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The pulmonary exam is a standard part of the screening evaluation for routine patient visits and also performed when patients present with specific concerns or findings (eg, shortness of breath, wheezing) that may be caused by lung disease.
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The 4 major components of the lung exam (inspection, palpation, percussion and auscultation) are also used to examine the heart and abdomen. Learning the appropriate techniques at this juncture will therefore enhance your ability to perform these other examinations as well. Vital signs, an important source of information, are discussed in Chapter 3.
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For a discussion of gown management and tips for respectfully examining your patients, please see this section in Chapter 6, Cardiovascular exam.
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REVIEW OF LUNG ANATOMY
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Understanding the lung exam is enhanced by recognizing the relationship between surface structures, the skeleton, and the main lobes of the lung. Some surface markers (eg, nipples of the breast) do not always maintain their precise relationship to underlying structures, but they provide a rough guide to which lobe is beneath and can be quickly correlated with findings on chest x-ray or computed tomography (CT) scan. Figure 7-1 demonstrates these relationships. Note how far up the back the lower lobes go and that the upper lobes are best heard anteriorly. The multicolored areas of the lung model identify precise anatomic segments of the various lobes, which cannot be appreciated on examination. Main lobes are outlined in black.
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The lungs are contained within the visceral (lung side) and parietal (chest wall side) pleura, which normally contains a small amount of lubricating pleural fluid (Figure 7-2). In disease, excess fluid or air or a tumor can fill that space, contorting the normal anatomy of the lungs. This will be suggested by exam findings discussed in this chapter and confirmed with imaging studies.
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The lung is responsible for bringing oxygen into the bloodstream and removing carbon dioxide. Breathing is driven by the respiratory center in the midbrain and pons and occurs without thought, responding to changes in oxygen and carbon dioxide levels in the blood. Key elements include the following:
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Inhalation (inspiration) is active and caused by shortening and downward contraction of the diaphragm and contraction of the intercostal muscles, drawing air into the lungs (Figure 7-3).
Exhalation (expiration)...