory rhythm. It may be difficult to discern abnormalities discern to difficult be may It rhythm. respiratory in variations any Note per- a is Tachypnea breaths/minute. 20 to 12 is rate respiratory adult resting normal The Xca UUTd] T_aca X]UTRcX^]b aTb_XaPc^ah UaT`dT]c aTPb^] ^U P]h 7Xbc^ah U^a } \dbR[Tb RWTbc aTPb^] FTPZT]TS P]h } U^a bfP[[^fX]V 3XU Rd[ch c^gXR } P]S ^QTbXch XaaXcP]cb 4gcaT\T _d[\^]Pah ^cWTa } ^a Sdbc PbQTbc^b c^ Tg_^bdaT X\\^QX[XiPcX^] >RRd_PcX^]P[ U^aRTS } ^a [XUTbch[T BTST]cPah SXbTPbT } R^]cPVX^db ^cWTa B\^ZX]V P]S cdQTaRd[^bXb } Qa^bXb RhbcXR PbcW\P ^U PVT WXbc^ah PSeP]RX]V fXcW 5P\X[h fXcW SX\X]XbWTb } X]Tg^aPQ[h bTgTb 8]RaTPbTb cWT 0VT) QTcfTT] SXUUTaT]RT } cWT Qdc \T] X] 6aTPcTa 6T]STa) } R R ESPIRATORY inhalants ]Tda^ Qa^\Pc^bXb age advancing ISK

CONTENT F

OF ACTORS deeper breath Frequently interspersed per minute,deepbreathing Faster than20breaths per minute Faster than20breaths per minute Slower than12breaths rate of12-20perminute Regular andcomfortableata D ISABILITY ELSEVIER

: B : ARRIERS

TO C - Ataxic Biot Kussmaul Cheyne-Stokes Air trapping OMPETENT NOT F UNCTION of respiration irregular andvaryingdepths Significant disorganizationwith sequence ofbreaths of apneainadisorganized Irregularly interspersedperiods Rapid, deep,labored depth interspersedwithapnea Varying periodsofincreasing getting breathout Increasing difficulty in a rate slower rate a Bradypnea, FINAL %%&/+(0,FC +0(/0', /%/%(&&/ [Zb+&U^f[ )c_$dZ'+ ')UcW_d$_dZZ I[_Z[bU+-&)U9^Wfj[h with drug-associated respiratory compromise (Box 13-5). (Box compromise respiratory drug-associated with or level cerebral the at damage brain with those particularly ill, seriously are who patients in occurs it otherwise but sleep, during pattern this in breathe may adults older and Children decrescendo sequenceofrespiration,iscalled excursion). limits pain pleuritic when (e.g., acidosis. with metabolic associated effort respiratory the to applied eponym the is rapid, often most and deep disease. metabolic and system nervous central can so but pnea, deeply breathing (tachypnea), A regular periodic pattern of breathing, with intervals of apnea followed by a crescendo/ a by followed apnea of intervals with breathing, of pattern periodic regular A Periodic apnea of of apnea Periodic breathing Apneustic apnea Sleep P_]TP AT Tg unless spontaneously begin not will it and stops Breathing apnea Secondary the to blow a after uncommon not and condition, self-limited A apnea Primary Wh_^_TaUdbX^] ^a disorders. sleep caPd\P bhbcT\ obstructive and ingestions, ]Tae^db drug passageway, respiratory the of infections RT]caP[ of variety a bTXidaTb X]R[dST R^]caXQdc^ab 2^\\^] abnormalities. cardiac and system nervous central of variety a in well, as and, system respiratory the in origin its have may respiration, spontaneous of absence the Apnea, A 13-5 BOX RTaTQad\ [TbX^]b bhbcT\ ]Tae^db Pain 2T]caP[ Wh_^gT\XP ]TTS >ghVT] poisoning Aspirin _^]b Anxiety [TbX^]b bhbcT\ ]Tae^db 2T]caP[ \TcPQ^[XR 0RXS^bXb With Increase will: breathing of depth and rate The I 13-4 BOX NFLUENCES PNEA PROPERTYnewborn the SAMPLE http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703

ON on the other hand, refers to abnormally shallow respirations shallow abnormally to refers hand, other the on Hypopnea,

THE ^\[R]XX]RPPcaiSQ ]XaV[a_cT]^ aP_XS ^U _PccTa] XaaTVd[Pa P] Qh RWPaPRcTaXiTS R^]SXcX^] ]^a\P[ 0 c^ P\^d]cb fWPc P]S X]b_XaPcX^] [^]V P Qh 2WPaPRcTaXiTS P]S QaTPcWX]V ^U PQbT]RT P] ^U _TaX^Sb Qh 2WPaPRcTaXiTS inhaled, are gases or vapors nausea-provoking and irritating When R usually associates with rapid eye movement sleep. movement eye rapid with associates usually one that apnea of periods brief with interspersed breathing constrained. expiration and prolonged are inspirations because gasping become can breathing affected, is it When pons. the in is control for center neural The apnea. expiration ]^c Xb PXa ^f mouth. and nose ^QbcadRcX^] the through maintained FXcW b[TT_ SdaX]V ^ghVT]PcX^] respiration. to halt temporary involuntary, an be can there apnea. secondary to lead will bloodstream the into oxygen of absorption the limits severely that event Any instituted. immediately are measures resuscitative bdU RXT]c fWT] circulation. the in b_^]cP]T^db[h accumulates dioxide carbon QaTPcWT fX[[ fW^ ]TfQ^a] a of birth the after immediately noted especially is It head. ATE or both. Exercise and anxiety can cause hyper- cause can anxiety and Exercise both. or (hyperpnea),

AND D EPTH periodic breathing Qbc TgcaT\T >QTbXch overdoses Narcotic gravis Myasthenia \TcPQ^[XR 0[ZP[^bXb CONTENT With Decrease

OF OF B ELSEVIER REATHING orCheyne-Stokesrespiration. always breathing, Kussmaul

- Lungs and Chest 13 CHAPTER NOT

FINAL 15 %%&/+(0-FC +0(/0'- /%/%(&&/

EXAMINATION AND FINDINGS EXAMINATION AND FINDINGS 16 also be congenital. be also \Ph Xc SXbTPbT bXV]X RP]c suggests it Although painless. and symmetric usually is Clubbing Clubbing F;7HB 9B?D?97B Chest and Lungs and Chest 13 CHAPTER PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 SAMPLE Looking for Clues at the Periphery the at Clues for Looking depressions, masses, and unusual movement. Expect bilateral symmetry and some elasticity some and symmetry bilateral Expect movement. unusual and masses, depressions, bulges, tenderness, of areas pulsations, for feeling skeleton, and muscles thoracic the Palpate PALPATION hunger. air of sign a is inspiration during nasi alae the of Flaring fibrosis. cystic or disease, heart congenital of cyanosis the cancer, lung emphysema, lung, the within terminal the changes fibrotic chronic of with example, for associated, is toes enlargement and/or fingers the of phalanges Clubbing, dyspnea. of effort the reduces it that taught being Pursing of the lips is an accompaniment of increased expiratory effort. Patients learn without difficulty. cardiac or pulmonary suggests clues peripheral these of Any flaring. for nasi alae the and clubbing, for fingers the pursing, for lips the cyanosis, for nails and lips the Observe of the medulla. It may be referred to as to referred be may It medulla. the of pressure, respiratory compromise resulting from drug poisoning, or brain damage at the level pattern. Biot respiration usually is associated with severe and persistent increased intracranial irregular an in occur may periods apneic the but regular, be may respirations the On occasion, respiration. periodic of pattern repetitive the lacking but apnea, of intervals by rupted chest barrel a to lead can This inflate. this as compensate; to order happens, the in effort becomes more shallow, the amount increases of trapped air increases, and respiration the lungs of rate The effort. expiratory ficient out. getting and resistance the overcoming respiration. normal in occur also Sighs is associated with emotional distress or an incipient episode of more severe hyperventilation. Retraction of the lower chest occurs with asthma and bronchiolitis. and asthma with occurs chest lower the of Retraction involved. not is notch suprasternal the but retraction, unilateral causes placement) vertical airway upper of event the in sleep, during obstruction. or disease; airway obstructive diaphragm; functioning poorly weakened, a by abdomen the to transmitted is pressure intrathoracic tive nega- when develops This occurs. opposite the expiration, on and in, drawn is thorax lower With stridor. by characterized is breathing ment), involve- laryngeal or tracheal with (e.g., tree respiratory the in high is obstruction the When 13-6). (Box obstruction of level and extent the on depend retraction of level and degree The age. Any significant obstruction makes the retraction observable with each inspiratory effort. block- overcome to effort an in back” “pulls musculature the negative, increasingly becomes pressure intrapleural As tract. respiratory the in point any at inspiration to obstruction suggests an This margins. costal lowest the at and clavicles, the above notch, suprasternal the the happens, this degrees. 90 When beyond widens angle heart. costal enlarged or aneurysm, tumor, a by compression of action valvelike the or obstruction outflow by caused probably are expiration on bulging and tion expira- prolonged A obstruction. respiratory to interspaces and ribs the of reaction a be can bulging bilateral or Unilateral mass. a or fluid, air, extrapleural by expansion of limitation or be associated with unequal expansion and respiratory compromise caused by a collapsed lung can asymmetry Chest muscles. accessory of use apparent without symmetric, be should sion Expan- deformities. possible and movement wall chest delineate help and inspection aid will illumination of angles different Again, respiration. during movement wall chest the Inspect Respiration Observing consists of somewhat irregular respirations varying in depth and inter- and depth in varying respirations irregular somewhat of consists respiration Biot difficulty has air inspired reason, any for obstructed seriously is tree pulmonary the If pattern respiratory regular otherwise an punctuates that sigh audible deep, occasional An A foreign body in a bronchus (usually the right because of its larger diameter and more and diameter larger its of because right the (usually bronchus a in body foreign A at ribs, the between sternum, the at in cave to seems wall chest the when are Retractions

