Download Chapter 8: The Thorax and Lung - Note special landmarks: ~ 2nd

Chapter 8: The Thorax and Lung
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Note special landmarks:
~ 2nd intercostals space for needle insertion for
tension pneumothorax
~ 4th intercostals space for chest tube insertion
~ T4 for lower margins of endotracheal tube on chest
x-ray
~ T7-8 interspace as landmark for thoracentesis
Chest Pain:
~ The myocardium- angina pectoris, myocardial
infarction
~ The pericardium- pericarditis
~ The Aorta- Dissecting aortic aneurysm
~ The trachea and large bronchi- Bronchitis
~ The parietal pleura- pericarditis, pneumonia
~ The chest wall, including the musculoskeletal
system and skin- costochondritis, herpes zoster
~ The esophagus- reflux esophagitis, esophageal
spasm
~ Extrathorcic structures such as the neck,
gallbladder, and stomach- cervical arthritis, biliary
colic, gastritis
A clenched fist over the sternum suggests angina
pectoris; a finger pointing to a tender area on the
chest wall suggests musculoskeletal pain; a hand
moving from neck to epigastrum suggests heartburn
Anxiety is the most frequent cause of chest pain in
children; costochonritis is also common
Anxious patients may have episodic dyspnea during
both rest and exercise, and hyperventilation, or rapid,
shallow breathing. At other times, they may sigh
frequently.
Wheezing suggests partial airway obstruction from
secretions, tissue inflammation, or foreign body
Cough can be a symptom of left-sided heart failure
Viral upper respiratory infections are the most
common cause of acute cough; also consider acute
bronchitis, pneumonia, left ventricular heart failure,
asthma, foreign body.
Subacute cough: postinfectious cough, bacterial
sinusitis, asthma
Chronic cough: postnasal drip, asthma,
gastroesophageal reflux, chronic bronchitis,
bronhiectasis
Mucoid sputum is translucent, white, or gray;
purulent sputum is yellowish or greenish
Foul-smelling sputum in anaerobe lung abscess
Tenacious sputum in cystic fibrosis
Large volumes of purulent sputum in bronchiextasis
or lung abscess
Diagnostically helpful symptoms include fever, chest
pain, dyspnea, Orthopnea, and wheezing
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Hemopytsis is rare in infants, children, and
adolescents; it is seen most often in cystic fibrosis
Blood originating in the stomach is usually darker
than blood from the respiratory tract and may be
mixed with food particles
Cyanosis signals hypoxia
Clubbing of nails in lung abscesses, malignancy,
congenital heart disease
Audible stridor, a high-pitched wheeze, is an
ominous sign of airway obstruction in the larynx or
trachea
Inspiratory contraction of the sternomastoids and
scalene at rest signals severe difficulty in breathing
Lateral displacement of the trachea in pneumothorax,
pleural effusion, or atelectasis
The AP diameter also may increase in chronic
obstructive pulmonary disease(COPD) although
evidence is not definitive
Retraction in severe asthma, COPD, or upper airway
obstruction
Unilateral impairment or lagging of respiratory
movement suggests disease of the underlying lung or
pleura
Intercostal tenderness over inflamed pleura
Bruises over a fractured rib
Although rare, sinus tracts usually indicate infection
of the underlying pleura and lung (as in tuberculosis,
actinomycosis)
Causes of unilateral decrease or delay in chest
expansion include chronic fibrosis of the underlying
lung or pleura, pleural pain with associated splinting,
and unilateral bronchial obstruction
Fremitus is decreased or absent when the voice is soft
or when the transmission of vibrations from the
larynx to the surface of the chest is impeded. Causes
include a very thick chest wall; an obstructed
bronchus; COPD; separation of the pleural surfaces
by fluid (pleural eddusion), fibrosis (pleural
thickening), air (pneumothorax), or an infiltrating
tumor
Look for asymmetric fremitus:
~ asymmetric decreased fremitus in unilateral pleural
effusion, pneumothorax, neoplasm from decreased
transmission of low frequency sounds;
~ asymmetric increased fremitus in unilateral
pneumonia from increased transmission
Dullness replaces resonance when fluid or solid
tissue replaces air-containing lung or occupies the
pleural space beneath your percussing fingers.
Examples include: lobar pneumonia, in which the
alveoli are filled with fluid and blood cells; and
pleural accumulations of serous fluid (pleural
effusion), blood (hemothorax), pus (empyema),
fibrous tissue, or tumor
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Generalized hyperresonance may be heard over the
hyperinflated lungs of COPD or asthma, but is not a
reliable sign.
