Download Class 4 - Cat`s TCM Notes

Course
Class
Physical Assessment 1
4
Date
8/7/08
Re-wrap from last week.
Pulse, resp, bp are 3 critical vital signs.
Pulse: 60-100 (below or above are bad news)
Fast pulse: tachycardia, thyroid problems (younger), pacemaker problems, heart attack.
Slow: post heart attack.
Resp: 6-20 (below 4 per minute, above 20 are critical)
Extreme rapid breathing can = asthma, pneumonia, pulmonary embolism, pulmonary edema,
pneumothorax
Very slow breath can = drug overdose (opiates, codeine, depressors, street depressors…), alcohol
overload, reticular activating system (see pharmacology class – xanax or valium switches off the
reticulating system which keeps you awake), liver or heart failure + drugs.
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Pulmonary Lecture
Thoracic Anatomy
Know the anatomy and landmarks of the thoracic area. One landmark omitted below is the “Angle of
Louis” or Manubriosternal Angle where the 2nd rib meets the sternum. This is also called the “Sternal
angle” in the illustration below.
Don’t confuse this with the sternal costal angle, which is also called the costal angle in the illustration.
The sternal costal angle is wider and flatter in children than in adults as their thoracic cages are not fully
formed. You can feel liver and spleen easily in children, while in adults the liver and spleen should be
covered by the ribcage. If one or both of them are palpable below the ribcage the organs (or organ) are
enlarged.
The xyphoid process hardens over time as one grows older. Children have a very soft xyphoid process
while elderly people have a very hard process. This can easily be mistaken for a lump in older patients.
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It is also critical to be able to count rib spaces accurately. This should be familiar from Point Locations.
Remember that the intercostal space number is the same as the rib above it. Example: the 2nd intercostal
space is below the 2nd rib.
One important reason to know how to count the
intercostal spaces, aside from the obvious acupuncture
applications, is because the apical pulse of the heart is
felt in the 4th, 5th, even the 6th intercostal space on the
left. I remember Dr. Luo mentioning this in his lecture
on the Heart in Diagnostics 2 and how it is important to
feel this pulse – a bounding pulse here indicates the
Heart Qi is leaking out. In biomedicine this is where
you can hear the mitral valve of the heart shut.
Cardiologists listen for, among other things, mitral
valve stenosis here. More on that later.
Remember too that the 11th and 12th ribs float, only
attached to the 11th and 12th thoracic vertebra
respectively, not attached to the sternum.
You cannot feel the intercostal space between the 1st rib
and collarbone because the collarbone/clavicle obscures it. The first one you can feel is the intercostal
space between the 1st and 2nd rib. You should be able to feel the 1st through 5th intercostal spaces right
next to the sternum easily in most people. Around the 6th space however, the configuration of the costal
cartilage makes this impossible. See the illustration above. You will need to move outward to about the
mamillary line to feel this. And of course, with women you need to use your most diplomatic skills to
avoid a sexual harrassment suit!
Anatomical Lines of the Thoracic Region
Anatomical lines should be a familiar concept
to an acupuncture student. ☺ (Think
mamillary line, axillary line, etc.)
The vertical anatomical lines on the anterior
side of the body you need to know are:
Midsternal
This line divides the left and right
sides of the body.
This is also called the anterior
midline among other things you
might remember from anatomy
and physiology, but which escape
me at the moment.
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Midclavicular line
Starts at mid-clavicle and extends downward through the nipple (in a perfect world!) and
chest/abdominal area.
Anterior axillary line
This line begins at the lateral extremity of the
clavicle and extends downward close the the tip
of the axillary fold.
The lateral anatomical lines you need to know are:
Anterior axillary line
See the bullet point above.
Midaxillary line
This isn’t such a great illustrative photograph.
The midaxillary line should extend down the
side of the body from the anatomical center of
the armpit.
Posterior axillary line
This mirrors the anterior axillary line.
Posterior anatomical lines you need to know:
Vertebral or Posterior Midline
Runs right down the middle of the spine.
Midscapular or Scapular line
Not really midscapular looking in the
photograph. It’s the posterior equivalent
of the mid-clavicular line.
Lung Anatomy
The liver is obscured by the thoracic/rib cage.
Upon deep inspiration the diaphragm pushes
the liver down 2-3 cm, but is still within the
ribcage if it isn’t enlarged. When you exhale
the diaphragm goes up and the liver does too.
At full exhale the top of the liver is
approximately level with the top of the nipple.
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The lung is located like this in the thoracic cavity.
Note this important stuff:
1. The apex (top point) of the lungs extend above
the clavicle.
