Hi, I'm Jessica, I'm the nurse practitioner. I'm going to be checking your lung and thorax out today and I'm going to be speaking so that the cameras and the students at home can learn and hear what I'm saying. I'm starting as I do all systems with inspection.
So in this case, I'm going to start and just inspect, palpate, percuss, listen to the front side of his anterior chest and then at the end I'm going to have him turn and we will do this over again on the posterior abdomen. aspect of his chest. When you're in clinical practice you might choose to inspect both sides at once and then palpate both sides at once and then listen to both sides at once.
But for the purposes of today we're going to do the anterior side and then we'll turn him around and do the posterior side. So at first I'm inspecting his anterior chest, looking for his breathing, the rate of breathing, his effort and breath. Is it shallow? Is it rapid? Is it even?
And he looks to be in no acute respiratory distress by any means. The next thing I'm going to do is palpate his chest. This is just palpating for any subcutaneous air trapping and also tactile phlebitis. I'm going to use the palmar aspect of my hand and place it in his intercostal muscles and have him say 99. 99. 99, 99, 99, 99, 99. Tactile Feminist is the vibrations of his words coming through, and you should normally feel those, and they should be symmetrical from side to side. So it's more important to compare one side to the next side, especially when you're dealing with the lung and thorax.
The fact that it's present is... is not as interesting or significant as if it's present and symmetrical between both sides. The next part of the exam on the anterior lungs is to auscultate. So I'm going to use my stethoscope and use the diaphragm of the stethoscope and auscultate his lung field.
So, Makana, when you feel my stethoscope placed on your chest, just take a deep breath, okay? I'm going to start with the anterior chest and then listen and note where I place the stethoscope in that I go in a ladder position, always comparing one side to the next side and put the stethoscope in approximately the same area on the opposite side. I like to start my examinations even above the clavicle where the anterior lung fields are, so take a deep breath for me.
In and out. Good. And out again.
Good. And women... Or in men, if they have large breast tissue, it's important to get a good assessment. So you can actually have the patient, just ask the patient to lift up their breast tissue so that you can listen to the appropriate positions that you need to.
And that's a lot less awkward than if you're trying to lift up their breast tissue and listen at the same time. So just ask the patient to lift up their breast tissue and listen at that time. So that concludes the anterior lung field. So I'm going to have Makana turn around so that we can assess his back.
Good. So now that Makana is turned around, we're going to take a look at the back side of his chest. And again, we start with inspection, looking that his chest rises symmetrically and falls symmetrically, looking for the rate, the work of breathing, looking for any...
I didn't mention this on the anterior chest, but looking for any intercostal muscle use. And then next after that, we're going to percuss his lung fields. You can do this on the anterior side also.
It's a little bit harder because of the musculature of the anterior chest wall and the breast tissue in females. But percussion, you want to stay away from the scapula because obviously that's going to be a dull sound. But percussion, again, with your non-dominant hand, you place it on the area you would like to percuss. I use my middle finger. And then with your dominant hand, middle finger, you strike the DIP joint of your non-dominant hand and then release.
So it's a quick tap, tap, and release so that you don't muffle the sound. And it should be a nice resonant sound because the lungs are filled with air. If you palpate over a rib, then you're going to get that dullness because it's going to be a dull, bony sound. So you want to palpate in between the ribs and the intercostal muscles.
And so you'll percuss down, map the borders of the lungs, get an idea of where the lung tissue ends. The next step then is to do a test. that we call diaphragmatic excursion. It maps out the diaphragm's movement during full inspiration and full expiration.
So I'm going to have Makana take a deep inhale and hold it. While he's doing that, I'm going to percuss down and mark the area where it changes from resonance to dullness. So it's right there. So if I had a pen, I would mark right there.
And I would do the same thing on this side. And I would mark right there. Go ahead and exhale.
Okay, and then take a deep breath and then exhale it out and hold your exhale. So once he's completely exhaled, I would start over again. And you can either start from here and percuss down, or you can start from down here.
and percuss up to where it sounds from dull to resonance. And then you mark that area. You do the same thing on the opposite side, and they should be equal from side to side.
And you mark how the change of where the resonance and dullness is. And this change here is the diaphragmatic excursion. It's the amount that the diaphragm moves during inspiration and expiration.
That should normally be between 3 and 6 centimeters. And someone who's well conditioned, a well conditioned athlete whose lungs are really in shape, they can sometimes get up to 7 and even 8 centimeters. I'm going to next palpate the back structures on the posterior back.
You could have done this before percussion. I didn't, so I'm going to do it now. So I'm first palpating the back.
