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9/23/98
PHYS DX
Manubrial-sternal junction—at 2nd rib level
# intercostal space by the rib above it
Tracheal bifurcation—upper level of heart
~ T4 in back
~ rib 2 in front
Lungs go down to ~ T10 (T12 on full inspiration)
Lung apices—extend above inner 1/3 of clavicle
 May have to assess specific lobes of lungs in National Boards or Comp Boards
Apex of lung
 Rises ~ 2 cm (1 in.) above clavicle
 Crosses 6th rib at midclavicular line
 Crosses 8th at mid axillary
Lines (Know abbreviations for tests)
 Midsternal—MSL
 Midaxillary—MAL
 Midclavicular—MCL
 Anterior axillary—AAL
 Posterior axillary—PAL
 Scapular line
 Vertebral line
Posterior—quiet respiration—bottom of lung ~ T10
—deep respiration—bottom of lung ~T12
Oblique/major fissures divide each lung ~ in half
 Cannot appreciate the right middle lobe on the posterior
Horizontal fissure—from 5th rib at midaxillary line to 4th rib at sternum
Inferior aspect of right middle lobe is at !rib 6 (on anterior chest wall)
 Comp Boards—asked to assess a specific lobe—cannot asses a RML on the posterior
 Many state boards ask you to assess: respiratory, cardiac, GI
At MCL (on anterior)—quiet inspiration ~ rib 6
—deep inspiration ~ rib 8
Lungs run obliquely (why levels vary anterior and posterior)
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9/23/98
Exam
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PHYS DX
Inspection
Palpation
Percussion
Auscultation
Inspection
 Note shape of chest and movement
 Note pt’s posture (and face)
 Inspect neck for contraction of accessory muscles or nasal flaring indicating functional
impairment
 Postures—early stage pulmonary edema
 Pt tends to lean to Left to try to get fluid to flow to lower borders (gurgling sounds)
 Postures can enhance respiration ex—in COPD (air trapping in lungs)
Emphysema
 Develops over time (smoking) ex—over 30-40 years
 Diaphragm has weakened
 Use accessory muscles of respiration
 Raise arms to help lift
 Purse lips, shoulder motions
Table 8-2 Deformities of the chest
 Side-to-side dimension is normally wider than front-to-back dimension
Barrel chest
  kyphosis can  A-P dimension
 COPD, emphysema, can  A-P
 Infants and small kids can have  A-P
 Ribs lose 45 angle and become more horizontal posteriorly
Flail chest—trauma
 Paradoxical movement
 When have multiple rib fractures
 Injured area caves inward on inspiration
 Injured area moves outward on expiration
Funnel chest
 Lower sternum is depressed
 Xyphoid may stick out
 Familial tendency
 Marfan’s
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Ricketts
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9/23/98
PHYS DX
Pigeon chest
 Sternum displaced anterior
 Ribs start to displace (protrude)
 Uncontrolled infantile asthma
 Rare
Thoracic scoliosis  asymmetric chest cavity
Inspection
 Use of accessory muscles (trapezuis, SCM) for inspiration
 Raises clavicle
 Does not move in normal quiet respiration
 If moves > 5mm, suspect COPD
Question—normal chest dimensions, but a delay of motion on one side—possibilities
 Partial collapse of lung
 Paresis (due to  phrenic)
 Underlying inflammation
 Pleurisy
 Pneumonia
 Fibrosis
 Paralysis of diaphragm
Observe pattern and effort of breathing and rate
Table 8-1
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Adult—12 to 20 breaths/minute (b/m)
Neonate—up to 80 b/m
2 weeks—40 to 60 b/m
10 years—20 to 25 b/m
Rapid shallow breathing (tachypnea)
 associated with pain
 restrictive lung disease, pleurisy, rib fractures, elevated diaphragm, partial obstruction
Rapid deep breathing (hyperpnea)
 exercise, anxiety
 metabolic acidosis—trying to blow of CO2
 raising of shoulders and clavicle
Inspection
 Kussmaul breathing—deep breathing due to metabolic acidosis
 May be fast, normal rate or slow
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9/23/98
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PHYS DX
Slow breathing (bradypnea)