This is why deep peripheral needling above the
clavicle can cause pneumothorax. Zoiks! It’s
also why Dr. Shen needles GB 21 from front to
back or back to front by pinching the muscle up
then inserting.
2. The right lung has 3 lobes –
a. Right upper lobe or RUL with the apex
protruding above the clavicle.
b. RML or right middle lobe between the
sternum and the nipple area. There is an
oblique fissure separating the RML and the right lower lobe.
c. Right lower lobe or RLL.
3. The left lung has 2 lobes –
a. Left upper lobe (LUL), which occupies most of the real estate.
b. LLL or left lower lobe which is a small portion on the lateral inferior edge of the lung
area.
4. The lungs expand upon inspiration to about the positions noted by the dashed lines in the
illustrative photograph above.
From the posterior side the lungs look like this.
‰
The trachea splits in two (bifurcates) at about T3. If
you listen at this location you will hear loud breathing
noises which is normal. (Acu-geek side note: this is
the Back Shu of the Lung) While you can listen from
the front of the chest and hear lung sounds, you can’t
do it from the back because the scapula blocks most
of the sound.
The dashed lines on the illustration are the levels to
which the lungs descend when they fill with air upon
inspiration.
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Regarding the anatomy of the back in the
thoracic area, be able to locate vertebrae on the
back. This too was covered extensively in Point
Location classes.
Specific thing to know:
1. Be able to locate C7. This quite often the
most prominent protruding vertebra at
the top of the base of the neck, hence the
name, vertebra prominens.
2. Know what a spinous process is.
Learned that in point locations too.
3. Be able to find the inferior border of the
scapula (bottom tip)
4. Be able to find the 12th rib. Sometimes
that’s a chore!
All of these landmarks are harder to locate on obese people, on patients who are very very muscular, on
people with connective tissue disorders, etc.
The Pleural Cavity
The pleura is a sac surrounding the
lungs, serving also as an envelope
between the lungs and the chest wall.
The outer layer of the pleura is called the
parietal pleura and the inner layer is
called the visceral pleura which is
attached to the lungs.
The pleura should have a thin layer of
lubricating fluid allowing the lungs to
slide across the pleura when you breathe.
If the pleural cavity becomes filled (with
water, blood or air) this is abnormal and
is called pleural effusion.
If there is a pneumothorax this space
becomes filled with air. If there is
bleeding into this space the term for blood here is hemapneumothorax.
Pleural mesothelioma is a cancer starting in the pleural layer which moves inward from the chest wall.
Shipyard workers and occupations such as asbestos miners are at risk for this.
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The Trachea and Bronchial Tree
The trachea is about 10 cm long and bifurcates (forks)
at about the vertebral level of T3 or T4 .
The bronchial tree is described by “generations”
meaning that as the bronchial tubes branch they become
smaller and smaller. Each smaller branching is a
generation. The smallest are described by the term
“bronchioles.”
The right bronchus is shorter and much more vertical
than the left. If a foreign object is aspirated (inhaled) it
goes directly down the right bronchus and generally
lodges in the right middle lobe.
Bronchioles lead to the alveoli or alveoli sacs which are
the site of gas
exchange. The
functional respiratory
unit in which gas is
exchanged is the
acinus.
Since it is critical to
keep the acinus and
alveoli sacs clean and clear, the bronchial tree is lined with cilia and
goblet cells which produce mucous which trap inhaled particles before
they reach the alveoli. Diseases affecting the cilia will result in pus
and excess mucous production. Ask a smoker . . . they’ll tell you!
Other tissues in the lungs which are filled with air, but not available
for gaseous exchange are considered “anatomical dead space” (which I
think is a pretty ungrateful thing to say about one’s lungs!). The trachea and bronchii fall into the
“anatomical dead space” category. Emphysema patients have a lot of non-working alveoli and thus are
said to have an awful lot of anatomical dead space. In emphysema the functional tissues expand and lose
their ability to contract again, leaving a lot of emptiness in the lung tissues. This why they sound so
tympanic when you percuss – they are more “hollow” than they should be. So even when they can
inhale easily, they feel short of breath…which technically they are.
The function of breathing/respiration is to:
1. Supply oxygen
2. Remove carbon dioxide
3. Maintain homeostasis through maintenance of the pH (acid-base) balance of the body.
This is a very important function of the lungs, actually, as is the next numeric…
4. Maintain heat exchange.
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Chest size and breathing
Inspiration increases chest size. The diaphragm drops down during inspiration, which is the active
phases of respiration. This creates a negative pressure in the thoracic cavity causing air to rush in as the
diaphragm contracts. Intercostal muscles then lift the sternum and ribs increasing the diameter of the
chest.
