CAPÍTULO I De las sanciones
COMERCIOS Y SERVICIOS 561920 Organizadores de convenciones y ferias comerciales e
The Health History
Complaints of chest pain or chest discomfort raise the specter of heart disease but often arise from conditions in the thorax and lungs. For this important symptom, keep the possible causes below in mind. Also see Table 8-1, Chest Pain, pp. 155–156.
C o m m o n o r C o n c e r n in g S y m p t o m s
● Chest in
● Shortness of bre th (dys ne ) ● Wheezing
● Cough
● Blood-stre ked s utu (he o tysis)
● D yti e slee iness or snoring nd disordered slee
S o u r c e s o f C h e s t P a in a n d R e la t e d C a u s e s
The yoc rdiu Angina pectoris, myocardial infarction, myocarditis
The eric rdiu Pericarditis
The ort Aortic dissection
The tr che nd l rge bronchi Bronchitis
The riet l leur Pericarditis, pneumonia, pneumothorax, pleural effusion, pulmonary embolus
The chest w ll, including the usculo- skelet l nd neurologic syste s
Costochondritis, herpes zoster
The eso h gus Gastroesophageal reflux disease, esoph- ageal spasm, esophageal tear
Extr thor cic structures such s the neck, g llbl dder, nd sto ch
Cervical arthritis, biliary colic, gastritis
For patients who are short of breath, focus on pulmonary complaints:
■ Dyspnea and wheezing
■ Cough and hemoptysis
See Table 8-2, Dyspnea, pp. 157–158. See Table 8-3, Cough and Hemoptysis, pp. 159–161.
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g
● Tob cco cess tion ● Lung c ncer
● I uniz tions—influenz nd stre tococc l neu oni v ccines
Despite declines in smoking over the past several decades, 19% of Ameri- cans still smoke. Regularly counsel all adults, pregnant women, parents, and adolescents who smoke to stop. Use “the ve As” and the Stages of Change Model to assess readiness to quit.
A s s e s s in g R e a d in e s s t o Q u it S m o k in g : B r ie f In t e r v e n t io n s M o d e ls
5 As Mo d e l S t a g e s o f Ch a n g e M o d e l
Ask bout tob cco use Precontemplation—“I don’t w nt to quit.” Advise to quit Contemplation—“I concerned but not
re dy to quit now.” Assess willingness to ke
quit tte t
Preparation—“I re dy to quit.” Assist in quit tte t Action—“I just quit.”
Arrange follow-u Maintenance—“I quit 6 onths go.”
Counsel patients to never smoke or quit smoking. The U.S. Preventive Services Task Force recommends annual low-dose computed tomography (LDCT) screening for current smokers (or those who have quit within the last 15 years) ages 55 to 79 years (grade B recommendation).
Provide u shots to everyone age 6 months or older and especially to those with chronic pulmonary conditions, nursing home residents, household contacts, and health care personnel.
Recommend pneumococcal vaccine to adults 65 years and older, smokers between the ages of 16 and 64 years, and those with increased risk of pneumococcal infection.
Snoring, witnessed apneas ≥10 seconds, awakening with a choking sensation, or morning headache point to obstructive sleep apnea.
■ Daytime sleepiness or snoring
Chapter 8 | The Thorax and Lungs 147
Techniques of Examination
In it ia l In s p e c t io n o f T h o r a x
EXAMINATIO N TECHNIQ UES P O SSIBLE FIN DIN GS
Manubrium of s ternum Body of s ternum Xyphoid proces s 2nd cos tal cartilage 2nd rib inters pace Cos tochondral junctions
Supras ternal notch
Sternal angle
2nd rib
Cos tal angle
Fig ure 8-1 Che s t wall anatomy.
Inspect the thorax (Fig. 8-1) and its respiratory movements for signs of distress and note:
■ Facial color
■ Rate, rhythm, depth, and effort
of breathing
■ Inspiratory retraction of the
supraclavicular areas
■ Inspiratory contraction of the
sternocleidomastoids
Cyanosis and pallor in lips and oral mucosa signal hypoxia.
Tachypnea, hyperpnea, Cheyne–Stokes breathing. Normally 14 to 20 breaths/ minute in adults. See Table 8-4 Abnor- malities in Rate and Rhythm of Breath- ing, p. 162.
Occurs in chronic obstructive pulmonary disease (COPD), asthma, upper airway obstruction
If distress, auscultate the neck and lungs for:
■ Stridor
■ Wheezes
Observe shape of patient’s chest.
