chest exam clinical chapter

8/4/2019 Chest Exam Clinical Chapter

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46 Chest ExaminationPETER G. TUTEUR

D e f i n i t i o n

T h e p a t i e n t ' s h i s t o r y d e t e r m i n e s t h e s c o p e a n d i n t e n s i t y o f

t h e c h e s t e x a m i n a t i o n . W h e n t h e h i s t o r y e l i c i t s s u s p i c i o n o f

t h e p r e s e n c e o f a c h e s t p r o b l e m , t h e p h y s i c a l e x a m i n a t i o n

o f t h e t h o r a x m u s t b e e x p a n d e d b e y o n d a m i n i m a l s c r e e n -

i n g e x a m i n a t i o n t o d e t e r m i n e t h e n a t u r e o f t h e p r o b l e m s o

t h a t a d i a g n o s i s c a n b e m a d e .

Technique

T h e s e t t i n g f o r t h e c h e s t e x a m i n a t i o n m u s t b e e n v i r o n -

m e n t a l l y c o m f o r t a b l e f o r b o t h c l i n i c i a n a n d p a t i e n t. The

p h y s i c a l e x a m i n a t i o n b e g i n s w i t h t h e c o m m e n c e m e n t o f h i s -

t o r y t a k i n g . T h e e x a m i n e r e x t e n d s a h a n d i n g r e e t i n g , a s k s

a b o u t t h e s y m p t o m s t h a t i n i t i a t e d t h e v i s i t , a n d b e g i n s p h y s -

i c a l i n s p e c t i o n , n o t i n g b o d y p o s i t i o n , a s s e s s i n g d e g r e e o f

c o m f o r t , i n s p e c t i n g a n d p a l p a t i n g t h e h a n d s , a n d n o t i n g

g r i p s t r e n g t h . T h e h i s t o r y d e t e r m i n e s t h e e x a m i n a t i o n f o r -

mat . E x p e r i e n c e d c l i n i c i a n s e x p l o i t t h e h i s t o r y t o h e l p t h e m

" l o o k " f o r s p e c i f i c p h y s i c a l f i n d i n g s t o a n s w e r q u e s t i o n s

p o s e d b y t h e t o t a l i t y o f d a t a c o l l e c t e d p r e v i o u s l y . When

u s i n g t h i s p r o c e s s , i t i s u n u s u a l f o r t w o c o n s e c u t i v e c h e s t

e x a m i n a t i o n s t o b e i d e n t i c a l . B y t h e t i m e t h e p h y s i c a l e x -

a m i n a t i o n i s c o m p l e t e , e v e n b e f o r e l a b o r a t o r y e v a l u a t i o n s

a r e i n i t i a t e d , t h e d i a g n o s i s s h o u l d b e r e a s o n a b l y c e r t a i n .

T h e p u l m o n a r y e x a m i n a t i o n c o n s i s t s o f i n s p e c t i o n , p a l -

p a t i o n , p e r c u s s i o n , a n d a u s c u l t a t i o n . T h e i n s p e c t i o n p r o c e s s

i n i t i a t e s a n d c o n t i n u e s t h r o u g h o u t t h e p a t i e n t e n c o u n t e r .

P a l p a t i o n , c o n f i r m e d b y p e r c u s s i o n , a s s e s s e s f o r t e n d e r n e s s

a n d d e g r e e o f c h e s t e x p a n s i o n . A u s c u l t a ti o n, a m o r e s en -

s i t i v e p r o c e s s , c o n f i r m s e a r l i e r f i n d i n g s a n d m a y h e l p t o

i d e n t i f y s p e c i f i c p a t h o l o g i c p r o c e s s e s n o t p r e v i o u s l y r e c -

o g n i z e d .

I n s p e c t i o n

I n s p e c t i o n ( T a b l e 4 6 . 1 ) i s a n a c t i v e p r o c e s s . I t i s d o n e w i t h

t h e e y e s a n d t h e i n t e l l e c t . I t b e g i n s w i t h th e i n i t ia l g r e e t i n g

a n d c o n t i n u e s u n i n t e r r u p t e d l y d u r i n g t h e e n t i r e d a t a c o l -

l e c t i o n p r o c e s s . E v e n a s t h e fi r s t s e r io u s q u e s t i on o f t h e fu l l y

d r e s s e d p a t i e n t i s a s k e d , t h e i n s p e c t i o n b e g i n s t h r o u g h a c -

t i v e o b s e r v a t i o n . S p e c i f i c a l l y , o n e m u s t n o t e t h e d y n a m i c s

o f t h e p a t i e n t ' s f a c i a l e x p r e s s i o n i n r e l a t i o n s h i p t o p h y s i o -

l o g i c a c t i v i t i e s ( i n s p i r a t i o n a n d e x p i r a t i o n ) a n d t o t h e q u e s -

t i o n s a s k e d b y t h e e x a m i n e r . S i m i l a r l y , a c t i v e o b s e r v a t i on

s k i l l s a r e u s e d t o s e a r c h f o r t h e u s e o f p u r s e d l i p s d u r i n g

e x p i r a t i o n , t h e a c t i v i t y a n d d e v e l o p m e n t o f t h e s t e r n o c l e i -

d o m a s t o i d m u s c l e s , t h e u s e o f o t h e r a c c e s s o r y m u s c l e s o f

v e n t i l a t i o n , t h e p r e s e n c e o f s h o u l d e r g i r d l e f i x a t i o n i n r e -

l a t i o n s h i p t o t h e u s e o f t h e s e a c c e s s o r y m u s c l e s , t h e f l a r i n g

o f t h e n a s a l a l a e , t h e p r e s e n c e o f j u g u l a r v e n o u s d i s t e n t i o n ,

t h e d e g r e e o f c o m f o r t , a n d , a s d i s c u s s e d i n p r e v i o u s c h a p -

t e r s , t h e p r e s e n c e o f c y a n o s i s a n d c l u b b i n g . N o t o n l y m a y

a v o l u n t a r y s m i l e b e h e l p f u l i n a s s e s s i n g n e u r o l o g i c f u n c -

t i o n , b u t a l s o i n s p e c t i o n o f t h e t e e t h a t t h a t t i m e ( e v e n t h o u g h

y o u a r e j u s t s t a r t i n g t o t a k e t h e h i s t o r y ) m a y r e v e a l e x t e n s i v e

p y o r r h e a t h a t s e r v e s t o a l e r t t h e c l i n i c i a n t o a d e n t a l p r o b -

l e m t h a t h a s a p o t e n t i a l a s a b a c t e r i a l s o u r c e f o r n e c r o t i z i n g

pneumonia .