Unilateral hyperresonance suggests a large
pneumothorax or possibly a large air-filled bulla in
the lung
An abnormally high level suggests pleural effusion,
or a high diaphragm as in atelectasis or
diaphragmatic paralysis
Sounds from bedclothes, paper gowns, and chest
itself can generate confusion in auscultation
Hair on the chest may cause crackling sounds. Either
press harder or wet the hair
If the patient is cold or tense, you may hear muscle
contraction sounds-muffled, low-pitched rumbling or
roaring noises
A change in the patient’s position may eliminate this
noise. You can reproduce this sound on yourself by
doing a Valsalva maneuver (straining down) as you
listen to your own chest
Breath sounds may be decreased when air flow is
decreased (as in obstructive lung disease or muscular
weakness or when the transmission of sound is poor
(as in pleural effusion, pneumothorax, or COPD)
If bronchovesicular or bronchial breath sounds are
heard in locations distant from those listed, suspect
that air-filled lung has been replaced by fluid-filled or
solid lung tissue
A gap suggests bronchial breath sounds
Fine late inspiratory crackles that persist from breath
to breath suggest abnormal lung tissue
Crackles may be from abnormalities of the lungs
(pneumonia, fibrosis, early congestive heart failure)
or of the airways (bronchitis, Bronchiectasis)
Wheezes suggest narrowed airways, as in asthma,
COPD, or bronchitis
Rhonchi suggest secretions in large airways
Clearing of crackles, wheezes, or rhonchi after
coughing or position change suggests inspissated
secretions, as in bronchitis or atelectasis
Findings predictive of COPD include combinations
of symptoms and signs, especially wheezing by selfreport or examination, plus history of smoking, age,
and decreased breath sounds. Diagnosis requires
pulmonary function tests such as spirometry
Increased transmission of voice sounds suggests that
air-filled lung has become airless
Louder, clearer voice sounds are called
bronchophony
When “ee” is heard as”ay” an E-toA change
(egophony) is present, as in lobar consolidation from
pneumonia. The quality sounds nasal
Louder, clearer whispered sounds are called
whispered pectoriloquy
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Persons with severe COPD may prefer to sit leaning
forward, with lips pursed during exhalation and arms
supported on their knees or a table
Severe asthma, COPD, or upper airway obstruction
Underlying disease of lung or pleura
Tender pectoral muscles or costal cartilages
corroborate, but do not prove, that chest pain has a
musculoskeltal origin
Dullness replaces resonance when fluid or solid
tissue replaces air-containing lung or occupies the
pleural space. Because pleural fluid usually sinks to
the lowest part of the pleural space (posteriorly in a
supine patient), only a very large effusion can be
detected anteriorly
The hyperresonance of COPD may totally replace
cardiac dullness
The dullness of right middle lobe pneumonia
typically occurs behind the right breast. Unless you
displace the breast, you may miss the abnormal
percussion note.
A lung affected by COPD often displaces the upper
border of the liver downward It also lowers the level
of diaphragmatic dullness posteriorly
Non disabled older adults taking 5.6 seconds or
longer are more likely to be disabled over time than
those taking 3.1 seconds or fewer. Early intervention
may prevent onset of subsequent disability
Patients older than 60 years with a forced expiratory
time of 6 to 8 seconds are twice as likely to have
COPD
An increase in local pain (distant from your hands)
suggests rib fracture rather than just soft- tissue
injury
Chapter 9: The Cardiovascular System
The term heart failure is now preferred over
“congestive heart failure” because not all patients
have volume overload on initial presentation
Classic exertional pain, pressure, or discomfort in the
chest, shoulder, back , neck, or arm in angina
pectoris, seen in 50% of patients with acute
myocardial infarction; atypical descriptors also are
common, such as cramping, grinding, pricking,
rarely, tooth or jaw pain
Annual incidence of exertional angina is 1 per 100 in
the population 30 years or older
Acute coronary syndrome is increasingly used to
refer to any of the clinical syndromes caused by acute
myocardial ischemia, including unstable angina, nonST elevation myocardial infarction, and ST elevation
infarction
Anterior chest pain, often tearing or ripping, often
radiating into the back or neck, in acute aortic
dissection
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Symptoms or signs or irregular heart action warrant
an ECG. Only atrial fibrillation, which is “irregularly
irregular,” can be reliably identified at the bedside
Clues in the history include transient skips and flipflops (possible premature contractions); rapid regular
beating of sudden onset and offset (possible
paroxysmal supraventricular tachycardia); a rapid
regular rate of less than 120 beats per minute,
especially if starting and stopping more gradually
(possible sinus tachycardia)
Sudden dyspnea in pulmonary embolus, spontaneous
pneumothorax, anxiety
Orthopnea in left ventricular heart failure or mitral
stenosis; also in obstructive lung disease
PND in left ventricular heart failure or mitral
stenosis; may be mimicked by nocturnal asthma
attacks
Dependent edema appears in the lowest body parts:
the feet and lower legs when sitting, or the sacrum
when bedridden. Causes may be cardiac (congestive
heart failure), nutritional (hypoalbuminemia), or
positional
Edema occurs in renal and liver disease: periorbital
puffiness, tight rings in nephrotic syndrome; enlarged
waistline from ascites and liver failure
A hypovolemic patient may have to lie flat before
you see the neck veins. In contrast, when juglar
