Thorax and Lungs Assessment: Symptoms

• The thorax and lungs are essential components of the respiratory system, responsible for gas exchange.
• A comprehensive health assessment of the thorax and lungs involves subjective data collection (history) and objective data collection (physical examination).

Subjective Data Collection (History)

• Collect the patient's history regarding any past or present respiratory issues.

Common or concerning symptoms

• Cough: Onset, duration, nature (dry, productive), sputum (color, quantity), aggravating or alleviating factors, associated symptoms such as fever, shortness of breath, or chest pain.
• Shortness of Breath (Dyspnea): Onset (sudden or gradual), severity, timing (constant or intermittent), associated factors (e.g., exertion, position), and impact on daily activities.
• Chest Pain: Location, onset, duration, character (sharp, dull, pressure), intensity, aggravating or alleviating factors, and associated symptoms (e.g., cough, shortness of breath).
• Wheezing: Onset, timing, triggers, associated symptoms (e.g., shortness of breath, cough), and response to medications.
• Hemoptysis: Onset, amount of blood, color, associated symptoms (e.g., cough, chest pain), and any recent trauma or procedures.

Past History

• Prior respiratory illnesses: Asthma, chronic bronchitis, emphysema, pneumonia, tuberculosis, or cystic fibrosis.
• Allergies: Known allergens and reactions, particularly those that affect the respiratory system.
• Vaccinations: Influenza and pneumococcal vaccines.
• Medications: Current medications, including inhalers, and their effectiveness.

Family History

• Family history of respiratory diseases: Asthma, cystic fibrosis, emphysema, lung cancer, or tuberculosis.

Social History

• Tobacco use: Type, duration, and quantity of tobacco use (pack-years).
• Environmental exposures: Occupational hazards, exposure to pollutants, and travel history to areas with endemic respiratory diseases.
• Use of alcohol
• Use of recreational drugs

Objective Data Collection (Physical Examination)

• The physical examination of the thorax and lungs includes inspection, palpation, percussion, and auscultation.

Preparation

• Explain the procedure to the patient to ease anxiety and promote cooperation.
• Ensure the patient is properly draped to maintain privacy while allowing adequate access to the chest and back.
• The patient should be sitting upright, if possible.
• Ensure the examination room is quiet to optimize auscultation.

Inspection

• Observe the patient's general appearance, noting any signs of respiratory distress such as nasal flaring, pursed-lip breathing, or cyanosis.
• Assess the shape and symmetry of the chest.
• Observe the respiratory rate, rhythm, and depth. Note any use of accessory muscles.
• Inspect the skin for scars, lesions, or discoloration.

Palpation

• Palpate the chest wall for tenderness, masses, or crepitus (subcutaneous emphysema).
• Assess symmetric expansion by placing hands on the patient's back, with thumbs meeting at the midline.
• As the patient takes a deep breath, observe the movement of the thumbs.
• Evaluate tactile fremitus by placing the palmar base of the fingers on the patient's chest and asking them to repeat a phrase like "ninety-nine."
• Assess for vocal fremitus, which is the vibration felt on the chest wall when the patient speaks. Increased, decreased, or absent fremitus can provide diagnostic information.

Percussion

• Percussion helps determine whether underlying tissues are air-filled, fluid-filled, or solid.
• Percuss the anterior and posterior chest systematically, comparing both sides.
• Percussion sounds:
• Resonance: Normal lung tissue.
• Hyperresonance: Hyperinflated lungs (e.g., emphysema, pneumothorax).
• Dullness: Fluid or solid tissue (e.g., pneumonia, pleural effusion, tumor).
• Flatness: Massive pleural effusion, atelectasis.

Auscultation

• Auscultation involves listening to breath sounds with a stethoscope.
• Instruct the patient to breathe slowly and deeply through the mouth.
• Listen to breath sounds systematically, comparing both sides.
• Identify normal breath sounds:
• Vesicular: Soft, low-pitched sounds heard over most of the lung fields.
• Bronchovesicular: Moderate pitch and intensity, heard over the major bronchi.
• Bronchial: Loud, high-pitched sounds heard over the trachea.
• Tracheal: Harsh, loud sounds heard over the trachea in the neck.
• Note any adventitious (abnormal) breath sounds:
• Crackles (rales): Fine, crackling sounds caused by air passing through fluid or collapsed alveoli.
• Wheezes: High-pitched, whistling sounds caused by narrowed airways.
• Rhonchi: Low-pitched, snoring sounds caused by secretions in the larger airways.
• Stridor: High-pitched, crowing sound heard during inspiration, indicating upper airway obstruction.
• Pleural Rub: Grating or squeaking sound caused by inflamed pleural surfaces rubbing together.
• If abnormalities are noted, assess voice sounds:
• Bronchophony: Increased clarity of spoken words.
• Egophony: "E" sounds like "A."
• Whispered Pectoriloquy: Whispered sounds are heard clearly.

Documentation

• Thorough documentation of the health assessment findings is essential.
• Record all subjective and objective data accurately.
• Note any abnormal findings and their location.
• Document patient education and any interventions performed.

Variations by Age Group

• Infants and Children: Respiratory rate is faster, and breath sounds may be louder and harsher.
• Older Adults: Chest wall may be more rigid, and respiratory muscle strength may decrease.

Common Abnormalities

• Pneumonia: Inflammation of the lung parenchyma, causing consolidation.
• Asthma: Chronic inflammatory disorder of the airways, leading to bronchoconstriction and wheezing.
• Chronic Obstructive Pulmonary Disease (COPD): Chronic airflow limitation caused by emphysema and chronic bronchitis.
• Pleural Effusion: Accumulation of fluid in the pleural space.
• Pneumothorax: Presence of air in the pleural space, causing lung collapse.
• Lung Cancer: Malignant tumor of the lung, often associated with smoking.