A s t h e i n t e r v i e w c o n t i n u e s , a s s e s s m e n t o f t h e l e v e l o f

c o n s c i o u s n e s s a n d t h e a p p r o p r i a t e n e s s o f b e h a v i o r m a y l e a d

o n e t o s u s p e c t a p r i m a r y p u l m o n a r y p r o c e s s t h a t s e c o n d -

a r i l y p r o d u c e s a l t e r a t i o n s o f c e n t r a l n e r v o u s s y s t e m f u n c -

t i o n . T w o e x a m p l e s a r e r e s p i r a t o r y a c i d o s i s a n d c e r e b r a l

m e t a s t a s e s f r o m p r i m a r y c a r c i n o m a o f t h e l u n g . D r e s s , t o o ,

m a y g i v e a c l u e t o o c c u p a t i o n o r h o b b y , g r o o m i n g m a y b e

r e l a t e d t o t h e c o n s c i e n t i o u s n e s s w i t h w h i c h t h e p a t i e n t m a y

f o l l o w a h e a l t h c a r e p l a n , a n d a b u l g i n g s h i r t p o c k e t m a y

b e s t u f f e d w i t h a n o p e n p a c k a g e o f c i g a r e t t e s , a n i m p o r t a n t

c l u e t o t h e p o s s i b i l i t y o f a c h e s t p r o b l e m .

T h e i n s p e c t i o n c o n t i n u e s e v e n t h o u g h t h e p a t i e n t r e -

m a i n s f u l l y c l o t h e d a n d t h e " f o r m a l " p h y s i c a l e x a m i n a t i o n

has not yet begun . I t i s o f t e n h e l p f u l t o m a k e a n i n i t i a l

a s s e s s m e n t o f t h e v e n t i l a t o r y p a t t e r n e a r l y i n t h e d a t a c o l -

l e c t i o n p r o c e s s . S p e c i f i c a l l y , o n e s h o u l d b e c o n c e r n e d a b o u t

r a t e , r h y t h m , b r e a t h v o l u m e , a n d t h e a p p a r e n t e f f o r t a s -

s o c i a t e d w i t h b r e a t h i n g . M o s t r e s t i n g a d u l t s b r e a t h e a b o u t

1 2 t i m e s p e r m i n u t e , n o t t h e c u s t o m a r y 2 0 o f t e n n o t e d i n

m e d ic a l r e c or d s . T i d a l v o l u m e s r a n g e a r o u n d 6 0 0 m l . E x -

c e p t f o r a n o c c a s i o n a l s i g h , t h e n o r m a l v e n t i l a t o r y p a t t e r n

i s r e g u l a r a n d e f f o r t l e s s . I n d i s e a s e t h i s p a t t e r n m a y c h a n g e .

T h e a s s e s s m e n t o f v e n t i l a t o r y p a t t e r n d u r i n g t h e h i s t o r y

d o e s n o t g i v e t h e p a t i e n t a n o p p o r t u n i t y t o a l t e r b r e a t h i n g

i n v o l u n t a r i l y a n d c o n f o u n d t h e d a t a . I t a l s o a l l o w s o n e t o

p r o c e s s d a t a e a r l i e r a n d t o i n c r e a s e e f f i c i e n c y .

W h e n t h e " f o r m a l " p h y s i c a l e x a m i n a t i o n d o e s b e g i n , t h e

s e t t i n g i s c h a n g e d . I n s p e c t i o n c o n t i n u e s , b u t w i t h t h e p a -

t i e n t u n d r e s s e d f r o m t h e w a i s t u p , e i t h e r e n t i r e l y o r s e -

q u e n t i a l l y , a s d r a p e s a r e c h a n g e d t o e x p o s e o n l y t h o s e a r e a s

b e i n g a c t i v e l y o b s e r v e d . A c h a p e r o n s h o u l d b e p r e s e n t w h e n

it would make either the patient or the examiner more

comfortable .

F i r s t , o n e s h o u l d o b s e r v e f o r t h o r a c i c c a g e d e f o r m i t y

( p e c t u s e x c a v a t u m , p e c t u s c a r i n a t u m , s c o l i o s i s , k y p h o s i s ,

s u r g i c a l o r t r a u m a t i c s c a r s , t h o r a c o p l a s t y , g y n e c o m a s t i a , a n d

s o - c a l l e d b a r r e l c h e s t d e f o r m i t y ) . T h e p r e s e n c e o f s o m e s k i n

l e s i o n s m a y r e f l e c t i n t r a t h or a c i c p a t h o l o g y . T h e s e a r e " s t a t i c "

o b s e r v a t i o n s . E v e n m o r e u s e f u l i n f o r m a t i o n c a n be o b t a i n e d

a s t h e p a t i en t b r e a t h es , b o t h qu i e t l y a n d d e e p l y . S u c h " d y -

n a m i c " o b s e r v a ti o n s i n c l u d e t h e s e a r c h f o r s u p r a c l a v i c u l a r

o r i n t e r c o s t a l r e t r a c t i o n , p a r a d o x i c a l m o v e m e n t o f t h e a b -

domen, any degree of asymmetry or asynchrony of chest

e x p a n s i o n, m u s c l e w a s t i n g o r h y p e r t r o p h y , a n d r e p r o d u -

c i b l e g r i m a c e s o f d i s c o m f o r t a t a g i v e n p o i n t i n t h e v e n t i -

l a t o ry cy c l e . O t h e r n o n m a n u a l l y e l i c i t e d d a t a s u c h a s a u d i b l e

musical breath sounds-wheezes-strongly infl uence the

d e c i s i o n -m a k i n g p r o c e s s .

239


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240 I I I . THE PULMONARY SYSTEM

Table 46 . 1

Inspection

Palpation

Palpation (Table 46 .2) is the next stage of the examination .