CONTENTOF ELSEVIER in its more extreme expression. extreme more its in ataxic - inef- but prolonged a of result the is trapping Air

on inspiration the inspiration on breathing, paradoxic NOT

FINAL addition, the scapulae obscure fremitus. obscure scapulae the addition, In wall. chest the of thickness and structure the and voice the of pitch and intensity the on costal spaceatthelevelof bifurcationofthebronchi.Thereisgreatvariabilitydepending inter- second the at parasternally felt best is Fremitus verbalizations. other or speech from bit. a together come even may hands your and further expand cannot it that inflated so is chest The this. demonstrate not may disease a suggests thumbs pulmonary obstructive chronic with patient the barrel-chested A sides. both of or one on problem movement the in symmetry of loss A breathing. deep and quiet during diverge thumbs your Watch 13-14). (Fig. surfaces posterolateral the with contact in lightly palms your with rib, tenth the of level the at processes spinal the along thumbs your leather. on rubbing leather of feel the as it of Think surfaces. pleural the of inflammation by caused attention. requires always Crepitus reaction. allergic an mimicking swelling associated the with face and arms the involving potentially area wider a cover or neck) the of over base and notch (e.g., suprasternal the localized be may It organism. gas-producing a with infection by or system tory respira- the in somewhere rupture a from tissue subcutaneous the in air indicates It feeling. rigid. spine thoracic the and inflexible relatively be should xiphoid and sternum the but cage, rib the of Note the quality of the of quality the Note place and patient the behind stand respiration, during expansion thoracic evaluate To a suggests inspiration, on usually vibration, grating coarse, palpable, A Crepitus, acracklyorcrinklysensation,canbebothpalpatedandheard—agentle,bubbly W]cT^baRX]X T^ W V[^ccXb) cWT QT[^f Xb ^QbcadRcX^] cWT FWT] } V[^ccXb) cWT PQ^eT Xb ^QbcadRcX^] cWT FWT] } fWT]) b^ BTeTaT[h } Xb) cWTaT FWT] } of evaluation complete a to essential is airway upper the of patency the Determining I 13-6 BOX S

^XX]] UcTWP b]cPUPRc^a P ]^c Xb WTPS cWT ^U ?^bXcX^]X]V QPaZX]V WPabW } Xb 2^dVW PUUTRcTS ]^c } Xb BfP[[^fX]V W^PabT aPb_X]V Xb \^aT } e^XRT [^dSTa CWT QT c^ } cT]Sb BcaXS^a } TV PXafPh cWT _aTbTaeT c^ _^bXcX^]TS PfZfPaS[h QT \Ph ]TRZ P]S WTPS UPRc^a CWT P ]^c } Xb 2^dVW SXU Rd[c \^aT } Xb BfP[[^fX]V \dU TS Xb } e^XRT `dXTcTa CWT QT c^ } cT]Sb BcaXS^a ^ghVT] bd__[T\T]cP[ } fXcW b_PRTb TeT] X]cTaR^bcP[ ^QeX^db P]S Xb bdQR^bcP[ 2hP]^bXb cWT X]e^[eT } P[b^ ATcaPRcX^]b QPaZX]V } Xb Tg_XaPc^ah 2^dVW P]S X]b_XaPc^ah } Xb BcaXS^a } ]^cRW bd_aPbcTa]P[ cWT Pc ]PbX ATcaPRcX^]  P[PT !) cWT cWP] } ^U \^aT Rah 5[PaX]V ^U ^a aPcX^ R^dVW } W^PabT 8)4 0 P] fXcW } bcaXS^a 8]b_XaPc^ah } ^QbcadRcTS. PXafPh d__Ta cWT Xb FWT] bcPcdb _d[\^]Pah THE PQbRTbb peritonsillar with side affected the to head abscess; retropharyngeal with extended http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 PROPERTY A SAMPLE IRWAY P ATENT the palpable vibration of the chest wall that results that wall chest the of vibration palpable the fremitus, tactile

OR O BSTRUCTED CONTENTOF ? ELSEVIER pleural friction rub friction pleural

- Lungs and Chest 13 CHAPTER NOT

FINAL 17

EXAMINATION AND FINDINGS EXAMINATION AND FINDINGS are at the level of the tenth rib. tenth the of level the at are thumbs The expansion. thoracic Palpating 13-14 FIGURE 18 Chest and Lungs and Chest 13 CHAPTER PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 SAMPLE barely noticeable deviation to the right is not unusual. not is right the to deviation noticeable barely slight, A 13-16). (Fig. simultaneously thumbs both with palpating by determined be also can This notch. suprasternal the above directly midline the both in be on should trachea equal the and be sides, should spaces These muscles. sternocleidomastoid the of borders the inner to above spaces the in and clavicle each of edges upper the along side, to side gently, it move and notch suprasternal the in finger index an Place trachea. the of position the Note Trachea the Examining processes. infectious and inflammatory some and consolidations lung some with occurs expected than fremitus tremulous more Gentle, tumor. or lung, compressed secretions, bronchial structive nonob- but heavy consolidation, lung by caused be may and lungs the within mass solid a or fluids of presence the in occurs feel, in rougher or coarser often fremitus, Increased tion. emphysema, pleural thickening or effusion, massive pulmonary edema, or bronchial obstruc- comparisons. make to forth and back it moving hand; to dominant their prefer use examiners Some 13-15). (Fig. side left to side right carefully: area each patient, palpating the about Move sides. two the between alternating quickly hand, one use or cally; establishing evencontact.Forcomparison,palpatebothsidessimultaneouslyandsymmetri- touch, light firm, a Use hand. the of aspects ulnar the with or fingers the of surfaces palmar the with chest the palpate systematically you while age) the on perhaps depending Mouse,” Decreased or absent fremitus may be caused by excess air in the lungs or may indicate may or lungs the in air excess by caused be may fremitus absent or Decreased Ask the patient to recite a few numbers or say a few words (“99” is a favorite, as is “Mickey From Wong, 2009. Wong, From cWT \PZTb _TaRdbbX^] RWTbc less. effusion pleural c^ makes fremitus vocal tactile reduced of 3d[[]Tbb absence the low, is effusion TUUdbX^] _[TdaP[ pleural of probability pretest U^a the When likely. more effusion pleural ]SX]Vb a of probability dbTUd[ \^bc cWT PaT fremitus tactile and percussion to dullness studies, of number a of review the on Based I E S VIDENCE T HERE With ulnar aspect. ulnar With B, fremitus. tactile evaluating for methods Two 13-15 FIGURE