Expiration is the passive phase of respiration. The diaphragm relaxes, reverting to it’s relaxed dome
shape. This pushes upward into the thoracic cavity, creating positive pressure in the alveoli and air
rushes out.
For this reason, proper breathing requires belly expansion! Many people do not use the belly during
breathing. While breath retraining is important for everyone, it is really important for people with lung
disease to retraining their breathing in order to get the best possible air intake.
Respiratory Control
There are stretch response nerve endings in the chest. The brain regulates the amount of time that they
can be stretched out before recoiling. The pons
and medulla in the brainstem are the breathing
centers of the brain, though higher emotional
responses can override the autopilot breathing
functions.
These structures receive stimulus from the
levels of O2 and CO2 in the body. An increase
in CO2 is called hypercapnia and triggers the
breathing response to get rid of CO2. That’s
what can cause you to yawn…that and
watching someone else yawn. Heck, I bet you
want to yawn right now!
Hypoxemia is a decrease in the O2 levels in the
blood. This too triggers your brain to grab more
oxygen.
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Changes in Respiration that come with Age
Even without smoking (pipes, cigarrettes, pot, whatever) or occupational aspiration of crud, lungs
undergo the following changes as they age. Aging people have special circumstances created simply by
living a good while. Here are some things to know.
Costal cartilage calcifies resulting in a more rigid thorax. This makes it harder for the
thoracic cage to expand and can result in posture changes all of which make it harder to
breathe.
Elastic properties in the lung decrease in function, so capacity of the lung is reduced as well.
Vital capacity decreases resulting in the closure of small airways.
There is an increase in residual (crud build up) volume.
Loss of alveoli results in less surface area available for gas exchange.
The bases of the lungs become less ventilated.
Pneumonia risk increases when this happens. Retraining for deeper breath through yogic
breathing and qigong greatly improves this situation.
Focused Subjective Pulmonary Assessment
A focused subjective pulmonary assessment takes the following factors into consideration: cough,
shortness of breath, chest pain upon breathing, medical history of upper respiratory infection, history of
or current smoking, environmental exposure, self-care behaviors.
You should also be familiar with the main symptoms of pulmonary disease:
Cough
Dyspnea – painful or difficult breathing
Hemoptysis – spitting up blood
Chest pain which is pleuritic – feels like a “stitch”
Wheezing – also wheezing with phlegm production
Cyanosis
Sputum (phlegm) production
Cough
Ask if your patient has a cough. If no, skip this section. If yes, determine the following:
1. Do you also have difficulty breathing? If so, what came first: the difficulty breathing or the
cough?
2. Is the cough barking or hacking?
3. When do you cough?
What activities make you cough?
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4. How long have you had it? (duration)
Acute cough would be 14-21 days or less. Chronic would be longer than 14-21. Why 14-21?
Depends upon whom you ask as to the definition of acute. Some say less than 14 days, some say
less than 21.
5. How frequently do you cough?
6. What time of day do you cough?
What is diagnosed as night-time asthma can be acid reflux disease irritating and inflaming the
esophagus.
7. Is your cough productive?
Productive: patient coughs up sputum (phlegm). If there is
excessive phlegm a doc will often ask the patient to collect the
sputum over a 24 hour period and then evaluate it. In the
picture to the right three layers are shown: froth at the top, a
thick and non-solid layer in the middle and a more solid
bottom layer of pus.
Dry or non-productive: no sputum/phlegm upon coughing.
Sometimes asthma presents as only a dry cough.
8. Is there blood when you cough?
If the answer is yes, you have to distinguish whether they are coughing blood (coming from the
lung) or spitting up blood (coming from the stomach).
a. Hemaptysis – coughing up blood from the lung.
Blood coming from the lung usually denotes a serious illness such as tuberculosis,
tumors, pulmonary embolism (PE), bronchiectasis, or cardiac disease. The patient should
be questioned carefully regarding how much is expelled, how frequently, if they have any
weight loss they cannot explain, etc.
Hemaptysis possible symptoms.
Compare these to hematemesis symptoms below.
i. Accompanied by a cough
ii. Frothy
iii. Bright red in color
iv. Presence of pus
v. Dyspnea
vi. Individual may be a cardiac patient
b. Hematemesis: Blood coming from the stomach.
Here are some possible symptoms
i. Nausea and vomiting
ii. Blood is not frothy
iii. Vomit looks like coffee grounds
iv. Food is always mixed in with the blood
v. Patient may have GI disease
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9. Do you cough more in one position than in another?