With the patient disrobed , place the entire palm of each

hand first on the superior portion of both hemithoraces

and then, gently though firmly , move the hand inferiorl y

to just below the twelf th rib . Repeat the process moving

laterally and subsequently anteriorly ; search for rib de-

formities, nodules, and areas of tenderness. In the face of

a history of chest discomfor t, ask the patient to point to the

area(s) of gr eatest discomfort . Palpate the area with increas-

ing f irmness in an attempt to elicit tenderness and to assess

if this maneuver reproduces the patient's symptoms . Pay

particular attention to the costochondral junctions in pa-

tients reporting an terior chest pain to evaluate the possi-

bility of costochondritis .

Palpation is also important in the assessment of venti-

lation . One can sensitively assess the symmetry, synchr ony,

and volume of each br eath . This is done by examining the

patient posteriorly, placing the examiner's thumbs together

at the midline at the level of the tenth rib with hands gr asp-

ing the lateral rib cage ; both visual and tactile observations

are made both during tidal volume breathing and during

deep forceful inhalation . With the latter, thumbs typicall y

separate by approximatel y 2 to 3 cm .

A part of the palpatory portion of the chest examination

is to assess the position of the trachea . This is accomplished

best with the examiner stationed b ehind the patient, pal-

pating the anterior inferior neck just ab ove the jugular notch

by gently pressing the fingertips between the lateral tracheal

wall and the medial portion of the sternocleidomastoid mus-

Minimal

examination

Cough/

Dyspnea Wheezing expectoration

C i g a r e t t e

Hemoptysis smoke Environmental Other organ disease

F a c i a l e x p r e s s i o n : MN a s a l a l a e

P u r s e d l i p s

Pyorrhea

IM MI M MS t e r n o c l e i d o - I I

mastoid

Jugular venous M I I Right-sided heartd i s t e n t i o n f a i l u r e

Posture : I

Fixed shoulder M M Ig i r d l e

Diaphoresis

S p l i n t i n g

IM M M I IntraabdominalBreathing pattern : I

Rate MRhythm I

process

Cerebral

Breath volume I M I m e t a b o l i c a c i d o s i sDegree of effort I M I I I

Chest configur ation

S t a t i c :

Pectus excava-

tum

Spine contour

S u r g i c a l s c a r s I

Gynecomastia

I

I MI

B a r r e l c h e s t N o c l i n i c a l s i g n i f i c a n c e

( T A-P in adultdiameter)Dynamic :Expansion M I

Retraction I M I IParadoxicalmovementMuscles

I

I NeuromuscularGrimacesAud i b l e w hee z es I M M I

disorders

Upper airway

Skin :

Spider heman-

obstruction

Liver

giomasFibroma Neurofibr omatosisAcanthosis nigri- Malignancy

cans

Acne + striae I Cushing's disease/syndromeI = indicated ; M = mandatory .


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46. CHEST EXAMINATION 241

Table 46. 2

Palpation

c l e . Comparing one side to the other, an assessment is made

of the position of the trachea: mid line or deviation away

from the centrist position .

Tactile appreciation of vibrations transmitted to the sur -

face of the thorax as upper airways sounds are generated

by b reathing or speaking is a traditional thoug h insensitive

maneuver referr ed to as tactile or vocal fremitus . Egophony

is both more specific and sensitive . It is discussed under

auscultation .

Percussion

The purpose of percussion (Tabl e 46 .3) is to determine if

the area under the percussed finger is air fil led (sounding

resonant like a dr um), fluid filled (a dull sound) or solid (a

flat sound) . To make this interpretation it is important not

only to listen for the sound produced but also to feel the

intensity and fr equency of vibrations produced b y this ma-

neuver.

The technique of percussion is best accomplished by the

following approach :

1 . Press the distal phalanx of the middl e finger f i r m l y

on the area to be percussed and raise the second and

fourth fingers off the chest surface ; otherwise, both

sound and tactile vibrations will b e blunted .

2 . Use a quick, sharp wrist motion (like a catcher throw-

ing a baseball to second base) to strike the finger in

contact with the chest wall with the tip of the third

finger of the other hand . The best percussion site is

between the proximal and distal interphalang eal joints .

The novice quickly l earns to trim the fingernail to

prevent personal d iscomfort of minor abrasions and

lacerations .

3 . If the sound and the vibrations prod uced seem subop-

timal, make sure that the finger pl aced directly on

the thorax is making very firm direct contact with the

chest wall . If not, few vibrations and little sound will

b e pr o d u c e d .

Table 46. 3

Percussion

Minimal

examination

Cough/

D ys pn ea W he ez i ng expectoration

Cigarette

Hemoptysis smoke Environmental Other organ disease

P a l p a t i o n f o r

cutaneous or

subcutaneous

nodules

S o f tHardPalpation for

tenderness :

Costochondral

junction

Other

A s s e s s v e n t i l a t o r y

excursion :

Symmetry

Synchrony

Expansion

Assess observed ab-

normalities :

Gynecomastia

Spider heman-

giomas

P o s i t i o n o f t r a c h e a

I

I

I

I

I

I

I

MI

M

I

I

I

M

I

I

I

I

I

I

Neurofibr omatoses

Chest pain (M)

Chest pain (M)

Liver (M)

I = i n d i c a t e d ; M = mandatory .

Minimal

examination

Cough/

Dyspnea Wheezing expectoration

Cigarette

Hemoptysis smoke Environmental Other organ diseases

General percus-

sion :

Note over thorax I M I II d e n t i f i c a t i o n o f I I I I Lymphoma

focal changes

Diaphragmatic :Movement I M I Myasthemia and otherAsymmetry M M I neuromuscularAsynchrony I I I disorders

I = i n d i c a t e d ; M = mandatory .


4/6

2 4 2 II I . THE PULMONARY SYSTEM

4 . P e r c u s s t h e p o s t e r i o r , l a t e r a l , a n d a n t e r i o r c h e s t w a l l

i n s u c h a m a n n e r t h a t t h e l o n g a x i s o f t h e p e r c u s s e d

f i n g e r i s r o u g h l y p a r a l l e l t o t h e r i b s . Compare one

s i d e t o t h e o t h e r .

