PHYSICAL DIAGNOSIS. CHEST. INTRODUCTION.
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Suprasternal fossa,supraclavicular fossa(left,right),infraclavicular fossa(left,right)
Suprascapular region (left,right),infrascapular region (left,right),interscapular region
the left lung: 2 lobes(upper,lower)
Visceral pleura:the pleura covering the surface of the lung
Parietal pleura: the pleura covering the inner surface of the chest wall,the diaphragm,and the mediastinum
Inspection of the chest,productive of the maximum amount of information, requires the following:
It is important that the patient be absolutely straight,whether seated or supine.
You should appreciate that in normal subjects there is a wide variation in the size and shape of the thorax.At times it is difficult to be certain where the normal variations and definite pathologic changes begin.
The anteroposterior diameter of the thorax in the normal adult is definitely less than the transverse diameter.
what to observe
persons with pulmonary emphysema --barrel chest
normal : 45 º degree angle
patients with emphysema :the ribs are nearly horizontal ; this angle becomes abnormally wide
The sounds that arise in the larynx are transmitted down along the air column of the tracheobronchoalveolar system into the bronchi of each lung,on through the smaller bronchi into the alveoli,setting in motion the thoracic wall that acts as a large resonator. Thus,vibrations are produced in the chest wall that can be felt by the hand of the examiner.
In eliciting vocal fremitus the patient is directed to count “one,two,three”---“one,two,three”,to repeat the words“ninety-nine”—“ninety-nine”,or to say “ e-e-e,e-e-e,e-e-e”. The patient should speak with a voice of uniform intensity throughout the examination so that the examiner can better compare the transmission of the fremitus in different areas of the chest.
1.Intensity of the voice
2.Pitch of the voice
3.Varying relations of the bronchi to the chest wall
4.Varying thickness of the thoracic wall
There are two principal methods that may be used for percussion of the thorax, abdomen,or other structures.
1. Mediate percussion is that in which the examiner strikes the middle finger of one hand held against the thorax, thus producing a sound by setting the chest wall and underlying structures in motion. This is the method in almost universal use today.
2. Immediate percussion may be useful in demonstrating changes in percussion note.This can be done by striking the chest with the tips of all of the fingers held firmly together.
Practical experience has demonstrated that useful sounds produced by percussion probably do not penetrate more than about 4 to 5cm below the surface. Also a lesion must be at least 2 or 3cm in diameter to be detectable. Thus,it is obvious that percussion will only locate rather gross abnormalities.
1. The distal phalanx of the pleximeter finger must be pressed firmly on the chest wall;otherwise,a clear note is not ob tained.
2. The plexor finger should strike the pleximeter finger only instantaneously and must be immediately withdrawn.
The sound waves produced by percussion are influenced more by the character of the immediate underlying structures than by those more distant.Consequently the tone produced by percussion over the airfilled lung will be definitely different from the tone heard over a solid structure,such as the heart or liver.This is the basis for the scientific application of percussion.
Over the apices,where there are large amounts of muscle and bone with relatively little underlying resonant lung,the note is less resonant than over the bases,where there is a relatively greater amount of lung with less thoracic wall and muscle.
The development of the pectoral muscles,the heavy muscles of the back,the breasts,and the scapulae,all tend to make the percussion note lessresonant (duller).
It should be notedthat below the dome of the right diaphragm there is flatness because of the presenceof the liver.on the left there is ordinarily a relatively tympanic note that results from the presence of the partially air-filled stomach and bowel under the hemidiaphragm.
The change from resonance to flatness on the right and from resonance to tympany on the left is not immediate;instead ,there is a zone of transition.
Dullness from the liver is usually noted at approximately the fifth interspace in the midclavicular line,and this dullness soon gives way to flatness as that part of the liver not covered by the lung is reached.
Also the change from pulmonary resonance to tympany over the left lower chest at about the sixth rib in the midclavicular line has the same general tendency to transition not an abrupt change .
There is also dullness to the left of the sternum,caused by the underlying heart, another solid organ in the left fifth interspace. This dullness normally extends to a point 1 or 2cm medial to the midclavicular line.
Occasionally the patient is too ill to sit up to permit percussion of the posterolateral aspects of the chest.So the posterior and posterolateral thoracic wall must be examined with the patient rolled on his side.This is much less satisfactory than the upright position.
The lateral recumbent position causes the following changes:
happening in bronchitis,bronchial asthma etc.
Whether fluid,air,or solid in the pleural space,all interfere with the conduction of breath sounds so that they are decreased or even absent .
Rales may be divided roughly into three categories: fine, medium, and coarse.
Pneumonias usually sudden, often coughing is usually present. It may be severe and associated with sharp pain in the affected side.
The sputum at first is mucoid, but later becomes bright red and then rusty brown.