T h e P o s t e r io r C h e s t
Inspect the chest for:
■ Deformities or asymmetry
■ Abnormal inspiratory retraction
of the interspaces
■ Impairment or unilateral lag in
respiratory movement Palpate the chest for:
■ Tender areas
■ Assessment of visible abnor-
malities
■ Chest expansion (Fig. 8-2)
EXAMINATIO N TECHNIQ UES P O SSIBLE FIN DIN GS
Stridor in upper airway obstruction from foreign body or epiglottitis
Expiratory wheezing in asthma and COPD
Normal or barrel chest (see Table 8-5, Deformities of the Thorax, pp. 163–164)
Kyphoscoliosis
Retraction in asthma, COPD, upper air- way obstruction
Disease of the underlying lung or pleura, phrenic nerve palsy
Fractured ribs Masses, sinus tracts
Fig ure 8-2 As s e s s lung expans ion.
Impairment, both sides in COPD and restrictive lung disease; unilateral decrease or delay in chronic fibrosis of the underlying lung or pleura, pleural effusion, lobar pneumonia, pleural pain with associated splinting, unilateral bronchial obstruction, and paralysis of the hemidiaphragm
■ Tactile fremitus as the patient
says “aa” or “blue moon”
Decreased or absent fremitus when transmission of vibrations to the chest is impeded by a thick chest wall, obstructed bronchus, COPD, or pleural effusion, fibrosis, air (pneumothorax), or an infil- trating tumor.
Chapter 8 | The Thorax and Lungs 149
Percuss the chest, comparing one side with the other at each level, using the side-to-side “ladder pattern,” as shown in Figures 8-3 and 8-4.
EXAMINATIO N TECHNIQ UES P O SSIBLE FIN DIN GS
Asymmetric decreased fremitus in uni- lateral pleural effusion, pneumothorax, or neoplasm; asymmetric increased fremitus occurs in unilateral pneumonia, which increases transmission through consolidated tissue. 1 2 3 4 5 1 2 3 4 5 6 6 7 7
Fig ure 8-3 Pe rcus s and aus cultate in a “ ladde r” patte rn.
Fig ure 8-4 Strike the plexim e te r finge r w ith the right m iddle finge r.
Dullness when fluid or solid tissue replaces normally air-filled lung; hyper- resonance in emphysema or pneumo- thorax
P e r c u s s io n N o t e s a n d T h e ir C h a r a c t e r is t ic s
Re la t ive In t e n s it y,
P it ch , a n d Du ra t io n Exa m p le s
Flat Soft/ high/short L rge leur l effusion Dull Mediu / ediu / ediu Lob r neu oni
Resonant Loud/ low/ long He lthy lung, si le chronic bronchitis
Hyperresonant Louder/ lower/ longer E hyse , neu othor x Tympanitic Loud/ high (ti bre is usic l) L rge neu othor x
Percuss level of diaphragmatic dullness on each side and estimate diaphragmatic descent after patient takes full inspiration (Fig. 8-5).
Pleural effusion or a paralyzed diaphragm raises level of dullness.
Re s ona nt Leve l of dia phra gm Dull Loca tion a nd s e que nce of pe rcus s ion
Figure 8-5 Identify the extent of diaphragmatic excursion.
EXAMINATIO N TECHNIQ UES P O SSIBLE FIN DIN GS
See Table 8-6, Physical Findings in Selected Chest Disorders, p. 165.
Vesicular, bronchovesicular, or bronchial breath sounds; decreased breath sounds from decreased airflow.
Crackles (fine and coarse) and continu- ous sounds (wheezes and rhonchi) Clearing after cough suggests atelectasis.
Auscultate the chest with stetho- scope in the “ladder” pattern, again comparing sides.
■ Evaluate the breath sounds.
■ Note any adventitious (added)
sounds.
Observe qualities of breath sound, timing in the respiratory cycle, and location on the chest wall. Do they clear with deep breathing or coughing? C h a r a c t e r is t ic s o f B r e a t h S o u n d s Du ra t io n In t e n s it y a n d P it ch o f Exp ira t o ry S o u n d Ex a m p le Lo c a t io n s
Vesicular Ins > Ex Soft/ low Most of the lungs Bronchovesicular Ins = Ex Mediu / ediu 1st nd 2nd inter-
s ces, intersc - ul r re
Bronchial Ex > Ins Loud/ high Over the nu- briu
Tracheal Ins = Ex Very loud/ high Over the tr che
Dur tion is indic ted by the length of the line, intensity by the width of the line, nd itch by the slo e of the line.
Chapter 8 | The Thorax and Lungs 151
Assess transmitted voice sounds and bronchial breath sounds heard in abnormal places. Ask patient to:
■ Say “ninety-nine” and “ee.”
■ Whisper “ninety-nine” or
“one-two-three.”