A

CONTENT A -B

OF P ASED LEURAL P

ELSEVIERE RACTICE FFUSION

IN ? P - HYSICAL NOT With palmar surface of both hands. both of surface palmar With A, E B XAMINATION FINAL the abdomen. the over percussion with associated usually sound effusion, the pleural is Tympany atelectasis, asthma. or pneumonia, pneumothorax, suggests flatness or Dullness asthma. or thorax, pneumo- emphysema, indicate may hyperinflation with associated Hyperresonance lungs. the of areas all over heard be usually can sound, expected the Resonance, consistently. it use and you for comfortable most one the Adopt follow. may you that many of one is sequence This 13-19). and 13-18 (Figs. lateral to medial and inferior to superior from systematically rior chest. For all positions, percuss at 4- to 5-cm intervals over the intercostal spaces, moving ante- and lateral the percuss you while overhead arms the raise to patient the ask the Then lung. of more exposing laterally, scapulae the moves This front. in folded arms and forward sequence servesasonemodel.First,examinethebackwith thepatientsittingwithheadbent finger. your on bang not do but wrist the from consistently and sharply Tap dullness. to resonance from area transitional a miss to are you likely more the use, you stroke the heavier the that Remember 3. Chapter in described as sum- indirectly, or directly percuss and can You 13-1. Table 3 and 13-17 Figure in Chapter marized in described are elsewhere, as chest, the over heard tones Percussion PERCUSSION “tug.” a called is respiration with midline of out pull palpable A forward. pushed be may trachea the mediastinitis, with posteriorly; it push may tumors mediastinal Anterior side. the affected to deviates trachea the where lung collapsed a simply or side affected the from away is deviation the where pneumothorax; tension a is there whether on depending way either go cause the trachea to deviate away from the affected side. Pneumothorax can make the trachea may effusion pleural or enlargement Thyroid lung. affected the toward trachea the pulls thy) adenopa- or tumor to due as such atelectasis or fibrosis (from loss Volume pulsate. to seem Resonant Tone of Type Flat Dull Tympanic Hyperresonant* *Hyperresonance isanabnormalsound,theresultofairtrapping(e.g.,inobstructivelungdisease). See Chapter3fordefinitionsandamorecompletediscussionofthesetones. opr al ra bltrly uig n sd a a oto fr h ohr Te following The other. the for control a as side one using bilaterally, areas all Compare occasion, on may, and chest the within problems of because deviated be may trachea The Chest the Over Heard Tones Percussion 13-1 TABLE

PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 SAMPLE nest Pitch Intensity Loud Soft Medium Medium to high Medium Dull thud Dull Medium high to Medium Medium Loud Th[d Th[^f ETah [^dS ETah Low High High CONTENTOF ELSEVIER Long uainQuality Duration Short eimDrumlike Medium ogrBooming Longer Chest and Lungs and Chest 13 CHAPTER Hollow - Sd[[ ETah NOT position of the trachea. the of position midline evaluate to Palpating 13-16 FIGURE possibility of such a mass. a such of possibility the to clue a is action that compression— the relieve to attempt an in forward lean and up sit may patient the Instinctively, breathing. SXU Rd[ch \^aT fXcW bcaXS^a of sound harsh the develop may Patients respiration. compromise and trachea the compress may mass mediastinal anterior An Mass Mediastinal a to Clue F;7HB 9B?D?97B patient to do this for you. for this do to patient the ask to or gently breast the move to necessary, when permissible, is It breasts. the by obscured be may chest woman’s a of examination The Chest Woman’s A F;7HB 9B?D?97B FINAL jbYW_ ed Wj[b[YjWi_i ed Wd_cWj_ed Wd 7YY[ii Video/Animation 19

EXAMINATION AND FINDINGS EXAMINATION AND FINDINGS percussion. bc ^U Pb_TRc d[]Pa using percussion Direct A, 13-18 FIGURE view. Posterior B, chest. throughout tones Percussion 13-17 FIGURE 20 Anterior view. Anterior A, Chest and Lungs and Chest 13 CHAPTER PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703

Indirect B, SAMPLE B A A

CONTENTOF ELSEVIER

B - muscles andbones Flat overheavy

NOT spinous process Flat over heavy muscles scapula and Flat over flatness Vi tympany Stomach dullness Cardiac Resonance dullness Liver sceral FINAL V V V V V V liver. the of bulk the over sits it because left the on than right the on higher usually is diaphragm The rib). fractured (e.g., pain superficial or tumor), logic processes: pulmonary (e.g., as a result of emphysema), abdominal (e.g., massive ascites, patho- of types several by limited be may descent Its excursion. diaphragmatic the Measure Excursion Diaphragmatic C A percussing directly with the other and estimating the distance. the estimating and other the with directly percussing esr ad eod h dsac i cniees ewe te ak o ec sd. The side. each on marks the between centimeters in distance the record and Measure reso- to dullness from change the at mark a make and point marked the from up Percuss hold to then and possible, as much as exhale to breaths, several take to patient the Ask and breathe, to patient the Allow line. scapular the at pencil skin a with point the Mark a by marked point the border, lower the locate you until line scapular the along Percuss it. hold and breath deep a take to patient the Ask The following steps suggest one approach to measuring the diaphragmatic excursion: diaphragmatic the measuring to approach one suggest steps following The lentvl, o mgt s srp o tp, r s oe ad s sainr landmark, stationary a as hand one use or tape, of strips use might you Alternatively, 13-20). (Fig. cm 6 or 5 to 3 usually is distance excursion side. other the on Repeat breathing. start to patient the Remind nance. 13-7). (Box side. other the on procedure the repeat then dullness. to resonance from note in change http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 PROPERTY 13 12 16

SAMPLE 17 8 1 9 4 5 3 6 2 10 7 D

CONTENTOF 26 23 22 B ELSEVIER19 20 21 14 18 24 11 25 15

- Lungs and Chest 13 CHAPTER NOT ^bQT cX TTRP ^QT c^ systematic. QT]T RXP[ Xb 8c _^bbXQ[T PaT bT`dT]RTb ^cWTa W^fTeTa bdVVTbcTS* bT`dT]RT ]d\TaXR cWT the in moved is stethoscope ^a ]VTa _[TgX\TcTa CWT thorax. thorax. lateral thorax. Posterior A, thorax. the of auscultation and percussion systematic U^a bT`dT]RT BdVVTbcTS 13-19 FIGURE FINAL Anterior thorax. Anterior D, Left lateral Left C, Right B, 21