venous pressure is increased, an elevation up to 60
degrees or even 90 degrees may be required. In all
these positions, the sterna angle usually remains
about 5 cm above the right atrium
Increased pressure suggests right-sided congestive
heart failure or, less commonly, constrictive
pericarditis, tricuspid stenosis, or superior vena cava
obstruction
In patients with obstructive lung disease, venous
pressure may appear elevated on expiration only; the
veins collapse on inspiration. This finding does not
indicate congestive heart failure
An elevated JVP is 98% specific for an increased left
ventricular end diastolic pressure and low left
ventricular ejection fraction, and it increases risk of
death from heart failure
Local kinking of obstruction is the usual cause of
unilateral distention of the external jugular vein
Prominent a waves in increased resistance to right
atrial contraction, as in tricuspid stenosis; also in
first-degree atrioventricular block, supraventricular
tachycardia, junctional rhythms, pulmonary
hypertension, and pulmonic stenosis
Absent a waves in atrial fibrillation. Large v waves in
tricuspid regurgitation, constrictive pericarditis
A tortuous and kinked carotid artery may produce a
unilateral pulsatile bulge
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Causes of decreased pulsations include decreased
stroke volume and local factors in the artery such as
atherosclerotic narrowing or occlusion
Pressure on the carotid sinus may cause a reflex drop
in pulse rate or blood pressure
Small, thready, or weak pulse in cardiogenic shock;
bounding pulse in aortic insufficiency
Delayed carotid upstroke in aortic stenosis
Pulsus alternans, bigeminal pulse (beat-to-beat
variation); paradoxical pulse (respiratory variation)
Note that an aortic valve murmur may radiate to the
neck and sound like a carotid bruit
The prevalence of asymptomatic carotid bruits
increases with age, reaching 8% in people 75 years or
older, with a three-fold increased risk of ischemic
heart disease and stroke. Presence of a carotid bruit
does not predict the degree of underlying stenosis, so
pursue further investigation
Low-pitched extra sounds such as an S3, opening
snap, diastolic rumble of mitral stenosis
Soft decrescendo diastolic murmur of aortic
inefficiency
S1 is decreased in first-degree heart block
S2 is decreased in aortic stenosis
Thrills may accompany loud, harsh, or rumbling
murmurs as in aortic stenosis, patent ductus
arteriosus, ventricular septal defect, and , less
commonly, mitral stenosis. They are palpated more
easily in patient positions that accentuate the murmur
On rare occasions, a patient has dexrocardia-a heart
situated on the right side. The apical impulse will
then be found on the right. If you cannot find an
apical impulse, percuss for the dullness of the heart
and liver and for the tympany of the stomach. In situs
inversus, all three of these structures are on opposite
sides from normal. A placed liver and stomach is
usually associated with congenital heart disease
The apex beat is palpable In only 25% to 40% of
healthy adults in the supine position and in 50% of
healthy adults in the left lateral decubitus position,
especially those who are thin
Pregnancy or a high left diaphragm may displace the
apical impulse upward and to the left
Lateral displacement from cardiac enlargement in
congestive heart failure, cardiomyopathy, ischemic
heart disease. Displacement in deformities of the
thorax and mediastinal shift
Lateral displacement outside the midclavicular line
increases the likelihood of cardiac enlargement and a
low-left ventricular ejection fraction by 3-4 and 10,
respectively
In the left lateral decubitus position, a diffuse PMI
with a diameter greater than 3 cm indicates left
ventricular enlargement
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Increased amplitude may also reflect
hyperthyroidism, severe anemia, pressure overload of
the left ventricle (as in aortic stenosis), or volume
overload of the left ventricle (as in mitral
regurgitation)
A sustained, hih-amplitude impulse that is normally
located suggests left ventricular hypertrophy from
pressure overload (as in hypertension). If such an
impulse is displaced laterally, consider volume
overload
A sustained low-amplitude (hypokinetic) impulse
may result from dilated cardiomyopathy
A brief middiastolic impulse indicates an S3; an
impulse just before the systolic apical beat itself
indicates an S4
A marked increase in amplitude with little or no
change in duration occurs in chronic volume overload
of the right ventricle, as from an atrial septal dect
An impulse with increased amplitude and duration
occurs with pressure overload of the right ventricle,
as in pulmonic stenosis or pulmonary hypertension
In obstructive pulmonary disease, hyperinflated lung
may precent palpation of an enlarged right ventricle
in the left parasternal area. The impulse is felt easily,
however, high in the epigastrium where heart sounds
are also often heard best
A prominent pulsation here often accompanies
dilation or increased flow in the pulmonary artery. A
palpable S2 suggests increased pressure in the
pulmonary artery (pulmonary hypertension)
A palpable S2 suggests systemic hypertension. A
pulsation here suggests a dilated or aneurismal aorta
A markedly dilated failing heart may have a
hypokinetic apical impulse that is displaced far to the
left. A large pericardial effusion may make the
impulse undetectable
Heart sounds and murmurs that originate in the four
valves range widely, as illustrated below. Use
anatomical location rather than valve area to describe
where murmurs and sounds are best heard
This position accentuates or brings out a left-sided S3
and S4 and atrial murmurs, especially mitral stenosis.