5 . O v e r e a c h a r e a , b e g i n p e r c u s s i o n s u p e r i o r l y a n d e x -

t e n d i n f e r i o r l y t o i d e n t i f y t h e l e v e l o f t h e d i a p h r a g m

d u r i n g q u i e t ( t i d a l v o l u m e ) b r e a t h i n g . N o t e t h e p o -

s i t i o n o f t h e d i a p h r a g m . T h e n a s k t h e p a t i e n t t o i n -

h a l e f u l l y a n d " h o l d i t" ; c o n t i n u e t o p e r c u s s i n f e r i o r l y

to determine the new level of the d iaphragm, now

d u r i n g f o r c e d m a x i m a l i n s p i r a t i on . T h e n , d o n ' t f o r -

g e t t o t e l l t h e p a t i e n t t o " b r e a t h e n o r m a l l y . " T h e d i f-

ference between the two levels is known as

d i a p h r a g m a t i c e x c u r s i o n a n d s h o u l d e q u a l 2 t o 3 c m .

A u s c u l t a t i o n

A u s c u l t a t i o n o f t h e c h e s t ( T a b l e 4 6 . 4 ) i s p a r t o f e v e r y c h e s t

e x a m i n a t i o n b u t i t i s t h e d a t a c o l l e c t e d d u r i n g i n s p e c t i o n ,

p a l p a t i o n , a n d p e r c u s s i o n t h a t a l e r t t h e c l i n i c i a n w h a t t o

l i s t e n f o r d u r i n g a u s c u l t a t i o n i n o r d e r t o i d e n t i f y t h e c o r r e c t

d i a g n o s i s m o s t e f f e c t i v e l y .

T h e s t e t h o s c o p e i s a n i n s t r u m e n t t h a t d o e s n o t s i g n i f i -

c a n t l y a m p l i f y s o u n d , b u t , m o r e i m p o r t a n t , a c t s a s a s e l e c t i v e

f i l t e r o f s ou n d . B r i e f l y , t h e b e l l f i l t e r s h i g h - f r eq u e n c y s o u n d s

g r e a t e r t h a n 1 5 0 0 c y c l e s p e r s e c o n d a n d t h e r e f o r e s h o u l d

b e u s e d t o d e t e c t l o w - f r e q u e nc y s o u n d s . O n t h e o t h e r h a n d ,

t h e d i a p h r a g m s e l e c t i v e l y f i l t e r s l o w - f r e q u e n c y s o u n d s . S i n c e

s o u n d s p r o d u c e d b y b r e a t h i n g t e n d t o b e o f r e l a t i v e l y h i g h

p i t c h , t h e c h e s t i s a u s c u l t e d w i t h t h e d i a p h r a g m

A u s c u l t a t i o n o f t h e c h e s t i d e a l l y i s p e r f o r m e d i n a q u i e t

r o o m w i t h t h e p a t i e n t e i t h e r s i t t i n g o r s t a n d i n g . When the

p o s t e r i o r t h o r a x i s e x a m i n e d , t h e p a t i e n t ' s a r m s s h o u l d b e

c r o s s e d a n t e r i o r l y t o m o v e t h e s c a p u l a s l a t e r a l l y a s m u c h a s

p o s s i b l e . C o m p a r i n g o n e s i d e t o t h e o t h e r i s a h e l p f u l m a -

n e u v e r t o i d e n t i f y t h e p a t i e n t ' s " n o r m a l . " A u s c u l t a t i o n s h o u l d

b e p e r f o r m e d d u r i n g t i d a l v e n t i l a t i o n , d e e p f o r c e f u l i n s p i -

r a t i o n , a n d f o r c e f u l e x p i r a t i o n . I t i s n o t o n l y i n t u i t i v e l y

o b v i o u s b u t r i g o r o u s l y p r o v e d t h a t t h e i n t e n s i t y o f b r e a t h

s o u n d s i s r e l a t e d t o f l o w r a t e s ; t h a t i s , t h e l o u d er t h e s o u n d ,

t h e g r e a t e r t h e f l o w r a t e , a l l o t h e r t h i n g s b e i n g e q u a l .

Basic Science

T h e p r i m a r y s t r u c t u r e o f t h e c h e s t i s d e s i g n e d t o f a c i l i t a t e

v e n t il a t i o n , w h i c h c a n b e a c c o m p l i s h e d o n l y b y i n c r e a s i n g

t h e i n t r a t h o r a c i c v o l u m e . T h i s i n c r e a s e i s d u e t o e l e v a t i o n

o f t h e r i b s , c o n t r a c t i o n o f t h e s c a l e n e a n d i n t e r c o s t a l m u s -

c l e s , a n d d e s c e n t o f t h e d i a p h r a g m . B e c a u s e o f t h e s t r u c t u r e

o f t h e r i b s , t h e s c a l e n u s m u s c l e s e l e v a t e t h e f i r s t r i b a n d t h e

s t e r n u m a n t e r i o r l y . T h i s c a u s e s s l i g h t i n c r e a s e i n t h e a n -

t e r o p o s t e r i o r (A-P) d i a m e t e r o f t h e c h e s t . T h e l o w e r r ib s

( T 6 - T 1 2 ) e x p a n d l a t e r a l l y b y c o n t r a c t i o n o f t h e i n t e r c o s t a l

m u s c l e s . T h e d i a p h r a g m , b y c o n t r a c t i n g , e l e v a t e s t h e l o w e r

r i b s s u p e r i o r l y a n d l a t e r a l l y a s w e l l a s i n c r e a s e s t h e i n t r a -

t h o r a c i c v o l u m e . A n y d e v i a t i o n f r o m t h e n o r m a l a n a t o m i c a l

r e l a t i o n s h ip o f t h e s k e l e t a l s y s t e m a n d t h e a s s o c i a t e d m u s -

c l e s w o u l d b e e x p e c t e d t o c a u s e s o m e a b n o r m a l i t y i n t h e

i n s p i r a t o r y c y c l e o f v e n t i l a t i o n

D u r i n g v e n t i l a t i o n, t h e m o v e m e n t o f g a s p r o d u c e s s o u n d

a u d i b l e w i t h a s t e t h o s c o p e . G e n e r a l l y , t h e v e l o c i t y o f g a s

m o v e m e n t i s p r o p o r t i o n a l t o t h e i n t e n s i t y o f t h e s o u n d .