EXAMINATION AND FINDINGS [Zb+&U^f[ )c_$dZ(( ')UcW_d$_dZZ I[_Z[bU+-&)U9^Wfj[h EXAMINATION AND FINDINGS

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CONTENT A

OF is It rhonchus. of form a as of thought sometimes is wheeze) (sibilant wheeze A occurs outside the respiratory tree. It has a dry, crackly, dry, a has It tree. respiratory the outside occurs rub friction ELSEVIER Crackles with a dry quality, more crisp than crisp more quality, dry a with Crackles sonorous. - NOT When pectoriloquy). (whispered FINAL If bronchophony. the sibilant; ’s become e’s %%&/+(0(FC +0(/0*( /%/%(&&/ [Zb+&U^f[ )c_$dZ(- ')UcW_d$_dZZ I[_Z[bU+-&)U9^Wfj[h infrequent cough may result from allergens or environmental insults. environmental or allergens from result may cough infrequent re a b a uo) r ore f t s asd y ru. etsi poue a inspiratory an produces adults. and children Pertussis older in croup. coughing of paroxysm by a of end caused the at whoop is it if hoarse or tumor) a by (as tree low-pitched. causes (e.g., cardiac problems, allergies), which may be indicated by the quality of its sound. its of quality the by indicated be may which allergies), problems, cardiac (e.g., causes of variety a have can cough non-productive or dry A production. sputum by accompanied Quality. Influences. Postural Loudness. and Pitch Regularity. Occurrence. of Frequency Onset. Moist. or Dry it. ignore not do cause, serious a have not may cough a Although cause. the to clue some offer may cough of type The circumstances. and quality state. anxiety an to clue a be also may They tree. respiratory the compressing sort any of mass a or agent, infectious an larger), or tary, but they are usually reflexive responses to an irritant such as a foreign body (microscopic volun- be may Coughs tract. respiratory the in point any at insults general more or localized chest, to related be may causes The exhaled. are the secretions and Air glottis. the of opening sudden a of contraction forcing expiration, and spasmodic sudden, a glottis then and the muscles, pelvic the of even and abdominal, closure by followed is this inspiration; deep a by preceded usually are They problem. respiratory a of symptom common a are Coughs Coughs emphysema). of chest barrel the with (e.g., tree respiratory the within tissue of loss is there when intensity loses and ishes dimin- resonance vocal Conversely, tissue. lung consolidates that condition any in present broad stuffy foreign body or irritant, or a tumor within or compressing the bronchial tree). bronchial the compressing or within tumor a or irritant, or body foreign inspired an failure, heart congestive early smoking, (e.g., causes of variety a have may cough an erect position (e.g., with a nasal drip or pooling of secretions in the upper airway). upper the in secretions of pooling or drip nasal a with (e.g., position erect an a foreign body or inhaled irritants are additional possible causes. possible additional are irritants inhaled or body foreign a See Box 13-9 for a summary of expected findings of a healthy chest and lungs. and chest healthy a of findings expected of summary a for 13-9 Box See ecie cuh codn t is osue feuny rglrt, ic ad loudness, and pitch regularity, frequency, moisture, its to according cough a Describe From Rennard, 2004. Rennard, From ^da Xb 8c RXVPaTccT P fXcW regard. this Tg_TaX\T]c abc in education patient to attention cWT our in persistent be to providers Xb care as responsibility PS^[TbRT]RT Xb P]S UPRc^a RWX[SW^^S aXbZ [PcT \PY^a during CWT health pulmonary of preservation the to ! !  risk major A cigarette. a tasting Qh never f^abT yet, better or, smoking VTc of cessation the is prevention to [XZT[h key vital the smoked, never fX[[ have cWXb disease the from die who P]S people of 20% as many as BcPcTb Although smoking. cigarette D]XcTS cWT X] STPcW of cause leading fourth the moment, the at is, disease pulmonary obstructive Chronic N S EVER PROPERTY TAYING An acute onset, particularly with fever, suggests infection; in the absence of fever, of absence the in infection; suggests fever, with particularly onset, acute An S http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 A dry cough may sound brassy if it is caused by compression of the respiratory the of compression by caused is it if brassy sound may cough dry A MOKE s, h adtr qaiy s called is quality auditory the a’s), W

SAMPLEoccurring irregularly An pertussis. in heard is cough paroxysmal regular, A /S ELL TOP mit r rdcie og my e asd y neto ad a be can and infection by caused be may cough productive or moist A S MOKING A cough may occur soon after a person has reclined or assumed or reclined has person a after soon occur may cough A A cough may be loud and high-pitched or quiet and relatively and quiet or high-pitched and loud be may cough A Note whether the cough is seldom or often present. An present. often or seldom is cough the whether Note CONTENT

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- Lungs and Chest 13 CHAPTER NOT

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EXAMINATION AND FINDINGS EXAMINATION AND FINDINGS 28 Chest and Lungs and Chest 13 CHAPTER PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 SAMPLE [cX*PSfTi]\R ^T ]cTabXP^hcaTT aTb_XaPc^ah cWT X] [^fTa \dRW fWTTiX]V P]S V[^ccXb* the of area the in stridor, nasopharynx; the in arise to tend gurgling and Snoring noise. of type the determine will breathing noisy to stimulus the of location and nature exact The S D ;h\_WPST]^_PcWh cd\^ab ^U } ePaXTch Q^Sh 0 U^aTXV] ^a } Rhbcb 4b^_WPVTP[ } Airway) the of Outside (From Compression TST\P 0]VX^]Tda^cXR } AWX]XcXb Level Every (at Abnormality Acquired } 0bcW\P } Allergens and Irritants Ra^d_ EXaP[ } 1a^]RWX^[XcXb } 1a^]RWXcXb } CaPRWTXcXb } ;Pah]VXcXb } 4_XV[^ccXcXb } PQbRTbb ATca^_WPah]VTP[ } PQbRTbb ?TaXc^]bX[[Pa } Infection W ]PdbRd[cPcX^] >] } _TaRdbbX^] >] } _P[_PcX^] >] } X]b_TRcX^] >] } found: be will characteristics following the mobile, and structured appropriately and symmetrically wall chest the and disease, by unaffected pleurae the clear, tree respiratory the healthy, are lungs the When S 13-9 BOX OME UMMARY IFFERENTIAL HEEZING TXdP aPWbdSTR_ ^ a]WebR[abdS TXTcTbcTa]d\ cWT QTbXST b^d]Sb Qa^]RW^eTbXRd[Pa U^a TgRT_c b^d]Sb QaTPcW ETbXRd[Pa b^d]Sb PSeT]cXcX^db } ^U 0QbT]RT SXP_WaPV\ ^U } STbRT]c ]^cTb cWT _TaRdbbX^] X] bh\\TcaXR R\ P]S $ ATb^]P]c c^ " } ^U AP]VT } UaT\Xcdb cPRcX[T d]PRRT]cdPcTS cdV Bh\\TcaXR P fXcW^dc } caPRWTP

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SAMPLE D OF S IAGNOSIS PUTUM Blue or pale Body pink, extremities blue Completely pink Completely blue extremities pink, Body pale or Blue response No Limp Absent 0 Possible Sputum Characteristics Sputum Possible RPX][[aTP^]b^ Q[^^S ^U P\^d]cb [PaVT >RRPbX^]P[ blood of amounts large clotted; Blood streaking blood intermittent persistent, Slight, R^\\^] ]^c bcaTPZTS Q[^^S eXbRXS* R[TPa eTa QTPcb\X] QT[^f B[^f 1 CONTENTOF ELSEVIER ^V ab]TTiT ^a 2^dVW Active motion Active ^SRahX]V 6^^S 2

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CONTENTOF ELSEVIER

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FINAL 31

EXAMINATION AND FINDINGS EXAMINATION AND FINDINGS 32 Chest and Lungs and Chest 13 CHAPTER PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 SAMPLE symptoms. other of absence or presence the of context the in evaluated be must finding This lungs. the and pace the Adapt well. when even needs. individual quickly to examination of demands more tire may they and patients, younger diameter. lateral the to relation in increased is chest the of diameter AP The 13-25). (Fig. curve lumbar the of flattening with (kyphosis) prominent is spine thoracic the of curve dorsal marked, The tissue. subcutaneous of loss are is there and prominences Bony muscles. accessory of use requiring expansion, chest with physical disability, or a sedentary lifestyle. Calcification of rib articulations may also interfere general weakness, muscle of because muscles respiratory the use to able less be may patient The decreased. often is expansion Chest findings. expected some in variations be may there although adults, younger for that as same the is adults older for procedure examination The frequency. equal about have a varied course, getting worse, getting better, or being unaffected by the pregnancy with pregnant the Overall, woman changes. increases her ventilation by breathing more deeply, not physiologic more frequently. Asthma can normal of result a usually is and pregnancy in common is Dyspnea changes. ventilatory and structural both experience women Pregnant chest. the throughout heard be may sounds breath Bronchovesicular adult. the of those than bronchial more and harsher, less. move crying they because a areas resonant with than resistance times more having at as sensed handy are areas in dull The comes child. that sense tactile a areas, dull the feel to learn can finger pleximeter your percussion with Also, adult. or adolescent the in dullness frank give underlying an of dullness the miss would you as importance much as it give resonance, of to loss some sense you If consolidation. easy is it percussion, indirect or direct either With child. young the in common is hyperresonance and hear, to easier are sounds intrathoracic child the when hallway. sounds the down and breath up running the after deeply more hear breathes to easier also is It sounds. expiratory end to-hear flashlight ortoblowawayabitoftissueinyourhandmayhelpbringoutotherwisedifficult- your out” “blow to them Asking wheezing. subtle suspect you when particularly you, satisfy sound. breath a from murmur a distinguish to chance the giving held, is breath the as prolonged bit a be may pauses These heard. be may sounds use the whole hand, palm and fingers. The crying child may pause occasionally, and the heart The sobitselfallowstheevaluationofvocalresonanceandfeelfortactilefremitus;gently cystic as ominous. be such can years 6 or problem 5 of age the at pulmonary chest barrel a of obstructive persistence The fibrosis. chronic a of possibility the about cerned years 17 years 10 years 6 Minute per Respirations years 3 year 1 Newborn Age Some older patients may display hyperresonance as a result of increased distensibility of distensibility increased of result a as hyperresonance display may patients older Some than breath their holding and deeply breathing difficulty more have may patients Older ADULTS OLDER WOMEN PREGNANT louder, sound may child young the of sounds breath the wall, chest thin the of Because the chest; adult’s the than resonant more ordinarily and thinner is chest child’s The to expiration an of enough give to able be not may years 6 or 5 than younger Children Seize the opportunity that a crying child presents. A sob is often followed by a deep breath. con- be life, of year second the past persists chest child’s young the of roundness the If