I'm palpating for any tenderness, any pain, and just looking that the structures are symmetrical. But similar as I did on the front side, I'm going to be checking for tactile femoriness. Can you say 99? 99, 99, 99, 99, 99. And you'll note that if you feel over the scapula like I just did, you don't really feel any of the vibrations in your hand.
But over the lung fields, you feel good vibrations. And even more importantly or significantly than the fact that you can feel them is that they're the same from side to side. Another part of palpation is to check for long expansion, for symmetrical long expansion. So I'm going to show you a little bit of a video.
I'm going to put my hands around the 10th rib and span my hands out laterally over his ribs. And then with my thumbs close to his spine, I'm going to actually push them medially so that I get a little bit of the skin there so I can watch it expand. So go ahead and take a deep breath in, Makana. And as you take a deep breath in, my thumbs go with him. And you can see that the thumbs expanded together, that one side didn't go up and the other side didn't.
stayed the same. They should equally go up and equally fall back down. That's chest expansion.
Finally, we're going to end with auscultation of the posterior aspect of the lungs. Similar as we did on the anterior side, it's important to check one side and compare it to the other. Whenever you feel my stethoscope touch your back, if you could take a deep breath in and out, that'd be great. Actually, Makana, I'm going to check underneath your arms as well.
If you can put your arms... out like this that'd be helpful okay and I again I start up really high to the anterior lung fields good you want to avoid the scapula and I use this ladder approach where you go one side then the next and then down on that same side and then the next and then over to the lateral side. And then finally underneath on the lateral aspect of both arms to check the right middle lobe is the best area to check the right middle lobe.
Very good. You're listening for normal lung sounds, which on the posterior aspect of the chest are mostly going to be vesicular. On the anterior side, you can get some tracheal sounds up by your trachea. You can get some vesicular tracheal sounds up in the anterior portion of the chest, but the majority of the lung fields should be vesicular sounds. You're also listening for normal lung sounds, which are mostly going to be vesicular.
for adventitious sounds or abnormal lung sounds and those include crackles which are going to be coarse sounds and they are described a lot in the literature as the sound of your hair being crinkled in front of your ear so it's like a snap crackly pop they can be really coarse or they can be fine so those are descriptions of the crackles themselves. Wheezing is another abnormal lung sound and it is common with asthma and some of the bronchitis. syndromes as air is, during inspiration or expiration, air is trying to get through a bronchial that is constricted or there's some mucosal edema. So as the air goes into that constricted vessel, it produces a whistling sound.
So you might hear whistling or wheezes in the lungs as well. And finally, you may hear some bronchi, which are coarse sounds. They're rough.
and harsh sounds that you may hear in the bases or all throughout the entire lung fields. There are a couple of special tests if you suspect that the patient may have pneumonia or some consolidation. If the patient's complaining of coughing or that their chest is hurting when they're coughing, you can perform a couple of tests called the voice transmission. The transmitted voice sounds, one of these is called bronchophony. Whenever you listen, place your stethoscope on the patient's chest, you have the patient say 99 and you listen for what you hear.
So I'm going to place my stethoscope on your chest and just 99. Good. If you hear a little bit of change, you'll want to compare it to the other side. Usually, the voice should be muffled and indistinct.
You shouldn't necessarily hear them say 99 very clearly. If there's some consolidation, you will hear 99, just like you didn't have a stethoscope in your ear. It would be much more clear and more distinct.
Another one is called whispered petriloquy. During this, you have the patient say 99 or 1, 2, 3, but you have them whisper it. So every time I place my stethoscope, if you could say... whisper one two three and I can tell that he's saying it because I can watch his mouth move but I can't hear anything which is a normal which is a normal finding if I could hear him through my stethoscope through his lungs then that means that he has some consolidation and sound travels better through consolidation, so that's why we would hear it better.
So his whispered 1, 2, 3 would actually come out clear when I'm listening to him. The last one is called Egophne, and I'm going to again... listen with my stethoscope to his lungs and I'm going to have the Makana say E. Every time I touch my stethoscope on your back say E.
E, E, E, E, E, E. Good. What I hear is E. When he says E, I hear E. If I heard an A sound or A, A, what we call E to A changes, then that can indicate that there's some consolidation in his lungs also.
I did those exams on the post-treatment. aspect of the chest, but really you should do them on the posterior and the anterior lung fields because you're going to hear different. The posterior aspect of the lungs is mostly going to be the lower lobes of both lungs, whereas on the anterior chest, you're going to get the upper lobes of the lungs, and then on the right, you're going to get the middle lung in the anterior chest line.
So that concludes our lung and thorax examination today. Thank you all.