Q u a l i t a t i v el y , t h e r e a r e t h r e e t y p e s o f " n o r m a l " b r e a t h

sounds : v e s i c u l a r , b r o n c h o v e s i c u l a r , a n d b r o n c h i a l . The

t h r e e s o u n d s a r e c l e a r l y d i f f e r e n t i a t e d b y t h e c h a r a c t e r i s t i c s

o f d u r a t i o n , p i t c h , a n d i n t e n s i t y ( s e e T a b l e 4 6 . 4 ) .

Vesicular sounds are thought to be produced by gas

m o v e m e n t t h r o u g h t h e d i s t a l m o s t p o r t i o n s o f l u n g u n i t s .

T h e y a r e l o w i n p i t c h , p r e d o m i n a n t l y i n s p i r a t o r y i n t i m i n g ,

a n d h a v e a b r e e z y c h a r a c t e r . B r o n c hi a l o r t ra c h e a l s o u nd s

a r e p r o d u c e d h ig h i n t h e u p p e r a i rw a y s a n d t r a c h ea . T h e y

a r e o f t e n l o u d a n d h i g h p i t c h e d . T h e ex p i r a t or y p h a s e i s

l o n g e r t h a n i n s p i r a t i o n a n d f o l l o w s a " s i l e n t g a p . " B r o n -

c h o v e s i c u l a r s o u n d s a r e i n t e r m e d i a t e b e t w e e n t h e t w o . U n d e r

n o r m a l c i r c u m s t a n c e s , a i r - f i l l e d l u n g u n i t s a c t a s h i g h - f r e -

q u e n c y f i l t e r s s o t h a t t h e b r o n c h i a l b r e a t h s o u n d s g e n e r a t e d

i n t h e u p p e r a i r w a y s a r e p o o r l y t r a n s m i t t e d t h r o u g h a i r -

f i l l e d l u n g . O n t h e o t h e r h a n d , w h e n t h e r e i s l i t t l e a i r - f i l l e d

l u n g b e t w e e n a i r w a y s a n d t h e s t e t h o s c o p e , o r w h e n l u n g

u n i t s a r e f i l l e d w i t h l i q u i d r a t h e r t h a n g a s , b r o n c h i a l b r e a t h

s o u n d s a r e h e a r d c l e a r l y . A s a r e s u l t , b r o n c h i a l b r e a t h s o u n d s

a r e h e a r d n o r m a l l y o v e r t h e t r a c h e a , t h e u p p e r s t e r n u m ,

a n d p a r a s p i n a l a r e a s o f t h e u p p e r t h o r a c i c v e r t e b r a e . A s

T a b l e 4 6 . 4

A u s c u l t a t i o n

M i n i m a l

e x a m i n a t i o n

Cough/

D y s p n e a W h e e z i n g e x p e c t o r a t i o n

C i g a r e t t e

Hemoptysis smoke E n v i r o n m e n t a l O t h e r o r g a n d i s e a s e s

B r e a t h s o u n d s :

G e n e r a l I

I n a p p r o p r i a t e :

L o c a t i o n o f I

b r o n c h i a l

b r e a t h s o u n d s

A b n o r m a l b r e a t h

s o u n d s :

W h e e z e s :

G e n e r a l

I MML o c a l I I

C r a c k l e s

E a r l y i n s p i r a t o r y

I M I ML a t e i n s p i r a t o r y M " C o l l a g e n v a s c u l a rG u r g l e s I I

d i s e a s e s " ; c o n g e s t i v e

h e a r t f a i l u r e

P u l m o n a r y e d e m a

I = i n d i c a t e d ; M = m a n d a t o r y .


5/6

46. CHEST EXAMINATION 2 4 3

o n e m o v e s p e r i p h e r a l l y a n d m o r e a i r - f i l l e d l u n g i s f o u n d

b e t w e e n t h e a i r w a y s a n d t h e s t e t h o s c o p e , b r e a t h s o u n d s f i r s t

b e c o m e b r o n c h o ve s i c u l a r i n q u a l i t y a n d e v e n tu a l l y v e s i c u l a r .

A s s t a t e d a b o v e , t h e i n t e n s i t y o f s o u n d i s a f u n c t i o n o f

a i r f l o w . C a r e f u l e x a m i n a t i o n o f u p p e r l u n g f i e l d s r e v e a l s

g r e a t e r i n t e n s i t y o f b r e a t h s o u n d s e a r l y d u r i n g t h e i n s p i -

r a t o r y p h a s e c o m p a r e d t o t h e s o u n d s g e n e r a t e d d u r i n g i n -

s p i r a t i o n o v e r l o w e r l u n g f i e l d s w h e r e t h e i n t e n s i t y p e a k s

r a t h e r l a t e . T h i s i s a r e f l e c t i o n o f t h e n o r m a l p h y s i o l o g i c

p h e n o m e n o n t h a t a s o n e i n h a l e s f r o m r e s i d u a l v o l u m e , t h e

i n i t i a l b o l u s o f g a s e n t e r s u p p e r l o b e a l v e o l i ; a n d o n l y w h e n

t h e s e l u n g u n i t s a r e n e a r l y f i l l e d i s t h e r e b u l k m o v e m e n t

o f g a s t o t h e l o w e r l u n g f i e l d s . W h e n t h e r e i s o b s t r u c t i o n

t o t h e a i r w a y s o f t h e u p p e r l o b e s , t h i s p a t t e r n i s n o l o n g e r

p r e s e n t .