CONTENTOF

ELSEVIER 20 to 12 20 to 16 22 to 16 30 to 20 40 to 20 80 to 30

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FINAL Physical findings associated with many common conditions are listed in Table 13-4. Table in listed are conditions common many with associated findings Physical

dR[PX] aR[bfa Ta ] X ^ [P XWRdW aPWbdS XXXWS TP]T U[] TS [P P]S R[TPa T[Sb [d]V ^U ^] AT\PX]STa Sd[[* SX\X]XbWTS ]^cT b^d]Sb ^eTa 26. Chapter _TaRdbbX^] see documentation, QaTPcW sample additional cT]STa]Tbb For X]RaTPbTS* R^dVW* ^a UaT\Xcdb fXcW adQb cPRcX[T R[TPa UaXRcX^] _^bcTaX^a[h ]^c ]^ bilaterally. cm QPbT 3 excursion Diaphragmatic SXS tones. cdV* percussion resonant [TUc with sounds, adventitious P]S of fXcW^dc free cWT WTPaS \XS[X]T >eTa fTaT X] _a^\X]T]RTb RaPRZ[Tb caPRWTP Q^]h PdbRd[cPcX^] _P[_PcX^] ^cWTa >] ^a bcaXS^a aXQb ^a cWT aTcaPRcX^]b Qh PRR^\_P]XTS ]^c 110/72 Pressure Blood C, 38.2° Temperature 24, rate Respiratory 98, Pulse OBJECTIVE relief. without syrup cough nonprescription a Taking F. 101° to up Fever breath. of short Feels “heavy.” feels fever and Cough concern: Chief SUBJECTIVE H Documentation Sample ISTORY Chest, without kyphosis or other distortion. Thoracic expansion symmetric. Respirations rapid and somewhat labored, somewhat and rapid Respirations symmetric. expansion Thoracic distortion. other or kyphosis without Chest, Chest ill. Feels down. lies when worse Persistent, days. several past for cough Nonproductive illness: present of History

PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703

SAMPLE AND P HYSICAL E XAMINATION A ABNORMALITIES CONTENTOF ELSEVIER B

- Lungs and Chest 13 CHAPTER NOT B, adult. older in curvature dorsal Pronounced 13-25 FIGURE FINAL Zh_W^bXb TgcaT\T 6XQQdb Kyphosis. A, 33

ABNORMALITIES [Zb+&U^f[ )c_$dZ)* ')UcW_d$_dZZ I[_Z[bU+-&)U9^Wfj[h ABNORMALITIES 34 *Physical findingswillvaryinintensity dependingontheseverityofunderlyingproblemandoccasion maynotbepresentintheearlystages. Tachycardia Pneumothorax Pneumonia effusion Pleural Tachypnea Emphysema Chronic Bronchitis Tachypnea Bronchiectasis diminished and/or Delayed Atelectasis Tachypnea Inspection Asthma Condition consolidation thickening or and/ disease pulmonary obstructive PROPERTY Conditions* Respiratory Common With Associated Findings Physical 13-4 TABLE Chest and Lungs and Chest 13 CHAPTER SAMPLE http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 Tracheal deviation with deviation Tracheal affected on lag Respiratory spaces intercostal Bulging distress Respiratory Cyanosis times at movement Limited RhP]^bXb >RRPbX^]P[ nasi alae of Flaring breathing Shallow Tachypnea delayed and Diminished underweight Thin, chest Barrel lips Pursed breathing Deep rarely Clubbing, veins, neck of Distention Cyanosis fWTTiX]V 0dSXQ[T distress Respiratory Ua^\ STeXPcX^] ]^ >UcT] QaTPcWX]V bWP[[^f >RRPbX^]P[ cPRWh_]TP >RRPbX^]P[ Qa^bXb RhbcXR Tb_ 2[dQQX]V 7h_TaX] PcX^] distress Respiratory Tachypnea retractions Intercostal PaX]V =PbP[ tension pneumothorax tension side splinting side; involved on side affected on [PV \^eT\T]c aTb_XaPc^ah UPX[daT WTPac right-sided of presence (in edema peripheral ]SX]Vb Tg_TRcTS side affected on spaces intercostals ]Paa^fTS [PV aTb_XaPc^ah movement wall chest

CONTENT Subcutaneous crepitance from crepitance Subcutaneous Tachycardia tactile absent to Diminished trachea, impulse, apical Cardiac fremitus absent to Diminished Tachypnea presence in fremitus Decreased presence in fremitus Increased Tachycardia fremitus Diminished contralaterally shifted Trachea shifted impulse apical Cardiac delayed and Diminished fremitus Diminished downward displaced edge Liver felt be not may impulse Apical vocal diminished Somewhat of mobility limited Somewhat Resonance undiminished fremitus Tactile XU ]SX]Vb d]dbdP[ =^ ]SX]Vb R^]bXbcT]c P]h XU 5Tf ipsilaterally deviated Trachea deviated impulse cardiac Apical fremitus Diminished fremitus Diminished Tachycardia Palpation

air leaking air fremitus contralaterally shifted mediastinum and effusion pleural or empyema concomitant a of consolidation of contralaterally side affected on movement respiratory OF fremitus diaphragm ipsilaterally ELSEVIER Hyperresonance Diminished to absent breath absent to Diminished Hyperresonance if Dullness note Hyperresonant Pc]Tbb c^ 3d[[]Tbb [XeTa ^U Q^aSTa D__Ta of descent Limited Hyperresonance >RRPbX^]P[ affected over Dullness [X\XcTS >RRPbX^]P[ >RRPbX^]P[ Percussion consolidation is great is consolidation effusion to superior area in downward pushed dullness inspiration on diaphragm - hyperresonance disorders pulmonary accompanying no are there lung lower level diaphragmatic descent; diaphragmatic hyperresonance NOT Diminished to absent to Diminished clicks precordial and Sternal air if audible splash Succussion bronchophony, Egophony, sounds breath Bronchial with crackles of variety A adQ UaXRcX^] >RRPbX^]P[ in crackles and/or Egophony whispered Bronchophony, breath absent to Diminished PSeT]cXcX^db ^RRPbX^]P[ >][h heart of audibility Diminished voice and breath Diminished somewhat sounds Breath (best crackles Inspirational rhonchi Postpertussive Tg_XaPc^ah RaPRZ[Tb >RRPbX^]P[ be may sounds Breath usually crackles, of variety A P]S aW^]RWX FWTTiTb or diminished lobe, lower In bronchial lobe, upper In sounds lung Diminished FWTTiTb expiration Prolonged Auscultation whispered voice sounds voice whispered area that underlies air if bXV] 7P\\P] RaPRZ[X]V P]S \Xg dXS P]S sounds _TRc^aX[^`dh fWXb_TaTS rhonchi occasional and lobar effusion to superior area _TRc^aX[^`dh sounds sounds sounds expiration prolonged occasional with sounds diminished \^dcW ^_T] ^eTa held stethoscope with heard fWTTiX]V bXQX[P]c P]S fWTTiTb b^]^a^db aW^]RWX P]S fWTTiTb prolonged cough after disappearing sometimes FINALrhonchi, and coarse; collapse of extent on depending amounts varying in crackles sounds breath absent _TRc^aX[^`dh fWXb_TaTS egophony, breathing, %%&/+(0.FC +0(/0*. /%/%(&&/ [Zb+&U^f[ )c_$dZ)+ ')UcW_d$_dZZ I[_Z[bU+-&)U9^Wfj[h V V Pathophysiology 13-26). (Fig. age any at lung the of collapse the or birth at lung the of expansion incomplete The ATELECTASIS V V Pathophysiology airways. hyperreactive and inflammation to due obstruction airway Small DISEASE) AIRWAY (REACTIVE ASTHMA Loss of elastic recoil of the lung may lung the of recoil elastic of Loss from compression by caused Collapse increased edema, mucosal in Result anxiety, allergens, by triggered episodes Acute A PROPERTYbody. foreign or exudates, plugging, surgery, abdominal or thoracic to due be obstruction internal complete of presence the in alveoli the from gas of resorption or tumors) exudates, (e.g., outside flow respiratory impeded and resistance airway increased with bronchoconstriction and secretions, agents environmental other or smoke, cigarette infections, respiratory upper exercise, air, cold SAMPLE http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 i^Wed Wij^cW ed Wd_cWj_ed Wd 7YY[ii Video/Animation V V Subjective Data Subjective Symptoms of postobstructive of Symptoms postoperative the in seen Frequently CONTENTtumor. or body foreign from obstruction airway of setting the in develop may pneumonia setting V V V V History B OF May be asymptomatic between episodes between asymptomatic be May or hours, minutes, for last may Episodes a it, with and, common is pain Chest and dyspnea paroxysmal of Episodes ac^UaPR[dT P ^UUTa abc at not cX\T may history The abc cWT U^a fWTTiX]V with presents youngster, a particularly patient, a when body foreign a of possibility the about Think Body Foreign F;7HB 9B?D?97B days. tightness. of feeling cough ELSEVIER Chest and Lungs and Chest 13 CHAPTER V V Objective Data Objective