EXAMINATIO N TECHNIQ UES P O SSIBLE FIN DIN GS
Bronchophony if sounds become louder; egophony if “ee”to “A”change from lobar consolidation
Whispered pectoriloquy if whispered sounds transmit louder and more clearly
T r a n s m it t e d V o ic e S o u n d s
Th ro u g h No rm a lly Air-Fille d Lu n g Th ro u g h Airle s s Lu n ga Usu lly cco nied by vesicul r
bre th sounds nd nor l t ctile fre itus
Usu lly cco nied by bronchi l or bronchovesicul r bre th sounds nd incre sed t ctile fre itus S oken words uffled nd indistinct S oken words louder, cle rer
(bronchophony)
S oken “ee” he rd s “ee” S oken “ee” he rd s “ y” (egophony) Whis ered words f int nd indistinct,
if he rd t ll
Whis ered words louder, cle rer (whispered pectoriloquy)
A d v e n t it io u s o r A d d e d B r e a t h S o u n d s
Cra ck le s (o r Ra le s ) Wh e e ze s a n d Rh o n c h i
Discontinuous Continuous
● Inter ittent, nonmusical, nd
brief
● Like dots in ti e
● Fine crackles: soft, high- itched
( 65 Hz), very brief (5–1 s)
● Coarse crackles: so ewh t louder,
lower in itch ( 35 Hz), brief (15–3 s)
● Sinusoid l, musical, rolonged (but
not necess rily ersisting throughout the res ir tory cycle)
● Like d shes in ti e
● Wheezes: rel tively high- itched
(≥4 Hz) with hissing or shrill qu lity (>8 s)
● Rhonchi: rel tively low- itched
(15 –2 Hz) with snoring qu lity (>8 s)
Source: Loudon R, Mur hy LH. Lung sounds. Am Rev Respir Dis. 1994;13 :663; Boh d n A, Izbicki G, Kr n SS. Fund ent ls of lung uscult tion. N Engl J Med. 2 14;37 :744.
Alternative Examination Sequence—While the patient is still sitting, you may inspect the breasts and examine the axillary and epitrochlear lymph nodes, and examine the temporomandibular joint and the musculoskeletal system of the upper extremities.
T h e A n t e r io r C h e s t
EXAMINATIO N TECHNIQ UES P O SSIBLE FIN DIN GS
Inspect the chest (Figs. 8-6 and 8-7) for:
■ Deformities or asymmetry
■ Intercostal retraction
■ Impaired or lagging respiratory
movement
Palpate the chest for:
■ Tender areas
■ Assessment of visible abnor-
malities ■ Respiratory expansion ■ Tactile fremitus Midste rna l line Midclavicula r line Ante rior a xilla ry line
Fig ure 8-6 Mids te rnal and m idclavicu- lar line s . Ante rior a xilla ry line Pos te rior a xilla ry line Mida xilla ry line
Fig ure 8-7 Ante rior, pos te rior, and m idaxillary line s .
Pectus excavatum
From obstructed airways
Disease of the underlying lung or pleura, phrenic nerve palsy
Tender pectoral muscles, costochondritis Flail chest
Chapter 8 | The Thorax and Lungs 153 1 1 2 2 3 3 4 4 5 5 6 6
Fig ure 8-8 Palate and pe rcus s in a “ ladde r” patte rn.
Normal cardiac dullness may disappear in emphysema.
EXAMINATIO N TECHNIQ UES P O SSIBLE FIN DIN GS
Auscultate the chest. Assess breath sounds, adventitious sounds, and if indicated transmitted voice sounds.
Older adults walking 8 feet in <3 seconds are less likely to be disabled than those taking >5 to 6 seconds.
Patients age ≥60 years with a forced expiratory time of ≥9 seconds are four times more likely to have COPD.
Percuss the chest in the areas illus- trated in Figure 8-8.
S p e c ia l T e c h n iq u e s
Clin ic a l As s e s s m e n t o f P u lm o n a ry Fu n c t io n . Walk with patient down the hall or up a ight of stairs. Observe the rate, effort, and sound of breathing, and inquire about symptoms. Or learn to do a standardized “6-minute walk test.”
Fo rc e d Exp ira t o ry
Tim e . Ask the patient to take a deep breath in and then breathe out as quickly and completely as possible, with mouth open. Listen over trachea with diaphragm of stethoscope, and time audible expi- ration. Try to get three consistent readings, allowing rests as needed.