T h e r e a r e t h r e e t y p e s o f a b n o r m a l b r e a t h s o u n d s . F r e -

q u e n t l y , t h e y a r e c o l l e c t i v e l y r e f e r r e d t o a s a d v e n t i t i o u s

b r e a t h s o u n d s . T h e m o s t ea s i l y r e c o g ni z e d a bn o r m a l b r e a th

s o u n d i s t h e w h e e z e , a c o n t i n u o u s m u s i c a l s o u n d p r o d u c e d

w h e n a c r i t i c a l v e l o c i t y o f g a s f l o w p a s s e s t h r o u g h a s l i t l i k e

opening . T h e p i t c h o f s o u n d i s a f u n c t i o n o f t h e c o m p l i a n c e

o f t h e m a t e r i a l p r o d u c i n g t h e s l i t l i k e o p e n i n g , n o t t h e o r i g -

i n a l s i z e o f t h e o b s t r u c t e d t u b e . O n e m a y a p p r e c i a t e w h e e z -

i n g o v e r t h e e n t i r e t h o r a x o r l o c a l l y . T h e o t h e r t w o a b n o r m a l

b r e a t h s o u n d s a r e n o n c o n t i n u o u s i n n a t u r e . Th e c r a c kl e ,

o f t e n c a l l e d " r a l e , " s o u n d s l i k e t h e r u b b i n g o f a l o c k o f h a i r

o v e r t h e e a r . I n v i v o , t h i s s o u n d i s p r o d u c e d b y t h e s n a p p i n g

o p e n o f p r e v i o u s l y c o l l a p s e d l u n g s t r u c t u r e s , e i t h e r a i r w a y s

o r a l v e o l i . T h e t i m i n g o f c r a c k l e s , w h i c h i n v a r i a b l y o c c u r

d u r i n g i n s p i r a t i o n , s h o u l d b e n ot e d . T h i s i s d o n e b y a s k i n g

t h e p a t i e n t t o e x h a l e f u l l y a n d t h e n n o t i n g t h e t i m i n g o f

c r a c k l e s d u r i n g t h e s u b s e q u e n t f u l l i n s p i r a t o r y m a n e u v e r .

W h e n c r a c k l e s a r e h e a r d d u r i n g t h e i n i t i a t i o n o f i n s p i r a t i o n ,

t h e y a r e c a l l e d e a r l y i n s p i r a t o r y c r a c k l e s . W h e n t h e y o c c u r

t o w a r d t h e t e r m i n a l p o r t i o n o f t h e i n s p i r a t o r y m a n e u v e r ,

t h e y a r e r e f e r r e d t o a s l a t e i n s p i r a to r y c r a c k l e s . A t t i m e s ,

c r a c k l i n g s o u n d s c a n b e h e a r d t h r o u g h o u t t h e i n s p i r a t o r y

p h a s e a n d a r e c a l l e d p a n i n s p i r a t o r y c r a c k l e s .

T h e f i n a l a b n o r m a l b r e a t h s o u n d i s c a l l e d a g u r g l e . I t i s

s i m i l a r t o t h e s o u n d p r o d u c e d w h e n o n e e x h a l e s t h r o u g h

a s t r a w p l a c e d i n a g l a s s o f w a t e r . G u r g l e s a r e p r o d u c e d b y

a i r f l o w t h r o u g h l i q u i d o f v a r y i n g v i s c o s i t i e s i n t h e a i r w a y s .

S i n c e s o m e c l i n i c i a n s u s e t h e t e r m r h o n c h u s to mean low-

pitched wheeze and others use this same term to mean

g u r g l e , i t i s r e c o m m e n d e d t h a t c o n f u s i o n b e m i n i m i z e d b y

n o t u s i n g t h e t e r m r h o n c h u s .

Clinical Significance

P h y s i c a l f i n d i n g s m u s t b e i n t e r p r e t e d i n l i g h t o f a l l p r e v i -

o u s l y c o l l ec t ed d a ta . T h e g e n e r a l s c h e m e i s t o d e v e l o p a

p o s t u l a t e a n d t e s t i t w i t h f u r t h e r h i s t o r y , a d d i t i o n a l o b s e r -

v a t i o n s o r m a n e u v e r s o n p h y s i c a l e x a m i n a t i o n s , a n d l a b o -

r a t o r y t e s t s . F o r e x a m p l e , a 6 0 - y e a r - o l d p i p e f i t t e r w i t h k n o w n

e x p o s u r e t o a i r b o r n e a s b e s t o s m a t e r i a l w h o n e v e r s m o k e d

c i g a r e t t e s a n d p r e s e n t s w i t h i n c r e a s i n g d y s p n e a a n d c o u g h

w o u l d m o s t l i k e l y h a v e a s b e s t o s i s ( i n t e r s t i t i a l f i b r o s i s c a u s e d

b y t h e a s b e s t o s i n h a l a t i o n ) i f o n e o b s e r v e d d r y , n o n p r o -

d u c t i v e c o u g h f o l l o w i n g e v e r y m o d e r a t e t o d e e p b r e a t h ; i f

t h e s a m e i n i t i a l d a t a d i f f e r e d b e c a u s e o f c i g a r e t t e s i n h i s

p o c k e t a n d a n i n t e r m i t t e n t c o u g h a s s o c i a t e d w i t h t h e e x -

p e c t o r a t i o n o f b l o o d , c a r c i n o m a o f t h e l u n g m i g h t h e a d t h e

d i f f e r e nt i a l d i a g n o s i s l i s t .

I n s p e c t i o n

T h e r e s p i r a t o r y r a t e m a y i n c r e a s e w i t h t h e p r e s e n c e o f a n

i n t e r s t i t i a l p u l m o n a r y p r o c e s s o r c h e s t w a l l r e s t r i c t i o n , b u t

t i d a l v o l u m e t y p i c a l l y r e m a i n s u n c h a n g e d . T h e p r e s e n c e o f

s l o w , g a s p i n g v e n t i l a t o r y m a n e u v e r s i s a n o m i n o u s s i g n s u g -

g e s t i n g c e r e b r a l h y p o x e m i a .

D y s r h y t h m i c b r e a t h i n g i s t y p i f i e d b y C h e y n e - S t o k e s r e s -

p i r a t i o n . T h i s e p o n y m r e f e r s t o a p e r i o d i c p a t t e r n o f a l t e r -

n a t i n g h y p e r p n e a a n d a p n e a . T h o u g h , a t t i m e s , i t i s a n o r m a l

p h e n o m e n o n s e e n i n i n f a n t s , t h e e l d e r l y , a n d d u r i n g a s c e n t

t o a l t i t u d e , m o r e o f t e n i t i s a r e f l e c t i o n o f s i g n i f i c a n t c a r d i a c

a n d / o r p l e u r a l n e r v o u s s y s t e m d y s f u n c t i o n .