Radiograph may show consolidation show may Radiograph the in muted or dampened Auscultation - pneumonia. postobstructive a with associated airless is lung the of area affected the because area involved NOT V V V V Objective Data Objective Decreased peak expiratory flow expiratory peak Decreased oximetry pulse by Hypoxemia more becomes Expiration on wheezing with Tachypnea rate increases. resistance airway as expression anxious and fatigue, breathing, labored with prolonged inspiration and expiration Wilson and Thompson, 1990.) Thompson, and Wilson Atelectasis. 13-26 FIGURE

(Modified from (Modified FINAL 35 %%&/+(0/FC +0(/0*/ /%/%(&&/

ABNORMALITIES [Zb+&U^f[ )c_$dZ), ')UcW_d$_dZZ I[_Z[bU+-&)U9^Wfj[h ABNORMALITIES V V Pathophysiology 13-28). (Fig. fibrinous and edematous becomes that pleura parietal and visceral the involving process inflammatory An PLEURISY 1990.) Thompson, bronchitis. Acute 13-27 FIGURE V V Pathophysiology airways. large the of Inflammation BRONCHITIS 36 Sometimes associated with neoplasm with associated Sometimes pulmonary of result the Often an to due usually is bronchitis Acute tubes bronchial the of Inflammation PROPERTYasbestosis. or lupus). (e.g., diseases tissue connective or viral) or (bacterial infections exposure. irritant to due usually is bronchitis chronic while infection, 13-27). (Fig. secretions mucous increased to leads Chest and Lungs and Chest 13 CHAPTER SAMPLE http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 (From Wilson and Wilson (From in bronchialtree Mucus secretions V V Subjective Data Subjective V V V Data Subjective In chronic bronchitis, the cough may cough the bronchitis, chronic In accompanied be may bronchitis Acute Pain can be referred to the ipsilateral the to referred be can Pain be can surfaces pleural the of Rubbing pain chest with onset sudden Usually be productive. be pain. chest and cough, nonproductive hacking fever, by CONTENTdiaphragm. the to close is inflammation pleural the if shoulder patient. the by felt (pleuritic) breath a taking when OF ELSEVIER Fluid Pleurisy. 13-28 FIGURE Fluid (Modified from Wilson and Thompson, 1990.) Thompson, and Wilson from (Modified V V Objective Data Objective V V V Data Objective - Greater involvement may lead to lead may involvement Greater no with findings auscultation Minimal Fever may be present. be may Fever auscultated. be can rub friction pleural A with shallow and rapid are Respirations the involved areas. involved the in auscultation dampened or wheezing distress respiratory diminished breath sounds. breath diminished NOT

FINAL Parietal pleura Vi sceral pleura Fluid Fluid %%&/+(0'FC +0(/0+' /%/%(&&/ [Zb+&U^f[ )c_$dZ)- ')UcW_d$_dZZ I[_Z[bU+-&)U9^Wfj[h V V Pathophysiology 13-30). (Fig. space pleural the in collected fluid exudative Purulent EMPYEMA effusion. Pleural 13-29 FIGURE V Pathophysiology 13-29). (Fig. space pleural the in fluid non-purulent Excessive EFFUSION PLEURAL May be complicated by pneumonia, by complicated be May fluid purulent Non–free-flowing include and vary fluid of Sources PROPERTYfistula bronchopleural a or pneumothorax, simultaneous tissues. traumatized sometimes or infected adjacent from commonly most develops collection trauma. and neoplasm, disease, tissue connective insufficiency, renal failure, heart infection, http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703

SAMPLE 1990.) Thompson, and Wilson from (Modified Effusion V V V Data Subjective Subjective Data Subjective V V Cough may produce blood or sputum. or blood produce may Cough develops. dyspnea Progressive and febrile often is patient The Pleuritic chest pain will occur with an with occur will pain chest Pleuritic the is dyspnea progressive with Cough and appears ill. appears and pain, chest and cough with tachypneic, CONTENTOF effusion. inflammatory concern. presenting typical ELSEVIER Empyema. 13-30 FIGURE Pus Pus Chest and Lungs and Chest 13 CHAPTER (Modified from Wilson and Thompson, 1990.) Thompson, and Wilson from (Modified V V Data Objective Objective Data Objective V V V V Percussion note is dull and vocal fremitus vocal and dull is note Percussion the in absent or distant are sounds Breath - sounds breath the areas, affected the In gravitate will it mobile; is fluid the When tactile and percussion to Dullness and auscultation on findings The is absent. is area. affected NOT perfusion. the above area the in hyperresonant often is note percussion the and muted are position. dependent most the to effusion. pleural for findings useful most the are fremitus patient. the of position the with also and present fluid of amount the with vary percussion

FINAL 37 %%&/+(0*FC +0(/0+* /%/%(&&/

ABNORMALITIES [Zb+&U^f[ )c_$dZ). ')UcW_d$_dZZ I[_Z[bU+-&)U9^Wfj[h ABNORMALITIES V V Pathophysiology 13-32). (Fig. viral) or fungal, (bacterial, agent infective an to alveoli and bronchioles the of response inflammatory An PNEUMONIA 1990.) abscess. Lung 13-31 FIGURE V V Pathophysiology 13-31). (Fig. necrosis central subsequent and suppuration, inflammation, by defined mass circumscribed well-defined, A ABSCESS LUNG 38 The infection and concomitant and infection The pulmonary the of infection Acute some a for diagnosis elude may It material infected or food of Aspiration bacterial pneumonia. bacterial acute of possibility the to you alert should ]SX]Vb R[X]XRP[ ^cWTa to proportion of out and crackles of absence the in cough productive possibly a and tachypnea, nasi, alae the of Flaring pneumonia. of evidence give to necessary not are crackles audible adults, in also but particularly, children In Pneumonia F;7HB 9B?D?97B PROPERTYconsolidation. lung to lead exudates inflammatory hospital). vs. (community acquired was pneumonia the which in setting the on part in depend which organisms, of variety a to due be may parenchyma time. causes. common most are infection of sources dental or respiratory upper from Chest and Lungs and Chest 13 CHAPTER http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703

SAMPLE Thompson, and Wilson from (Modified V V V V V Data Subjective Data Subjective Patient is usually obviously ill with ill obviously usually is Patient Involvement of the right lower lobe lower right the of Involvement nonspecific and rigors, fever, Chills, with common is production Sputum cough, of days) to (hours onset Rapid malaise, fever, and shortness of breath. of shortness and fever, malaise, abdominal process. abdominal an simulate and pain quadrant lower right cause to nerves thoracic eleventh and tenth the stimulate can present. be may vomiting and nausea of symptoms abdominal infection. bacterial dyspnea and pain, chest pleuritic CONTENTOF Abscess ELSEVIER ^P ]d^X aVcd_a[^QT 1990.) Thompson, and Wilson from d__Ta aXVWc _]Td\^]XP ;^QPa 13-32 FIGURE V V V V V V V Data Objective - Data Objective Cough may produce purulent, foul- purulent, produce may Cough auscultated. be may rub friction Pleural breath the and dull is note Percussion Dullness to percussion occurs over the over occurs percussion to Dullness whisper and bronchophony, Egophony, with common are rhonchi and Crackles tachycardic and tachypneic, Febrile, smelling sputum. smelling area. affected the over absent or distant sounds area of consolidation. of area pectoriloquy sounds. breath diminished NOT