10. What medications are you taking? Many ACE inhibitors and all of the “–pril” medications
(lisinopril, etc.) can cause a dry cough.
11. What makes it better (alleviates) or worse (aggravates)?
12. Does the cough have an associated manifestation? What is the location of this manifestation?
Sputum
If your patient has sputum/phlegm, you need to determine what it’s characteristics are.
Yellow-green: indicates bacterial infection
White: often a viral infection, but can also be bronchitis.
Rusty: indicates pneumococcal infection (strep pneumonia)
Currant jelly: in other words, gelatinous and bloody, indicating blood + sputum
Pink-blood tinged: acute pulmonary edema, leaking of fluids into the bronchii, left
ventricular heart failure
Frothy: heart failure
Bloody (not as gooey as the currant jelly kind): can indicate pulmonary embolism, cancer,
TB…
Foul smelling: abscess of the lung, pus in the alveoli or bronchial tubes. CSF patients will
have this.
Shortness of breath (SOB)
1. Position
Is there a position that makes it better or worse? More on this in the pathology section too.
Different pathologies have shortness of breath that is alleviated or aggravated in certain
positions. This called autopnia.
2. Aggravating or alleviating factors.
3. Time of day when patient is short of breath or more short of breath.
4. Self care
Here are some breathing patterns to be aware of when evaluating shortness of breath and rate of
breathing
Dyspnea – difficulty or pain upon breathing
Tachypnea – respiratory rate greater than 25 breaths per minute
Bradypnea – respiratory rate less than 8 breaths per minute
Paroxysmal Nocturnal Dyspnea or PND – sudden onset of SOB during sleep
Orthopnea – SOB while lying flat
Platypnea – SOB while sitting up (better when lying flat)
Trepopnea – SOB while lying in one lateral decubitus position which is improved by
turning on the opposite side
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Chest pain upon breathing
Always rule out a cardiac reason for pain upon breathing. Heavy pain in the center of the chest upon
breathing is almost always cardiac in nature. Cardiac is always central. Can’t emphasize this enough.
1. When does it happen?
2. How would you describe the pain?
Lung pain will usually be described as a “stitch” in the chest, a stabbing pain, worse when they
breathe in. Ask them to rate the pain on a scale of 1-10 with 10 being unbearable. Ask the patient
to point to where the pain is.
3. What brings it or brought it on?
4. What are the aggravating or alleviating factors? What interventions? (did you use an inhaler,
etc.)
5. What medications are you taking?
6. What self-care or prescribed care have you tried or do you do regularly?
There are numerous etiologies for chest pain. Here are some organs in which there can be dysfunction
generating a pain in the chest. Some examples of disease are given, but these are by no means the only
dysfunctions that can cause chest pain:
Pleura
Pleuritic dysfunction in the parietal pleura is one example. Manifests as a sharp stabbing
pain upon inspiration.
Esophagus
Esophageal reflux disease for instance
Heart
Myocardial infarction
Gallbladder
Cholecystitis
Chest Wall
Costochondritis
Large blood vessels
Dissection of the vessel for instance.
Lung
Pneumothorax.
Past medical history (PMH)
It is always relevant to know about histories of asthma, TB, or other lung diseases and URI’s (upper
respiratory infections). TB is often found in low income settings, in international travelers, people
migrating from high density countries, long-term care facility workers, hospital workers, people who
have been in prisons, residents of dorms, HIV patients, people who have been taking immunosuppressants for a long time (think steroids), and diabetic patients. Also, people who move to an urban
setting from a rural one are more susceptible to urban diseases such as TB.
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Take into consideration the following:
1. Recent infection
2. History of allergy (self or family)
3. History of TB or asthma.
Smoking
Whether patient has quit smoking or still does, this is relevant information as well in a pulmonary
assessment.
1. What do or did you smoke?
Cigarettes, pipe, cigars…
2. How frequently did or do you smoke? How long have you or did you smoke?
How many packs per day or pack years?
“Pack years” is a way to quantify the collective damage of cigarette smoking. It’s not so much a
measure of how many packs one has smoked cumulatively per year, but the average number of
packs one daily and for how many years. The higher the number, the worse the damage.
To calculate “pack years:”
a. Multiply number of cigarettes smoked per day by number of years smoked.
b. Divide by 20.
3. Do you or have you lived with a smoker?
Environmental exposure
1. Where do you work and play?
If you work in a bar (exposure to cigarette smoke), in a dusty environment (silica, concrete dust,
asbestos, coal, even wood dust), hazardous environment, etc. you are more at risk for lung
damage/pneumoconiosis.
