3 Taking Medication Histories
Chapter 4 Physical Assessment Skills
A, Normal chest. B, Barrel chest
(From Swartz MH: Textbook of physical diagnosis: history and examination, ed 6, St Louis, 2004, Mosby.)
Percussion
Percuss over the intercostal spaces (between the ribs) to assess lung density (Figure 4-45).
Percussion over normal lung tissue creates a loud, low-pitched, resonant note. Percussion over areas of lung with increased air volume (e.g., emphysema) creates a very loud, low-pitched, hyperresonant note. Areas of consolidation (fluid) produce a dull or flat percussion note (e.g., lobar pneumonia); shifting dullness is associated with freely moving fluid within the pleural cavity (e.g., pleural effusion). Assess all lobes, comparing the right and left lungs.
Full-size image (23K) Figure 4-45.
Indirect Chest Percussion.
(From Jarvis C: Physical examination and health assessment, ed 5, St Louis, 2008, Saunders.) Percuss to determine diaphragmatic location and excursion (Box 4-8) (Figure 4-46). Determine the location of the diaphragm with the lungs fully expanded and with the lungs emptied. The difference between the two positions is the diaphragmatic excursion. Percuss down the posterior chest between the vertebral column and the scapula from about the sixth rib downward with the lungs fully expanded; repeat with the lungs emptied. The diaphragm is located where the percussion note changes from resonant to dull. Normal diaphragmatic excursion is about 3 to 5 cm for females and 5 to 6 cm for males; the right side of the diaphragm is slightly higher than the left side. The diaphragm is elevated when the lung on that side has collapsed (pneumothorax).
The diaphragm is abnormally low with decreased excursion in chronic obstructive airway diseases associated with chronic air trapping (e.g., COPD).
Box 4-8.
Diaphragmatic Excursion Checklist Right Side of the Diaphragm
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□ Instruct the patient to stand.
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□ Instruct the patient to inspire and hold the breath.
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□ Percuss starting midscapula.
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□ Note the location where the percussion note changes.
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□ Let the patient breathe normally for a few moments.
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□ Instruct the patient to expire and hold the breath.
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□ Percuss starting midscapula.
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□ Note the location where the percussion note changes.
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□ Report/record the distance. (Example: Right diaphragmatic excursion is 5 cm.) Left Side of the Diaphragm
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□ Instruct the patient to stand.
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□ Instruct the patient to inspire and hold the breath.
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□ Percuss starting midscapula.
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□ Note the location where the percussion note changes.
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□ Let the patient breathe normally for a few moments.
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□ Instruct the patient to expire and hold the breath.
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□ Percuss starting midscapula.
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□ Note the location where the percussion note changes.
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□ Report/record the distance. (Example: Left diaphragmatic excursion is 5 cm.)
Full-size image (58K)
Figure 4-46.
Diaphragmatic Excursion.
Determine the difference in the border between resonance and dullness with inspiration and expiration.
(From Swartz MH: Textbook of physical diagnosis: history and examination, ed 6, St Louis, 2004, Mosby.)
Palpation
Palpate the chest for masses, pulsations, crepitation, and tactile fremitus. To assess for tactile fremitus, place the palm of the hand on the chest and have the patient say “ninety-nine” or “one- two-three.” Vibrations are increased over areas of consolidation (e.g., lobar pneumonia).
The chest wall moves outward with lung expansion. Palpate for respiratory excursion by placing your hands on the patient’s anterior or posterior chest. Place the hands so that the hands cover the lower ribs with moderate pressure (thumbs touching each other, fingers spread apart) (Box 4-9).
Instruct the patient to take a deep breath. With normal respiratory excursion, the hands pivot apart a few centimeters at the thumbs.
Box 4-9.
Respiratory Excursion Checklist
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□ Instruct the patient to stand.
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□ Place the palms of the hands with thumbs together and pointing up at the center of the lower rib margin.
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□ Spread the fingers apart and hold the chest with light pressure.
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□ Instruct the patient to inhale deeply.
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□ The hands should move apart slightly with the patient’s inspiration.
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□ Report/record the results. (Example: Normal respiratory excursion.)
Auscultation
Auscultate the lungs with a stethoscope (Box 4-10). On the posterior chest, auscultate between the scapulae and vertebral column (not directly over the scapulae, vertebral column, or ribs)
(Figure 4-47). Place the diaphragm of the stethoscope flat against the chest wall and instruct the patient to breathe deeply and slowly through the mouth each time the stethoscope touches the skin. Assess at least one complete respiratory cycle over each anterior and posterior lobe, comparing right and left sides; assess each lobe more thoroughly if abnormalities are detected.
Box 4-10.
Pulmonary Auscultation Checklist Anterior
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□ Stand to the patient’s right.
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□ Auscultate the right upper lobe (RUL).
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□ Auscultate the left upper lobe (LUL).
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□ Auscultate the right middle lobe (RML).
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□ Auscultate the right lower lobe (RLL).
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□ Auscultate the left lower lobe (LLL).
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□ Report/record the results. (Example: Normal breath sounds.) Posterior
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□ Stand to the patient’s right.
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□ Auscultate the RUL.
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□ Auscultate the LUL.
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□ Auscultate the RLL.
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□ Auscultate the LLL.
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□ Report/record the results. (Example: Normal breath sounds.)
Full-size image (22K) Figure 4-47.
Posterior Chest Auscultation.
(From Seidel HM: Mosby’s guide to physical examination, ed 7, St. Louis, 2011, Mosby.) Breath sounds are described as tracheal, bronchial, bronchovesicular, or vesicular. These breath sounds are distinguishable through auscultation over areas of the lungs that normally produce the sounds (i.e., auscultation over the trachea, large central bronchi, small airways just distal to the central bronchi, and small lateral airways identifies tracheal, bronchial, bronchovesicular, and vesicular breath sounds, respectively) (Figure 4-48). These sounds are considered abnormal, however, if heard over other areas of the lungs. Other abnormal breath sounds include wheezes, rhonchi, stridor, and crackles. Abnormal breath sounds are described by location (e.g., tracheal), timing (inspiration, expiration, or both), and duration (e.g., end-expiration). Wheezes, high- pitched continuous musical sounds, are associated with airway inflammation and constriction (e.g., asthma, COPD, bronchitis, pneumonia, pulmonary edema). Rhonchi, coarse rattling sounds that change location with cough, are associated with mucus in the airways. Stridor, a high-
pitched sound, is heard with upper airway constriction (e.g., croup). Crackles, intermittent crackling sounds of short duration, are associated with fluid in the alveoli and airways (e.g., bronchitis, pneumonia, heart failure, pulmonary edema). A pleural friction rub, created when the visceral and parietal pleurae rub together, sounds like creaking leather and is heard best at the base of the lung. Voice sounds are transmitted more clearly (egophony, whispered pectoriloquy) over areas of consolidation (e.g., lobar pneumonia); vocal resonance is decreased over areas of hyperinflation (e.g., COPD).
Full-size image (35K)
Figure 4-48.
Locations of Expected Ausculatory Breath Sounds.