B r e a t h v o l u m e s a r e i n c r e a s e d w i t h o u t s u b s t a n t i a l m o d -

i f i c a t i o n o f r a t e a s a c o m p e n s a t o r y m e c h a n i s m t o b l u n t t h e

e f f e c t s o f a m e t a b o l i c a c i d o s i s s u c h a s o c c u r s w i t h u n c o n -

t r o l l e d d i a b e t e s . W h e n t h i s o c c u r s , t h e e f f o r t a s s o c i a t e d w i t h

t h i s K u s s m a u l b r e a t h i n g s e e m s t o b e m i n i m a l .

T h e c o n f i g u r a t i o n o f t h e c h e s t m a y a i d i n t h e d i a g n o s t i c

p r o c e s s . T y p i c a l l y , p e c t u s e x c a v a t u m ( f u nn e l c h e s t ) o r i t s

c o u n t e r p a r t p e c t u s c a r i n a t u m ( p i g e o n b r e a s t ) a r e a s s o c i a t e d

w i t h u n e q u i v o c a l p h y s i c a l f i n d i n g s b u t r a r e l y h a v e a n a d -

verse impact on pulmonary function . S c a r s i d e n t i f y p r e -

v i o u s s u r g e r y o r t r a u m a a n d a l e r t t h e c l i n i c i a n t o t h e n e e d

f o r a c o m p l e t e h i s t o r y o f t h e e v e n t . T h e s o - c a l l e d b a r r e l

c h e s t d e f o r m i t y , s o m e t i m e s r e f e r r e d t o a s i n c r e a s e d A - P

d i a m e t e r , o f t e n e r r o n e o u s l y i s i n t e r p r e t e d a s a s s o c i a t e d w i t h

t h e p r e s e n c e o f p u l m o n a r y e m p h y s e m a . S e v e r a l s t u d i e s h a v e

p r o v e d t h a t t h i s d e s c r i p t i o n i s n o t n e c e s s a r i l y a s s o c i a t e d w i t h

u n d e r l y i n g p u l m o n a r y d i s e a s e b u t r e g u l a r l y i s a f u n c t i o n

o f w e i g h t l o s s a n d m i l d k y p h o s i s , a f u n c t i o n o f t h e a g i n g

p r o c e s s .

D u r i n g b r e a t h i n g , a s s e s s m e n t o f c h a n g i n g c h e s t s h a p e

c a n b e m o r e h e l p f u l . T h e p r e s e n c e o f i n t e r c o s t a l r e t r a c t i o n ,

p u r s u e d - l i p b r e a t h i n g , a n d u s e o f a c c e s s o r y m u s c l e s s u g g e s t

a i r w a y s o b s t r u c t i o n . Parad oxical movement of chest and

a b d o m i n a l m u s c l e s s h o u l d a l e r t t h e c l i n i c i a n t o t h e p o s s i b l e

u s e f u l n e s s o f p u l m o n a r y p h y s i o t h e r a p y t o i m p r o v e v e n t i -

l a t o r y e f f i c i e n c y . G r i m a c e s o r o t h e r e x p r e s s i on s o f d i s c o m -

f o r t o c c u r r i n g a t t h e s a m e p o i n t i n e a c h v e n t i l a t o r y c y c l e

s h o u l d i n f l u e n c e t h e e x a m i n e r t o i d e n t i f y t h e o r i g i n o f t h a t

d i s c o m f o r t m o r e p r e c i s e l y . F i n a l l y , w he e z in g h e a r d by t h e

examiner during tidal volume breathing or exagger ated

b r e a t h i n g m a y b e a r e f l e c t i o n o f u p p e r a i r w a y o b s t r u c t i o n

( s t r i do r ) o r s e v e r e l o w e r a i r w a y n a r r o wi n g . T h e s e a r c h f o r

d e r m a t o l o g i c a b n o r m a l i t i e s a l s o m a y l e a d o n e t o t h e i d e n -

t i f i c a t i o n o f o t h e r s y s t e m i c o r p u l m o n a r y p r o c e s s e s .

Palpation

P a l p a t i o n i s u s e d b o t h a s a s c r e e n i n g t e c h n i q u e a n d a s a

m e a n s t o c o n f i r m a s p e c i f i c d i a g n o s i s . L i g h t p a l p a t i o n o v e r

t h e e n t i r e t h o r a x p o s t e r i o r l y , l a t e r a l l y , a n d a n t e r i o r l y w i l l

a i d i n t h e i d e n t i f i c a t i o n o f c u t a n e o u s a n d s u b c u t a n e o u s n o d -

u l e s a n d t h e s i t e o f p r e v i o u s l y u n s u s p e c t e d t e n d e r n e s s . N o d -

u l e s t h a t a r e f i r m a n d f r e e l y m o v e a b l e s u g g e s t a f o c a l b e n i g n

i n f l a m m a t o r y o r c l i n i c a l l y i n s i g n i f i c a n t p r o b l e m . T h o s e t h a t

a r e h a r d , f i x e d , a n d m u l t i p l e s u g g e s t m e t a s t a t i c m a l i g n a n c y .

F l e s h y n o d u l e s m a y b e i n d i c a t i ve o f a s y s t e m i c d i s e a s e s u c h

a s n e u r o f i b r o m a t o s i s .

T e n d e r n e s s m a y b e e l i c i t e d d u r i n g t h i s s a m e m a n e u v e r .

A t t i m e s , i t i s u n s u s p e c t e d b y b o t h t h e p a t i e n t a n d t h e e x -

aminer . U n d e r o t h e r c i r c u m s t a n c e s , i t i s u s e d t o a i d i n a

d i a g n o s i s o f t h e c o m p l a i n t o f c h e s t p a i n . L o c a l i z i n g a r i b


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244 I I I . THE PULMONARY SYSTEMfracture, either traumatic or pathologic, or r eproducing the

chest pain of costochondritis by firm palpation of an in-

flamed costochondral junction may be most helpful in plan-

ning further management. Tenderness over an inflamedor infarcted area of l ung may also aid in the localization of

the disease process .