2. Do you do any self care (cardio workout) for your lungs?
3. Education?
4. Health promotion
5. Have you had a PPD or chest x-ray
6. What immunizations have you had?
Lung exam
After the patient interview and data gathering, you need to gather some objective data.
Inspection
1. First verify that the sternocleidomastoid muscles are the same side.
If so, see if trachea protrudes to one side or another. If the lung is scarred and collapsed it will
pull the trachea to one side.
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2. Look for symmetry of both the clavicular region and the thoracic cage. Unevenness could
indicate breakage. Uncorrected or poorly healed bone breakage of the clavicle or ribs can affect
the ability of the lung to expand properly.
Longstanding lung disease are indicated by a hollowing under the clavicle. This could include
long term asthma, cancer, tuberculosis, etc.
3. Look at breathing and see how chest wall moves. Ask them to deepen breath if needed.
Use a measuring tape around the circumference of the chest at the level of the nipples/4th
intercostal space. Ask the patient to exhale fully and hold while you measure. Hold the tape in
place, but loosely enough that it will expand along with their chest. Ask them to breathe in fully
and measure again. Compare the difference between the two measures. There should be a
difference of between 2 ½ and 3 inches in the diameter (super atheletes: 4-5 inches) for healthy
lung expansion. Obstructive or restrictive diseases of the lung will have smaller measurement
differences.
4. Measure the respiratory rate if you have not already (you have!). 12-20 breaths per minute is
considered within normal ranges. Also observe the regularity of breathing as well as whether it
seems to be an effort to breathe. Note whether the patient breathes from the chest or from the
diaphragm.
5. Look at lips and tongue (central) and nails (peripheral at
fingers/toes) for bluing indicating compromised lung
function.
6. Look at the distal interphalangeal and base of nailbed from
the side. You are looking for clubbing of the fingers. This is
enlargement of the connective tissues in this area. It is
painless and the fingertips and nails are curved and warm.
A patient with clubbing will also have Schamroth’s sign, the
loss of the subungual angle.
While clubbing can be hereditary, it is often symptomatic of chronically low blood oxygen levels
and indicative of disease such as interstitial fibrosis, tumor, bronchiectasis, heart disease and
endocarditis. It can also be caused by a lung abscess or lung cancer.
Be aware that diseases which cause mal-absorption like cystic fibrosis or celiac disease can also
cause clubbing.
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Know these main symptoms of pulmonary disease:
Palpation
When palpating for a lung assessment, there are 4 things you are doing:
1. Identifying any areas of tenderness if the patient has reported pain or
injury
2. Assessing observed abnormalities.
3. Assessing “respiratory excursion” or the range of respiratory movement
like you did above with the tape measure.
4. Evaluating tactile fremitus. This is the term for vibrations (some people call it “thrills”) felt
from lungs when the patient is speaking. To evaluate tactile fremitus use only one hand and find
the area of your hand that is most sensitive to vibration. For many people this is the back or ulnar
side of the hand. You probably won’t find that your fingertips are sensitive enough to vibration
for that to work for you. Finger pads are more tactile than vibration sensitive.
a. Solid tissues such as scars will transfer vibration well.
b. Fluids (pleural effusion, fluid in the lung) and air space (pneumothorax or emphysema
does not transmit well.
Here are some ways to feel for tactile fremitus. Once you have picked a method that works best
for you, procede to the steps below.
c. Have your patient repeat the same phrase which makes full rich vibration sounds such as
“ninety-nine” or “one-one-one.”
d. Place the part of your hand where you best feel vibration on the right shoulder just above
the clavicle and feel. Move to the left at the same level and feel again. Work your way
down zigzagging like this to about the 3rd or 4th intercostal space on women and slightly
lower for men. The vibration should be the same for both sides, though it decreases at the
lower levels.
e. Note any increases between left and right. Remember that there will be a decrease where
there is fluid or excessive air space and an increase where there is solidity such as
scarring, tumors or pneumonia.
f. Repeat on the back of the body, noting your findings. The illustration indicates the
sequence on the back to use for this procedure.
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Tactile fremitus:
Increases with pneumonia.
Decreases with pneumothorax, emphysema, pleural effusion, COPD, and fat.
Percussion
When you percuss you are feeling mostly for resonance.
Hyperresonance is found in cases such as emphysema while dullness is found in pneumonia or tumors.
