1. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 1 Welcome to Mosby’s Guide to PHYSICAL EXAMINATION, 6th edition

2. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 2 Chapter 13 Chest and Lungs

3. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 3 Anatomy and Physiology

4. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 4 Chest (1)  Chest or thorax, a cage of bone, cartilage, and muscle  Sternum  Manubrium  Xiphoid process  12 pairs of ribs connected to the thoracic vertebrae and to the sternum by the costal cartilages Anatomy and Physiology

5. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 5 Chest (2)  Primary muscles of respiration  Diaphragm—the primary muscle—contracts during inspiration.  External intercostal muscles increase the anteroposterior chest diameter during inspiration.  Interior intercostal muscles decrease the transverse chest diameter during expiration  Sternocleidomastoid and trapezius accessory muscles are brought into play when there are pulmonary problems and compromise. Anatomy and Physiology

6. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 6 Chest (3)  Interior divided into three spaces  Mediastinum Situated between lungs Situated between lungs Contains all thoracic viscera except the lungs Contains all thoracic viscera except the lungs  Right and left pleural cavities Lined with parietal and visceral pleurae Lined with parietal and visceral pleurae Lungs enclosed by serous membrane Lungs enclosed by serous membrane Anatomy and Physiology

7. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 7 Lungs  Highly elastic lungs paired but not symmetric  Right lung: three lobes.  Left lung: two lobes and a lingula.  Lobes contain  Blood vessels  Lymphatics  Nerves  Alveolar ducts connecting with alveoli  Alveoli, as many as 300 million in adult Anatomy and Physiology

8. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 8 Tracheobronchial Tree (1)  Components  Trachea divides into right and left main bronchi.  Right bronchus divides into three branches.  Left bronchus divides into two branches.  Each branch divides into bronchioles and ultimately into respiratory bronchioles so that each is associated with only one acinus.  Acini are the terminal respiratory units. Anatomy and Physiology

9. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 9 Tracheobronchial Tree (2)  Bronchial functions  Air transport  Trap and dispose of foreign particles  Supply blood to lung parenchyma and stroma; bronchial arteries branch from anterior thoracic aorta and intercostal arteries Anatomy and Physiology

10. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 10 Chemical and Neurologic Control of Respiration  Respiration keeps body supplied with oxygen and protects it from excess accumulation of carbon dioxide.  Transport of air to and from alveoli  Diffusion and perfusion, gas exchange across alveolar membranes  Circulatory system transport to and from the peripheral tissues  Respiratory control processes involving chemoreceptors are only partially understood. Anatomy and Physiology

11. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 11 Anatomic Landmarks  Topographic markers  Nipples  Manubriosternal junction  Suprasternal notch  Costal angles  Vertebra prominens  Clavicles Anatomy and Physiology

12. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 12 Infants and Children  Fetal lungs contain no air; gas exchange is through placenta.  At birth, lungs adapt to postnatal function.  Chest circumference is same as head circumference until about 2 years of age.  Chest wall is thinner and bony structures more prominent and yielding than in adults. Anatomy and Physiology

13. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 13 Pregnant Women  Mechanical and biochemical factors lead to changes in respiratory function.  Anatomic changes in chest  Lower ribs flare.  Diaphragm rises above usual position.  Diaphragm movement increases so that major work of breathing is done by diaphragm.  Tidal volume increases. Anatomy and Physiology

14. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 14 Older Adult  Barrel chest from loss of muscle strength in thorax and loss of lung resiliency  Skeletal changes emphasizing dorsal curve of thoracic spine  Alveoli less elastic, causing fatigue and dyspnea on exertion  Decrease in vital capacity/increase in residual volume  Mucous membranes drier Anatomy and Physiology

15. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 15 Review of Related History

16. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 16 History of Present Illness (1)  Coughing  Onset  Nature  Pattern  Severity  Associated symptoms  Efforts to treat  Medications Review of Related History

17. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 17 History of Present Illness (2)  Shortness of breath  Onset  Pattern  Severity  Associated symptoms Review of Related History

18. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 18 History of Present Illness (3)  Chest pain  Onset and duration  Associated symptoms  Efforts to treat  Medications Review of Related History

19. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 19 Past Medical History  Thoracic trauma or surgery, dates of hospitalization for pulmonary disorders  Use of oxygen and ventilation-assisting devices  Chronic pulmonary diseases  Chronic disorders  Testing Review of Related History

20. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 20 Family History  Tuberculosis (TB)  Cystic fibrosis  Emphysema  Allergy  Asthma  Atopic dermatitis  Malignancy Review of Related History

21. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 21 Personal and Social History  Employment  Home environment  Tobacco use  Exposure to respiratory infections, flu, TB  Nutritional status  Regional/travel exposures  Hobbies  Use of alcohol/drugs  Exercise tolerance Review of Related History

22. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 22 Infants and Children  Low birth weight and prematurity  Coughing and sudden onset shortness of breath  Possible aspiration of noxious substances  Difficulty feeding  Apneic episodes; use of apnea monitor  Sudden infant death syndrome in sibling  Possible gastroesophageal reflux Review of Related History

23. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 23 Pregnant Women  Weeks of gestation  Presence of multiple fetuses, polyhydramnios, other conditions in which uterus displaces diaphragm  Exercise type and energy expenditure  Exposure to and frequency of respiratory infections  History of flu and pneumococcal immunization Review of Related History

24. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 24 Older Adults (1)  Exposure to and frequency of respiratory infections  History of pneumococcal and flu vaccine  Effects of weather on respiratory efforts and infection occurrence  Immobilization and sedentary habits  Difficulty swallowing  Altered activities from respiratory symptoms Review of Related History

25. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 25 Older Adults (2)  Emphasize  Smoking history  Cough  Dyspnea on exertion or breathlessness  Fatigue  Weight changes  Fever and night sweats Review of Related History

26. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 26 Examination and Findings

27. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 27 Equipment  Marking pencil or eyeliner (silver good for dark skin)  Centimeter ruler and tape measure  Stethoscope with bell and diaphragm (may use smaller diaphragm for children)  Drapes Examination and Findings

28. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 28 Inspection (1)  Chest  Shape and symmetry  Chest wall movement  Superficial venous patterns  Prominence of ribs  Anteroposterior vs. transverse diameter  Sternal protrusion  Spinal deviation Examination and Findings

29. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 29 Inspection (2)  Peripheral clues may suggest pulmonary or cardiac difficulties:  Fingers: clubbing  Breath: odor  Skin, nails, and lips: cyanosis or pallor  Lips: pursing  Nostrils: flaring Examination and Findings

30. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 30 Inspection (3)  Respiration  Rate  Quality  Pattern  Count rate while palpating pulse Examination and Findings

31. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 31 Inspection (4)  Modes of respiration  Thoracic (costal)  Diaphragmatic  Abdominal  Paradoxic Examination and Findings

32. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 32 Inspection (5)  Inspect for airway obstruction  Stridor  Nostril flaring  Cough  Chest retraction Examination and Findings

33. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 33 Inspection: Descriptors of Respiration  Cheyne-Stokes  Sighing  Air trapping  Biot  Ataxic  Apnea  Dyspnea  Tachypnea  Bradypnea  Hyperpnea  Hypopnea  Kussmaul Examination and Findings

34. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 34 Palpation (1)  Thoracic muscles/skeleton  Pulsations  Tenderness  Bulges/depressions  Unusual movement/positions  Elasticity of rib cage  Immovability of sternum  Rigidity of thoracic spine Examination and Findings

35. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 35 Palpation (2)  Crepitus  Friction rub  Thoracic expansion  Tactile fremitus  Position of trachea Examination and Findings

36. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 36 Percussion (1)  Percuss chest  Anterior  Lateral  Posterior  Compare tones bilaterally  Measure diaphragmatic excursion Examination and Findings

37. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 37 Percussion (2)  Percussion tone indicators for lungs  Resonance is normal.  Hyperresonance indicates hyperinflation.  Dullness indicates diminished air exchange. Examination and Findings

38. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 38 Auscultation (1)  Breath sounds  Vesicular  Bronchovesicular  Bronchial/tracheal  Amphoric  Cavernous Examination and Findings

39. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 39 Auscultation (2)  Adventitious breath sounds  Crackles: fine, medium, coarse  Rhonchi  Wheezes  Friction rub  Mediastinal crunch Examination and Findings

40. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 40 Auscultation (3)  Vocal resonance  Bronchophony  Pectoriloquy  Egophony Examination and Findings

41. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 41 Cough  Describe  Moisture  Onset  Frequency  Regularity  Pitch/loudness  Postural influences  Quality Examination and Findings

42. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 42 Sputum  Describe  Color  Consistency  Odor Examination and Findings

43. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 43 Infants (1)  Examination approach is similar to that in adults; percussion is less reliable in infants.  Compare thoracic cage size with head size.  Acrocyanosis is common and normal.  Respiratory rate varies between 40 and 60 respirations per minute.  Coughing is rare; sneezing is frequent. Examination and Findings

44. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 44 Infants (2)  At first, breathing is primarily diaphragmatic; use of intercostal muscles is gradual.  Localization of breath sounds may be difficult.  Crackles or rhonchi may not be problematic in neonatal hours.  Stridor, retractions, grunting, flaring indicate problems. Examination and Findings

45. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 45 Children (1)  Thoracic muscles for breathing by 6 or 7 years  Variable respiratory rate, reaching adult rates at about 17 years  Roundness of chest persisting past second year possible indication of a pulmonary problem  The younger the infant or toddler, the more difficult to evaluate wheezing Examination and Findings

46. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 46 Children (2)  Breath sounds  More resonant  Hyperresonance common  Easy to miss dullness  Bronchovesicular sounds may predominate Examination and Findings

47. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 47 Pregnant Women  Dyspnea common with expected normal physiologic changes  Vital capacity and tidal volume increase  Ventilation increases by deeper and more frequent breathing Examination and Findings

48. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 48 Older Adults  Chest expansion decreased  Bony prominences marked  Kyphosis with flattening of lumbar curve  Increased anteroposterior diameter  Hyperresonance common Examination and Findings

49. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 49 Common Abnormalities

50. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 50 Common Abnormalities (1)  Asthma (reactive airway disease)  Atelectasis  Bronchitis  Pleurisy  Pleural effusion Common Abnormalities

51. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 51 Common Abnormalities (2)  Empyema  Lung abscess  Pneumonia  Influenza  Tuberculosis Common Abnormalities

52. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 52 Common Abnormalities (3)  Pneumothorax  Hemothorax  Lung cancer  Cor pulmonale  Pulmonary hypertension  Tuberculosis Common Abnormalities

53. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 53 Children and Adolescents  Cystic fibrosis  Epiglottis  Croup  Tracheomalacia  Bronchiolitis Common Abnormalities

54. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 54 Older Adults  Chronic obstructive pulmonary disease  Emphysema  Bronchiectasis  Chronic bronchitis Common Abnormalities

55. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 55 Summary of Examination (1)  Inspect the chest, front and back, noting thoracic landmarks, for the following:  Size and shape (anteroposterior diameter compared with transverse diameter)  Symmetry  Color  Superficial venous patterns  Prominence of ribs

56. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 56 Summary of Examination (2)  Evaluate respirations for the following:  Rate  Rhythm or pattern  Inspect chest movement with breathing for the following:  Symmetry  Bulging  Use of accessory muscles

57. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 57 Summary of Examination (3)  Note any audible sounds with respiration (i.e., stridor or wheezes)  Palpate chest for the following:  Symmetry  Thoracic expansion  Pulsations  Sensations such as crepitus, grating vibrations  Tactile fremitus

58. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 58 Summary of Examination (4)  Perform direct or indirect percussion on chest, comparing sides, for the following:  Diaphragmatic excursion  Percussion tone intensity, pitch, duration, and quality

59. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 59 Summary of Examination (5)  Auscultate the chest with the stethoscope diaphragm, from apex to base, comparing sides for the following:  Intensity, pitch, duration, and quality of expected breath sounds  Unexpected breath sounds (crackles, rhonchi, wheezes, friction rubs)  Vocal resonance