 Diabetes, trauma  intracranial pressure
 May be deeper than normal, but not always
 May be more shallow
Cheyne-Stokes breathing
 Deep breathing alternating with apnea (no breathing)
 Children and older people (naturally)
 Heart failure, uremia, brain damage, drugs
Ataxic breathing (Biot’s)
 Unpredictably irregular
 Possible brain damage
Exam—October 7—1st hour—30 questions
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Sighing respiration
 Occasional sighs are normal
 If a problem, consider hyperventilation
Obstructive breathing
 Long expirations due to narrowed airways resisting air flow
 Ex.: COPD, emphysema
 breathing rate
 metabolic acidosis
 aspirin poisoning
 hypoxemia
 pain, anxiety
 exercise
 breathing rate
 metabolic alkalosis
 CNS (cerebrum)
 Narcotic OD
 Obesity
 Myasthenia gravis
Table 4-4
Nails—clubbing
 Normal angle ~ 160
 Abnormal ~ ______
 Intrathoracic tumors
 Near a mainstem bronchus or more infiltrative
 TB
 Lung abscesses
 Heart malformations (ex—shunts, congenital or acquired)
 Chronic pulmonary diseases—bronchiectasis
 Chronic liver failure
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9/23/98
PHYS DX
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Pulmonary/aortic valve stenosis
Look for cyanosis or skin lesions
Do not usually see clubbing with emphysema since emphysema is a slow process and your body
adapts
See clubbing more in rapid processed, toxins, rapid onset carcinomas, etc.
Cyanosis—central cyanosis with lung disease
Skin lesions—conditions arising secondary to lung disease, ex.—squamous cell carcinoma,
shingles (herpes zoster may show up if there’s a problem)
Palpation
 Skin lesions—shingles, nodules, edema
 Scars, eczema
 Tender spots
 Do in a way that pt is comfortable with
 Be careful of hand placement on females—ex.—use ulnar aspect of hand
 Have pt move breast tissue for you
 Develop a pattern
 Usually side-to-side, across-down method
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Check trachea—may be displaced to one side
 Pulled—atelectasis, fibrosis, pneumothorax
 Pushed—thyroid enlargement, tumor, pleural effusions, pneumothorax
 Check for adhesions
 Atelectasis—in upper areas of lung near mainstem bronchus
 Lung in this region becomes airless (not ventilated)
 Would sound different, also
 Pneumothorax
 Small ones pull trachea
 Large ones push trachea
 Pleural effusion—acts like large pneumothorax
Respiratory excursion/chest expansion
 Posterior
 Normal lateral movement in inspiration is 3-4 cm (~T10)
 Anterior—apex of lung above clavicle
 Symmetric slow motion
 Upper lobe checked above nipple ~ rib 2-3  1-2 cm motion
 Lower lobe below nipple ~ rib 5-6  2-3 cm motion
 Lateral
 Depends on level
 ~ rib 7-8  2-3 cm motion
 Palpation
 Vocal/ Tactile fremitus
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9/23/98
PHYS DX
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Feel for vibration of chest wall when pt speaks (or hear it)
Gives info on density of area—possible tumors, fluid in area
Have pt say “99” or “1-1-1”—N’s provide most vibration in tissue
Feel for waves that are not absorbed
Areas of  density   transmission (solid transmits better than air)
 fremitus
 pneumonia (fluid consolidation)
 atelectasis (airless lung)
 tumor
 fremitus—unilateral
 pneumothorax (pleural space has air)
 pleural effusion (fluid separates)
 bronchial obstruction (fibrosis)
 infiltrative tumor
 fremitus—bilateral
 COPD
 Chest wall thickening (fat, muscle), (breast tissue)
What is normal?
 Most conditions are unilateral, so can use pt as his/her own control
 Listen to variety of people—different sizes, etc.
 Can listen to a different system on your pts every few weeks
Estimate level of diaphragm
 Approximates level
 Abnormally high
 Pleural effusion
 Paralysis
 Atelectasis (Table 8-5)—acts differently at different levels
 Air trapping (ex—emphysema)
 Cause  transmission
 Fluid—may deflect sound waves
 Ex—pleural effusion
Air in the pleural space can also deflect sound waves