Some other things you might feel:
Flatness. This is soft in intensity but high in pitch and short in duration. Percuss on your thigh to
feel this. Mandyam’s notes don’t cover flatness at all… Got it from this groovy website:
Free-ed.net. Flatness indicates about the same as dullness: solidity of some sort. You will hear
flatness or dullness on tumors, pneumonia, etc.
Dullness is medium in intensity, pitch and duration of feedback sound when you percuss. Percuss
on your liver to feel this. Mandyam’s notes also say you can hear dullness on the thigh. You
might hear this in pleural effusion, tumors, pneumonia, anything solid in the lungs.
Resonance is loud in intensity, low in pitch and long in duration of sound made. Percuss a
normal lung to hear resonance.
Tympany is the term used to describe a percussion sound which is loud and sounds musical. You
can percuss your puffed out cheek to hear what this sounds like. You can also hear it over the
abdomen. Tympany or hyperresonance indicates empty space – it’s like tapping on a drum head.
This indicates lots of empty air space – pneumothorax, emphysema.
To percuss, identify you dominant and non-dominant hands. You tap
with the middle finger of your dominant hand on the middle finger of
the non-dominant hand at the middle phalanx. (For this reason, you
should keep your nails short or you’ll be cleaning up your own blood!)
Stretch your non-dominant middle finger out on the spot where you wish
to percuss. Don’t let your other fingers touch the patient.
With your dominant hand you tap using the motion of the wrist.
Withdraw the striking finger immediately to avoid dampening the
sound. Strike once, wait long enough to hear the whole duration of the
sound and if you need to hear it again, strike once more.
Move symmetrically to the other side of the chest to compare the sounds coming from the same level on
both sides.
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Shown here is a one-handed method of percussion in which the practitioner is
tapping in the intercostal spaces
This is also called “direct percussion.”
Here is the two handed method of percussion, described above (all but the
middle fingers are indeed lifted off the skin, but it doesn’t show clearly in the
photo).
This method is referred to as “indirect percussion.”
Here is the anterior percussion pattern to follow when palpating the
chest. Obviously, be sensitive to women’s breast tissues. Position 5 is
on the lateral of the body. Bear in mind that lung cancer often starts on
the periphery and moves inward.
Here is the pattern to follow on the posterior side
Always move from one side to the other symmetrically. No need to percuss over the
shoulder blades since all that will tell you is that there is bone there…and you pretty
much know that already!
Auscultation
Auscultation refers to listening to lung sounds with your stethoscope to estimate airflow through the
tracheobronchial tree, detecting any obstructions and assessing the condition of the surrounding lung and
pleural space.
General Guidelines:
You can position your patient either sitting or lying supine for this, though sitting gives easier
access to both sides of the body and is often more comfortable for patients with breathing
difficulty.
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Show your patient how you want them to breathe, through the mouth and more deeply/forcefully
than usual.
Use the diaphragm side of your stethoscope to listen. Start at the top of the back and work
downward moving symmetrically from left to right as you zigzag your way down. Next, start at
the top of the chest moving symmetrically downward. Compare each side as you listen, noting
differences from one side to another.
Listen to one full breath (inhale + exhale) before moving locations. Watch for patient discomfort
– lightheadedness and fainting which indicate hyperventilation.
Normal breathing sounds
Inhalation or inspiration normally takes 2ce the time that an exhale takes. Noises are generally softer in
the vesicular/lobe areas and louder and harsher over the trachea and bronchovesicular areas.
1. Bronchial/Tracheal
Listening over the trachea and larynx on the centerline of the body, you will
hear higher pitched, louder than sounds heard over the lung and harsh in
nature. Like wind blowing through a hollow tube. The sounds are:
Short = inhale
Long = exhale
You will not hear these noises elsewhere in a normal lung. If you hear them
over the posterior or lateral chest wall, this is pathological.
2. Broncho-vesicular
These sounds are heard near the center over the larger branchings of the bronchial tree. They are
moderate in pitch and in volume.
3. Vesicular
These are normal breath sounds made at the sites over the alveoli (but not over the manubrium,
sternum or interscapular regions). They sound long on inhale and short on exhale. They are low
in pitch, soft in volume and rustling.
The timing of normal breathing sounds is like this:
Tracheal: inspiration = expiration
Bronchial: inspiration is about 1/3 the length of expiration.
Bronchovesicular: inspiration = expiration
Vesicular: inspiration is 3 times longer than expiration.
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Adventitious or extra sounds
Abnormal sounds include, but are not limited to:
Ronchi
Ronchi are coarse rattling sounds produced on the exhale that tend to be continuous. The
sounds are usually clear, but may change if there is coughing. The sounds are low pitched
and usually occur when there is mucous in the bronchii.