Otherwise, you may miss these important findings
This position accentuates or brings out aortic
murmurs. You may easily miss the soft diastolic
murmur of aortic regurgitation unless you listen at
this position
Note that S1 is louder at more rapid heart rates (and
PR intervals are shorter)
When either A2 or P2 is absent, as indisease of the
respective valves, S2 is persistently single
Expiratory splitting suggests an abnormality
Persistent splitting results from delayed closure of the
pulmonic valve or early closure of the aortic valve
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A loud P2 suggests pulmonary hypertension
The systolic click of mitral valve prolapse is the most
common of these sounds
Diastolic murmurs usually indicate valvular heart
disease but often occur when the heart valves are
normal
Midsystolic murmurs typically arise from blood flow
across the semilunar (aortic and pulmonic) valves
Pansystolic murmurs often occur with regurgitant
(backward) flow across the atrioventricular valves
This is the murmur of mitral valve prolapse and is
often, but not always, preceded by a systolic click
Early diastolic murmurs typically accompany
regurgitant flow across incompetent semilunar valves
Middiastolic and presystolic murmurs reflect
turbulent flow across the atrioventricular valves
The presystolic murmur of mitral stenosis in normal
sinus rhythm
The early diastolic murmur of aortic regurgitation
The midsystolic murmur of aortic stenosis and
innocent flow murmurs
The pansystolic murmur of mitral regurgitation
For example, a murmur best heard in the 2nd right
interspace often originates at or near the aortic valve
A loud murmur of aortic stenosis often radiates into
the neck (in the direction of arterial flow), especially
on the right side
An identical degree of turbulence would cause a
louder murmur in a thin person than in a very
muscular or obese person. Emphysematous lungs
may diminish the intensity of murmurs
A fully described murmur might be: a “mediumpitched, grade 2/6, blowing descrescendo diastolic
murmur, hear best in the 4th left interspace, with
radiation to the apex” (aortic regurgitation)
Murmurs originating in the right side of the heart
tend to vary with respiration more than left-sided
murmurs
In a 60-year-old person with angina, you might hear a
harsh 3/6 misystolic crescendo-decrescendo murmur
in the right 2nd interspace radiating to the neck. These
findings suggest aortic stenosis but could arise from
aortic sclerosis (leaflets sclerotic but not stenotic), a
dilated aorta, or increased flow across a normal
valve. Assess any delay in the carotid upstroke and
the intensity of A2 for evidence of aortic stenosis.
Check the apical impulse for left ventricular
hypertrophy. Listen for aortic regurgitation as the
patient leans forward and exhales
Put all this information together to make a hypothesis
about the origin of the murmur
The murmur of hypertrophic cardiomyopathy is the
only systolic murmur that increases in intensity
during the valsalva maneuver (strain phase)
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Alternately loud and soft Korotkoff sounds or a
sudden doubling of the apparent heart rate as the cuff
pressure declines indicates a pulsus alternans
The upright position may accentuate the alternation
The level identified by first hearing Korotkoff sounds
is the highest systolic pressure during the respiratory
cycle. The level identified by hearing sounds
throughout the cycle is the lowest systolic prssue. A
difference between these levels of more than 10 mm
Hg indicates a paradoxical pulse and suggests
pericardial tamponade, possible constrictive
pericarditis, but most commonly obstructive airway
disease