FINAL (Modified %%&/+(0,FC +0(/0+, /%/%(&&/ [Zb+&U^f[ )c_$dZ)/ ')UcW_d$_dZZ I[_Z[bU+-&)U9^Wfj[h V V V Pathophysiology 13-34). (Fig. manifestations widespread have then may but lung the in begins often most that disease infectious chronic A TUBERCULOSIS V V Pathophysiology 13-33). (Fig. infections bacterial secondary to susceptible more is host infected the barrier, epithelial the in alterations to due infection, respiratory upper an normally is this While lung. the of infection viral A INFLUENZA There is always the potential for a for potential the always is There organism the when is period Latent from inhaled is bacillus tubercle The be may tract respiratory Entire a just be to seem may it mild, When PROPERTYbody. the throughout or locally spread post-primary . itself entrenches lung. recipient’s the infecting persons, infected of sneezes and coughs the of moisture airborne the tissue. alveolar and bronchiolar the throughout extending necrosis and inflammation interstitial by overwhelmed susceptible. particularly are ill chronically the and young, very the aged, the however, cold; SAMPLE http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 V V V Subjective Data Subjective V V Subjective Data Subjective 8] dT]iP 13-33 FIGURE History of travel to region with region to travel of History weight cough, fever, infection: Active some asymptomatic, period: Latent Significant respiratory distress can distress respiratory Significant malaise, fever, cough, by Characterized with infected person infected with contact close or tuberculosis endemic sweats night loss, involved be may nodes lymph regional CONTENTOF morbidity. high to leading develop, cold. common the of typical throat, sore mild and coryza, headache, (Modified from Wilson and Thompson, 1990.) Thompson, and Wilson from (Modified ELSEVIER Bronchioles Chest and Lungs and Chest 13 CHAPTER V V V Objective Data Objective V Objective Data Objective Positive tuberculin skin test skin tuberculin Positive and/or consolidation disease: Active findings pulmonary no disease: Latent - are tachypnea and rhonchi, Crackles, blood-streaked sputum blood-streaked with cough and findings corresponding with develop may effusion pleural NOT common. Wilson and Thompson, 1990.) Thompson, and Wilson Tuberculosis. 13-34 FIGURE Enlarged area Mucus

FINALEdema (Modified from (Modified Blood of bronchioles contraction muscle Smooth 39 %%&/+(0/FC +0(/0+/ /%/%(&&/

ABNORMALITIES ABNORMALITIES V V Pathophysiology 13-36). (Fig. cavity pleural the in blood of presence The HEMOTHORAX V V Pathophysiology 13-35). (Fig. cavity pleural the in gas or air of presence The PNEUMOTHORAX 40 When air is present with the blood; the with present is air When or trauma of result the be May In occur may or trauma from result May on physical examination. physical on detected be otherwise not will that pneumothorax minimal a to clue a be may tachycardia persistent but unexplained An Pneumothorax Minimal F;7HB 9B?D?97B this is called a called is this biopsy) pleural attempt, or placement line central thoracentesis, (e.g., procedures medical invasive space. pleural the in pressure increasing from emergency threatening life- potentially a in resulting space, pleural the into continually bleb acquired or congenital a of rupture of because perhaps spontaneously, , air leaks air pneumothorax, tension Chest and Lungs and Chest 13 CHAPTER PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703

SAMPLEhemopneumothorax. V V V Data Subjective Data Subjective Larger collections provoke dyspnea provoke collections Larger easily may air of collections Minimal Dyspnea and symptoms of symptoms and Dyspnea and chest pain. chest and rest. at is patient the when often most onset its has paradoxically pneumothorax spontaneous because particularly first, at symptoms without be and decreased pulmonary function. pulmonary decreased and loss blood of acuity and degree the on depending develop may hypovolemia Pneumothorax. 13-35 FIGURE diaphragm Depressed Collapsed lung CONTENTOF Air accumulation ELSEVIER 1990.) Hemothorax. 13-36 FIGURE chest wall Injury to - V V V V Data Objective Data Objective A mediastinal shift with tracheal deviation tracheal with shift mediastinal A the over sounds breath The Percussion note will be dull. be will note Percussion if absent or distant be will sounds Breath NOT can be seen with a tension pneumothorax. tension a with seen be can distant. are pneumothorax blood predominates. blood (Modified from Wilson and Thompson, and Wilson from (Modified Hemorrhage FINAL V V Pathophysiology 13-38). (Fig. failure heart right-sided involving condition chronic or acute An PULMONALE COR V Pathophysiology Generally referstobronchogeniccarcinoma,amalignanttumorthatevolvesfrombronchialepithelialstructures(Fig.13-37). CANCER LUNG C A In chronic cor pulmonale, gradual pulmonale, cor chronic In the of side right the phase, acute In smoke, tobacco include agents Etiologic progresses until ultimate heart failure. heart ultimate until progresses ventricle right the of hypertrophy embolism. pulmonary of result direct a as often most fails, and dilated is heart agents. carcinogenic inhaled other and radiation, ionizing asbestos,

PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 SAMPLE D B Thompson, 1990.) Thompson, hypertrophy. ventricular right and emphysema pulmonary extensive Notice pulmonale. Cor 13-38 FIGURE emphysema Pulmonary V V V Data Subjective Data Subjective Peripheral tumors without airway without tumors Peripheral of variety a wheezing, cough, cause May Dyspnea, fatigue, lightheadedness and lightheadedness fatigue, Dyspnea, obstruction may be asymptomatic. be may obstruction hemoptysis and pneumonitis, atelectasis, and emphysema of patterns developing pulmonary hypertension. pulmonary developing the to related are syncope, potentially Adenocarcinoma. C, CONTENTOFcarcinoma. cell lung. the of Cancer 13-37 FIGURE hypertrophy Right ventricular ELSEVIER B, \[ T[P T[ RPaRX]^\P RT[[ ^Pc RT[[ B\P[[ A, (Modified from Wilson and Wilson from (Modified Large cell carcinoma. cell Large D, `P^bT_XSTa\^XS B`dP\^db

- Lungs and Chest 13 CHAPTER V V V V V Data Objective Data Objective A malignant pleural effusion may develop may effusion pleural malignant A a obstruction, airway With the of extent the on based are Findings Elevated jugular venous pulsation and pulsation venous jugular Elevated right a with failure heart Right-sided with corresponding findings. corresponding with consolidation. with develop can pneumonia postobstructive metastasis. and invasion its of patterns the and tumor lower extremity edema extremity lower heave ventricular Pulmonary emphysema NOT

FINAL 41

ABNORMALITIES ABNORMALITIES V Pathophysiology 13-24). Fig. (see births live 2000 than more slightly in once occurs diaphragm, structured imperfectly an of result The HERNIA DIAPHRAGMATIC V Pathophysiology breathing. difficulty great has infant preterm The SYNDROME DISTRESS RESPIRATORY V Pathophysiology diagnose. to difficult very is that condition common relatively a is arteries pulmonary of occlusion embolic The EMBOLISM PULMONARY 42 It is on the left side at least 90% of the of 90% least at side left the on is It to due infants preterm in Develops age others, among include, factors Risk INFANTS, CHILDREN, AND ADOLESCENTS AND CHILDREN, INFANTS, way. the in get to there not is liver the time; deficiency surfactant thrombophilia. genetic or acquired and obesity, bones, leg and pelvis the of fracture cancer, disease, heart minutes, 30 than longer anesthesia with surgery thromboembolism, venous of history a years, 40 than older Chest and Lungs and Chest 13 CHAPTER ed [cXeb_ic fkbcedWho W ed Wd_cWj_ed 7YY[ii Video/Animation PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 SAMPLE V V Data Subjective V Data Subjective Data Subjective Pleuritic chest pain with or without or with pain chest Pleuritic The degree of respiratory distress can distress respiratory of degree The decreasing with seen frequently More dyspnea is a major clue to embolism. to clue major a is dyspnea invaded the chest through the defect. the through chest the invaded has bowel the CONTENTwhich to extent the on depending severe very or slight be OFasphyxia acute and diabetes, maternal age, gestational ELSEVIER