Wheezes
Wheezes are musical and high pitched continuous sounds. I think they sound like a very soft
high note on a clarinet. These are caused by partially constricted or obstructed airways. In
asthma you’ll hear them on the exhale most of the time, but can also be on the inhale.
Asthma and bronchitis can produce this noise. This said, not all that wheezes is asthma! Here
are some other possible causes for wheezing:
o Bronchitis (often heard on the inhale)
o Vocal chord dysfunction
o Aspiration of a foreign body
o Infections such as laryngitis
o Croup
o Congestive heart failure
o COPD
o Hard forced expiration in normal/undiseased people
o Cystic fibrosis
Crackles or rales
Fine or coarse rattling sounds, usually non-continuous. High pitched fine crackles sound like
carbonated beverages when you first pour them out of a can. The coarse rales can sound like
velcro when you pull it apart.
You usually hear this when the patient breathes in and sometimes when they start to exhale.
The cause is usually fluid in the alveoli and bronchioles. Coughing makes it sound louder.
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Pneumonia and emphysema can produce crackles/rales.
Friction rub or pleural rub
Pleuritis (inflamed pleura) can cause this scratchy sound, which sounds somewhat like Saran
wrap when you crinkle it. Can also sound like squeaking leather. This is the sound of two dry
surfaces rubbing against each other. Pulmonary embolism can also cause this noise. Doesn’t
follow inspiration or expiration. If you press deeply on it the sound will disappear.
A pulmonary embolism is a blood clot in the pulmonary artery which can result in infarction
of tissue, can cause a gangrenous place, or can heal and leave a scar.
Stridor
This is a high pitched noisy respiration sound, sometimes rattley, sounding like wind
blowing. This is usually heard on inspiration and is caused by obstruction of the upper
airway. Croup produces these noises along with a barking cough. Can also be caused by an
inflamed epiglottis or larynx.
Vocal sounds or auscultation of the spoken voice.
You can also learn a lot about the internal condition of the lung by listening with your stethoscope to the
sounds made in the lung when the patient vocalizes. This is also called vocal fremitus.
Bronchophony – have the patient say “99” while you listen on the chest. It should sound
muffled. If you clearly hear “99” then there is something dense in the lung.
Egophony – have the patient say “eeeeee.” If there is consolidation in the lung you will hear
“aaaaaaaa” (ay like the Fonz…not “ah”).
Whispered pectoriloquy – have the patient whisper “1-2-3.” If the sound is muffled, that’s
good. If you hear it clearly, there is some sort of consolidation in the lung.
Note: TB is often in the apical area of the lung and can produce a cavity called an ‘apical
lesion’ which is a caseous necrosis filled with gooey greenish pus. Produces a cold abscess,
not a hot one with inflammation and a “whispering dome” which transmits sound clearly in
places.
In summary:
You should know anatomical landmarks both surface and interior, pertinent vocabulary and how to
express what you have found from the assessment, symptoms and signs, how to perform the exam, how
to present the information, how to formulate a differential diagnosis.
Indications of Lung Pathologies
Pathologies sometimes are very obvious. In your interaction with the patient you might notice obvious
signs of respiratory distress:
Anxiousness
Labored breathing
Clutching of the chest
Engaging accessory muscles
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Cyanosis
o Cyanosis may be peripheral, affecting hands and
feet. Warming can decrease it. Indicative of
decreased cardiac output.
o Central cyanosis is of the lips, tongue, and
sublingual area. Right to left shunts.
o Pseudocyanosis is a blue pigmentation of the skin
resulting from something other than a lack of
oxygen, usually drug related. This is not true
cyanosis.
Gasping
Stridor
Clubbing of the nails
Also, make it a habit to observe the body habitus or the basic shape of the body which may have been
modified by disease or dysfunction. Many of the postures below which fall out of the range of the norm
can cause respiratory problems.
Barrel Chest
The 2nd posture above shows a barrel chest, as does the picture to the left. This is determined by
calculating a ratio of the anterior-posterior to the lateral. Normal is 0.70 to 0.75. Anything
greater than 0.9 is considered abnormal in an adult. In English, look
from the side of the patient – the anterior to posterior depth in a
normal patient is smaller than the full on frontal or posterior view. A
barrel chest is the same or wider when viewed from the side.
On a chest Xray the lung will show very little white area. All of this
can indicate COPD, emphysema + bronchitis. If the Xray shows a
big dark empty sac where the lung should show, this is an indication
of emphysema.