R e c o r d in g t h e T h o r a x a n d Lu n g s E x a m in a t io n
“Thor x is sy etric with good ex nsion. Lungs reson nt. Bre th sounds vesicul r; no r les, wheezes, or rhonchi. Di hr g s descend 4 c bil ter lly.” OR
“Thor x sy etric with oder te ky hosis nd incre sed ntero osterior (AP) di eter, decre sed ex nsion. Lungs re hy erreson nt. Bre th sounds dist nt with del yed ex ir tory h se nd sc ttered ex ir tory wheezes. Fre itus decre sed; no broncho hony, ego hony, or whis ered ectoriloquy. Di hr g s descend 2 c bil ter lly.” (These findings suggest COPD.)
Chapter 8 | The Thorax and Lungs 155
Aids to Interpretation
P ro b le m a n d Lo c a t io n Q u a lit y, S e ve r it y, Tim in g , a n d A s s o c ia t e d S ym p t o m s C a rd io va s c u la r Ang ina Pe ctorisRetrosternal or across the anterior chest, sometimes radiating to the shoulders, arms, neck, lower jaw, or upper abdomen
■ Pressing, squeezing, tight,
heavy, occasionally burning
■ Mild to moderate severity,
sometimes perceived as discomfort rather than pain
■ Usually 1–3 min but up to
10 min; prolonged episodes up to 20 min
■ Sometimes with dyspnea,
nausea, swelling
Myo ca rd ia l In fa rctio n
Same as in angina
■ Same as in angina
■ Often but not always a severe
pain
■ 20 min to several hours
■ Associated with nausea,
vomiting, sweating, weakness
Pe rica rditis
Retrosternal or Precordial: May radiate to the tip of the shoulder and to the neck
■ Sharp, knifelike quality
■ Often severe
■ Persistent timing
■ Relieved by leaning forward
■ Seen in autoimmune disorders,
postmyocardial infarction, viral infection, chest irradiation
Dis s e ctin g Aortic An e u rys m
Anterior chest, radiating to the neck, back, or abdomen
■ Ripping, tearing quality
■ Very severe
■ Abrupt onset, early peak,
persistent for hours or more
■ Associated syncope, hemiplegia,
paraplegia
Ch e s t Pa in
Table 8-1
P ro b le m a n d Lo c a t io n
Q u a lit y, S e ve r it y, Tim in g , a n d A s s o c ia t e d S y m p t o m s
P u lm o n a ry Ple u ritic Pa in
Chest wall overlying the process
■ Sharp, knifelike quality
■ Often severe
■ Persistent timing
■ Associated symptoms of the
underlying illness (often pneumonia, pulmonary embolism)
Ga s t ro in t e s t in a l a n d Ot h e r Ga s troin te s tina l Re flux Dis e a s e
Retrosternal, may radiate to the back
■ Burning quality, may be
squeezing
■ Mild to severe
■ Variable timing
■ Associated with regurgitation,
dysphagia; also cough, laryngitis, asthma
Diffu s e Es o p h a g e a l S p a s m
Retrosternal, may radiate to the back, arms, and jaw
■ Usually squeezing quality
■ Mild to severe
■ Variable timing
■ Associated dysphagia
Ch e s t Wa ll Pa in , Co s to ch o n d ritis
Often below the left breast or along the costal cartilages; also elsewhere
■ Stabbing, sticking, or dull
aching quality
■ Variable severity
■ Fleeting timing, hours or days
■ Often with local tenderness
An xie ty, Pa n ic Dis o rd e r ■ Pain may be stabbing, sticking,
or dull, aching
■ Can mimic angina
■ Associated with breathlessness,
palpitations, weakness, anxiety
Ch e s t Pa in (continued )
Chapter 8 | The Thorax and Lungs 157 P ro b le m Tim in g P ro vo k in g /Re lie v in g Fa c t o r s ; A s s o c ia t e d S y m p t o m s Le ft -S id e d He a r t Fa ilu re (Left Ventricular Failure or Mitral Stenosis)
Dyspnea may progress slowly or suddenly, as in acute pulmonary edema ↑ by exertion, lying down
↓ by rest, sitting up, though dyspnea may become persistent Associated Symptoms: Often cough, orthopnea, paroxysmal nocturnal dyspnea; sometimes wheezing
C h ro n ic Bro n c h it is (may be seen with COPD)
Chronic productive cough followed by slowly progressive dyspnea ↑ by exertion, inhaled irritants, respiratory infections ↓ by expectoration, rest though dyspnea may become persistent Associated Symptoms: Chronic productive cough, recurrent respiratory infections; wheezing possible C h ro n ic O b s t r u c t ive P u lm o n a ry D is e a s e (CO P D ) Slowly progressive; relatively mild cough later ↑ by exertion ↓ by rest, though dyspnea may become persistent
Associated Symptoms: Cough with scant mucoid sputum