- V V V V Data Objective V Data Objective Data Objective Hypoxia by pulse oximetry may be may oximetry pulse by Hypoxia an or fever low-grade a be may There The heart is usually displaced to the right. the to displaced usually is heart The with chest the in heard are sounds Bowel and grunting, retractions, Tachypnea, evident. tachycardia. isolated a flat or scaphoid abdomen. scaphoid or flat a cyanosis NOT

FINAL V V about from children in often most A syndrome that generally results from infection with a variety of viral agents, particularly the parainfluenza viruses occurring CROUP V Pathophysiology 13-40, (Fig. tissues surrounding and epiglottis the involving infection life-threatening acute, An EPIGLOTTITIS V V V Pathophysiology 13-39). (Fig. glands sweat and pancreas, lungs, the involving glands exocrine of disorder recessive autosomal An FIBROSIS CYSTIC Pathophysiology An aspirated foreign body may mimic may body foreign aspirated An and subglottic is inflammation The against immunization While by this for screen now states Many cyst with results Bronchiectasis progressive causes mucus Thick croup on occasion. on croup 13-40, Fig. (see (laryngotracheobronchitis) larynx the beyond areas involve may it give we attention the mandates worldwide occurrence its and gravity its country, this in incidence the reduced greatly has B type influenza Haemophilus regulator). conductance transmembrane fibrosis (cystic CFTR of mutations genetic for checking infection. pulmonary subsequent and formation bronchioles. and bronchi the of clogging B). PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 SAMPLE 1 1 2 to 3 years of age. of years 3 to V V V V V V V Data Subjective Data Subjective Subjective Data Subjective There may be a history of history a be may There such distinctive is sweat in loss Salt in hallmark a is sputum with Cough The child awakens suddenly, often suddenly, awakens child The the in begins frequently episode An most occurs but age any at occur May rapidly progresses and suddenly Begins intestinal obstruction. intestinal or gain, weight poor malabsorbtion, salty. unusually tastes skin child’s the that notice may parent a that years. 5 than younger children cough. barklike harsh, a with frightened, very sleep. to gone has child the after often evening, 7 and 3 of ages the between children in often death in result can and airway the of obstruction CONTENTfull to often cough, without OF ELSEVIER

- Lungs and Chest 13 CHAPTER V V V V V V V Data Objective Data Objective Objective Data Objective Pulmonary dysfunction leads to clubbing, to leads dysfunction Pulmonary malabsorption to due mass body Low findings associated the with Bronchiectasis Fever does not always accompany croup. accompany always not does Fever hoarseness, retraction, breathing, Labored epiglottis red beefy with fever High extended neck with up straight sits Child pulmonale. cor and hypertension, pulmonary drooling facies of persons with epiglottitis. with persons of facies drooling toxic, the have not does child The characteristic. are stridor inspiratory and mouth. open an from drooling and swallow, to unable ill, and anxious very appearing forward, held head and NOT filled withpus Dilated bronchialcysts and Thompson, 1990.) Thompson, and Qa^bXb 2hbcXR 13-39 FIGURE

A). FINAL (Modified from Wilson from (Modified 43

ABNORMALITIES ABNORMALITIES Chronic bronchitis, bronchiectasis, and emphysema are the main conditions that are included in this group. One need not need One group. this in included are that conditions main the are emphysema and bronchiectasis, bronchitis, Chronic occurs. obstruction airflow expiratory irreversible an Ultimately, features. prominent are dyspnea and production, sputum COPD is a nonspecific designation that includes a group of respiratory problems in which coughs, chronic and often excessive DISEASE PULMONARY OBSTRUCTIVE CHRONIC V Pathophysiology months. 6 than younger infants in often most occurring lungs the of hyperinflation to leading inflammation airway) (small Bronchiolar BRONCHIOLITIS V V V Pathophysiology airway. or trachea the of floppiness a or rigidity of lack A TRACHEOMALACIA 44 Usual cause is respiratory syncytial respiratory is cause Usual of possibilities the eliminate to Need self-limited and benign be to Tends the to response in change to Trachea OLDER ADULTS OLDER virus. body. foreign a even or stenosis, tracheal lesion), vascular a (e.g., lesions fixed age increasing with expiration. and inspiration of pressures varying Chest and Lungs and Chest 13 CHAPTER PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 Croup syndrome. Croup 13-40 FIGURE epiglottis Swollen Tr cords Vocal SAMPLE achea A Acute epiglottitis. Acute A, V Data Subjective V Data Subjective Expiration becomes difficult, and the and difficult, becomes Expiration in wheezing or breathing” “Noisy infant appears anxious and tachypneic. and anxious appears infant CONTENTstridor. inspiratory often is infancy

OF Laryngotracheobronchitis. B, ELSEVIER Esophagus B

- V V Data Objective V Data Objective

Lung hyperinflation leads to an increased an to leads hyperinflation Lung with short and rapid are Breaths of findings and wheezing, Stridor, NOT hyperresonant percussion. hyperresonant and cage thoracic the of diameter AP developing. cyanosis perioral and retractions generalized compromise. severe or collapse airway with develop distress respiratory

FINAL Vocal cords Esophagus Normal epiglottis Trachea Swollen trachealtissue V V obstruction bronchial and Pathophysiology infections pulmonary repeated by caused is bronchioles 13-42). (Fig. or bronchi the of dilation Chronic BRONCHIECTASIS V V V Pathophysiology 13-41). (Fig. function disrupts that way a in enlarge alveoli and elasticity for lose lungs the which tolerance in condition A limited and sputum and coughs of EMPHYSEMA episodes of legacy a reveal will exercise. history careful A smokers. been have be an older adult, of course, to have one of these problems. Most patients, however, are certainly not young, and most patients Malfunction of bronchial muscle tone muscle bronchial of Malfunction fibrosis cystic in seen Frequently in essentially trapped, is gas Alveolar common a is bronchitis Chronic extensive an have patients Most and loss of elasticity of loss and compromised. seriously is exchange gas and expiration, lung. the hyperinflating permanently walls, alveolar of rupture and bronchioles terminal the beyond spaces air the of dilation to leading precursor history. smoking

PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 SAMPLE Thompson, 1990.) Thompson, Bronchiectasis. 13-42 FIGURE V V V V Data Subjective Data Subjective 1990.) emphysema. lobar with disease pulmonary obstructive Chronic 13-41 FIGURE Cough is infrequent without much without infrequent is Cough rest, at even common is Dyspnea Severe hemoptysis may occur. may hemoptysis Severe most are expectoration and cough The production of sputum. of production severe. when oxygen supplemental requiring CONTENTclues. major the often OF (Modified from Wilson and Thompson, and Wilson from (Modified (Modified from Wilson and Wilson from (Modified ELSEVIER

- Lungs and Chest 13 CHAPTER V V V V V Data Objective Data Objective Inspiration is limited with a prolonged a with limited is Inspiration on hyperresonant are lungs Overinflated scattered and shaped, barrel be may Chest Crackles and rhonchi, sometimes rhonchi, and Crackles clubbing and Tachypnea expiratory effort (i.e., longer than 4 or 5 or 4 than longer (i.e., effort expiratory percussion. heard. be may wheezes or crackles disappearing after cough after disappearing NOT onds) to expel air. expel to onds)

FINAL 45

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*, ABNORMALITIES V V V Pathophysiology 40. than older patients for problem a commonly more is exposure, irritant chronic of result a usually inflammation, airway Large CHRONIC B 46 Recurrent bacterial infections are infections bacterial Recurrent history the in prominent is Smoking inflamed, chronically are airways Large common. emphysematous. being patients these of many with production. mucus to leading Chest and Lungs and Chest 13 CHAPTER PROPERTY http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 RONCHITIS SAMPLE V V Subjective Data Subjective Cough and sputum production are production sputum and Cough not although present be may Dyspnea CONTENTOF impressive. severe. ELSEVIER

- V V V Objective Data Objective Severe chronic bronchitis may result in result may bronchitis chronic Severe breath decreased with Hyperinflation crackles and Wheezing

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