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Pursed Lips while Breathing
COPD patients will often purse their lips while breathing. This decreases dyspnea, decreases
respiratory rate, increases tidal volume and decreases the work of breathing. This increases
resistance to airflow, forcibly dilating small bronchi.
White Noise or Noisy Breathing
You can hear this without a stethoscope in chronic bronchitis patients. The sound occurs with air
turbulence caused by narrowed airways. It lacks a musical pitch.
Abnormal Breathing Patterns
Apnea – lack of breath indicating cardiac arrest
BIOT’s – comes from increased intercranial pressure, drugs, and medullary suppression.
Cheyne Stokes – can be caused by CHF, drugs, cerebral ischemia
Kussmaul’s – metabolic acidosis
Specific Lung Pathologies
COPD
Chronic Obstructitive Pulmonary Disease patients have both chronic bronchitis and emphysema.
However, a patient will typically be classified as either suffering primarily from one or the other. They
are classified with the terms “pink puffers” and “blue bloaters.”
Pink Puffers
Patients suffering primarily from emphysema are referred to as "pink
puffers." The term is derived from the reddish complexion and the "puffing"
(hyperventilation) seen in patients suffering from Type A Chronic
Obstructive Pulmonary Disease (COPD).
A pink puffer is typically thin and breathes with pursed lips, has
tachypnoeic (increased respiratory rate) and experiences breathing
difficulty. An arterial blood gas test shows evidence of less hypoxemia than
blue bloaters and no carbon dioxide retention. The prognosis for pink
puffers is thus better than for blue bloaters. In addition to the signs above, look for Dahl’s Sign,
two patches of hyperpigmentation on the elbows and above the knees. This comes from long
term sitting forward with elbows on knees to improve breathing. Also look for nicotine stains
and a “smoker’s face” – very ruddy, possibly purplish or bluish.
Blue Bloaters
Patients with COPD and suffering primarily from chronic
bronchitis are referred to as “blue bloaters.” This term is derived
from the bluish coloration of the lips and skin commonly seen in
patients with Type B COPD.
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A blue bloater has a history of cough with sputum for 3 months to one year or more. Blue
bloaters experience cyanosis due to decreased amounts of oxygen reaching the blood. Ankles and
legs may be swollen and there may be distention in the neck veins. Blue bloaters develop signs
of right-sided heart failure. An arterial blood gas test will show evidence of hypoxemia, carbon
dioxide retention and compensated respiratory acidosis.
Prognosis for blue bloaters is poor, most dying within 2-4 years. Long-term oxygen therapy is
about the only way to improve prognosis.
Pneumonia
Decreased chest expansion.
Tactile fremitus increases.
Dull sound upon percussion over the infiltrate or infected
areas.
Increased breath sounds
You may hear crackles
This is chest X-ray of a patient with pneumonia in
the right upper lung. The consolidation noted will be
dull when you percuss on it.
This shows infiltrates in the right upper lung. The
triangular looking wedge you see is the fissure between
the upper and middle lobes.
Pneumothorax
Uneven expansion of the chest
Decreased tactile fremitus.
Hyper resonance
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Decreased diaphragmatic excursion
Absent or decreased breathing sounds.
This is a chest Xray of pneumothorax on the left
side.
The top label points to the collapsed lung tissue. The
black part on the patient’s left side is just empty space
at this point.
The middle label on the left of the x-ray indicates a
mediastinal shift to the patient’s right.
The bottom label points to the empty space.
Emphysema or Pleural Effusion
Barrel chest: increased antero-posterior diameter
Sits in tripod position, may have Dahl’s sign
Hyper resonance
Decreased breathing sounds upon auscultation
Occasional wheezing
Pleural Effusion results in a chest X-ray that looks like this:
This patient has a pleural effusion on the left side (our right as
we are viewing it). Note the difference between the left and
right. Look at the end of this document and compare this with
the normal chest x-ray given there.
Asthma
Low tactile fremitus due to increased alveolar sacs
Uses accessory muscles to breathe, looks uncomfortable
Hyper resonance upon percussion
Prolonged inspiration, wheezing upon expiration
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Gibbus
This is angulation of the spine. Note the bluish
bump on the spine about 2/3 of the way down. This
is tuberculosis of the spine.
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Chest X-Rays (CXR)
This is a normal CXR. It has been included for comparison with the X-ray examples given above as well
as for those that follow.
The X-ray below shows a mass in the right upper lung.
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This X-ray shows an aneurism in the aortic arch
Below is pericardial effusion and massive cardiomegaly
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Cardiomyopathy. Enlargement is greater than ½ of thoracic width
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