Assessment of ventilatory excur sion includes evaluation

of the synchrony of expansion and the degr ee of chest ex-

pansion associated with a deep f orceful inspiration from

residual volume. Asymmetrical expansion invariably implies

decreased ventilation to one side . This may be d ue to tho-

racic wall abnormalities, particularly those that are either

associated with structural immobility or def ect (thoraco-

plasty) or pain (rib fracture) . Similarly, the problem may be

caused by an inflamed, fibrosed, or malignantly infiltrated

pleura, a unilateral pleural ef fusion, an interstitial pulmo-

nary process, or a complete obstruction of an airway or

airways on the ipsilateral side . Functional severing of the

phrenic nerve or intraabdominal process causing paralysis

of the ipsilateral hemidiaphrag m may be responsible for

asymmetrical expansion . Asynchronous expansion may oc-

cur secondary to these processes but usually occurs with

functional diaphrag matic impairment or pain .

Palpation is used to assess further abnor malities; g y n e c

is confirmed by the palpation of breast tissue . Similarly,

spider hemangiomas are confirmed when the central ar-

terial supply is seen to feed the spider's radicals fol lowing

manual occlusion .

Finally , deviation of the trachea to one side can mean

that a process is either pulling the trachea to one side, such

as occurs with lung volume loss (lobar col lapse, atelectasis,

pneumothorax), or pushing the trachea away, such as might

occur with either a tumor or an inflammatory mass . Spon-

taneous movement of the trachea in synchrony with the

pulse suggests the presence of an aortic aneurysm .

Percussion

Percussion is a major aid in the assessment of ventilatory

exertion, the assessment of hyperinfl ation, and the presence

of focal thoracic disease .

The general percussion over a hemithorax can give a

clue as to the presence or absence of a pulmonary process .

When the percussion note is hyperr esonant, one can pos-

tulate that the lungs are hyperinflated, such as may occur

with emphysema or during so-call ed air trapping seen in

patients with acute asthma . This may also occur in patients

with an acute spontaneous pneumothorax . Dullness to per-

cussion, particularly associated with the presence of a high,

poorly moving diaphragm, is likel y to be associated with a

restrictive ventilatory defect if the findings are bilaterally

symmetrical . Usuall y this is associated with an interstitial

pulmonary process that can be further evaluated by the

presence or absence of late inspiratory cr ackles on auscul-

tation . Fl atness to percussion suggests the virtual absence

of air directly b eneath the percussed finger and may r eflect

either f luid in the pleural space (pleural effusion, em-

pyema), solid material in the pleural space (fibrothorax,

mesothelioma), or atelectases .

Auscultation

Bronchial br eath sounds may be either normal or ab normal .

When they are heard on the periphery, where vesicular

breath sounds are normally heard, one can imply that the

airw ays to the lung units are open but that the lung units

themselves are fill ed with liquid-like material . When this

occurs without pleural fl uid, the bronchial breath sounds

are loud ; when consolidation is associated with a pleural

effusion, the bronchial br eath sounds are present but often

quite decreased in intensity . Confir mation of the presence

of br onchial breath sounds can be obtained by listening for

egophony ("E to A" sound) . This sound is elicited by asking

the patient to say the letter "E" as one listens over the sus-

picious area with the stethoscope. When consolidation is

present, the spok en "E" sound is converted to an ausculted

"A" sound, similar to that produced by a bleating goat .

In addition to assessing the quality of b reath sounds, it

is also important to assess the duration of the expiratory

phase . Timing the duration of expiratory sound while lis-

tening w ith the diaphragm over the trachea during a f orced

expiratory volume maneuver is used to identify airw ays ob-

struction. Expirator y sound should ter minate within 6 sec-onds. If the sound is prolonged, airwa ys ob structionmanifested by an FEV, of l ess than 1 .5 liters can be assumed .

Auscultatory w heezes imply the presence of sl itlike open-

ings through which a critical velocity of gas is passing . When

wheezes are local, one must consider external compression

of an airway . Enlarged lymph nodes and tumors do this . A

lesion within the airway, such as an endobr onchial malig-

nancy or foreign body, also can produce a localized wheeze .

Diffuse wheezing is present in inflammatory processes such

as bronchitis (both acute or chronic), contraction of hyper -

trophied b ronchial smooth muscle as seen in asthma, in-

spissated thick secretions of pneumonia, and airway collapse

associated w ith the dynamic compression of pulmonaryemphysema .Crackles imply the snapping open of airw ays or alveoli .

Since larger airways open first as inhalation progr esses from

residual volume, early inspiratory crackles imply larg e air-

ways disease while late inspiratory crackl es either mean small

airways prob lems (less than 2 mm) or poorly compliant al-

veoli walls such as seen in congestive heart failure, pul-

monary fibr osis, or other interstitial pulmonary pr ocesses .

Gurgles suggest fluid in the airways . This may be pro-

duced b y excessive serous secretion in alveolar cell carci-

noma, infected purul ent secretion of acute or chronic

bronchitis or bronchiectasis, or transudated fluid entering

the airways f rom the alveoli as occurs in pulmonary edema .

ReferencesForgacs P . F u n c t i o n a l s i g n i f i c a n c e o f c l i n i c a l s i g n s i n d i f f u s e a i r w a y

obstruction . B r i t J D i s C h e s t 1 9 7 1 ;65 :170 .

Kilburn KH, et al . Anterior-posterior chest diameter in emphy-

sema. Arch Int Med 1969;123:379 .

Leblanc P, et al . Breath sounds and distribution of pulmonary

v e n t i l a t i o n . Amer Rev Resp Dis 1970;102 : 1 0 .

Lehrer S . Understanding lung sounds, Philadelphia : W. B . S a u n -

ders, 1984 .

Nath AR, Capel LH . I n s p i r a t o r y c r a c k l e s - e a r l y a n d l a t e . Thorax

1974;29:223 .

Pierce JA, Ebert RB . T h e b a r r e l d e f o r m i t y o f t h e c h e s t , t h e s e n i l e

lung and obstructive pulmonary emphysema . Am er J Med

1958 ;25 : 1 3 .

Rales, rhonchi, and Laennec, recorded by A . J o h n R o b e r t s o n , a f t e r

an evening with Robert Coope . Lancet 1957 ; 2 :417 .

chest exam clinical chapter

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