?!6.I'2018
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`Evaluation of the Pulmonary Patient - Pulmonary Disorders - Merck Manuals Professional Edilion
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`\\\ MERCK MANUAL
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`Ei'lll'
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`Professional f Pulmonary Disorders 3' Approach to the Pulmonary Patient
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`Evaluation of the
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`Pulmonary Patient
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`By Noah Lechtzin, MD, MHS, Associate Professor of Medicine and
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`Director, Adult Cystic Fibrosis Program, johns Hopkins University
`School of Medicine
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`Key components in the evaluation of patients with pulmonary symptoms are the history, physical
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`examination, and, in most cases, a chest x-ray. These components establish the need for
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`subsequent testing, which may include pulmonary function testing and ABG analysis, CT or other
`chest imaging tests, and bronchoscopy.
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`History
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`The history can often establish whether symptoms of dyspnea, chest pain, wheezing, stridor,
`hemoptysis, and cough are likely to be pulmonary in origin. When more than one symptom
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`occurs concurrently, the history should focus on which symptom is primary and whether
`constitutional symptoms, such as fever, weight loss, and night sweats, are also present. Other
`important information includes
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`0 Occupational and environmental exposures
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`- Family history, travel history, and contact history
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`a Previous illnesses
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`0 Use of prescription, OTC, or illicit drugs
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`0 Previous test results (eg, tuberculin skin test, chest x-rays}
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`Physical Examination
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`Physical examination starts with assessment of general appearance. Discomfort and anxiety,
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`body habitus, and the effect of talking or movement on symptoms {eg. inability to speak full
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`Evaluation of the Pulmonary Patient - Pulmonary Disorders - Merck Manuals Professional Edilion
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`sentences without pausing to breathe) all can be assessed while greeting the patient and taking a
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`history and may provide useful information relevant to pulmonary status. Next, inspection,
`auscultation, and chest percussion and palpation are done.
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`Inspection
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`Inspection should focus on
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`- Signs of respiratory difficulty and hypoxemia (eg, restlessness, tachypnea, cyanosis,
`accessory muscle use)
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`- Signs of possible chronic pulmonary disease (eg, clubbing, pedal edema)
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`. Chest wall deformities
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`- Abnormal breathing patterns (eg, Cheyne-Stokes respiration, Kussmaul respirations)
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`o Jugular venous distention
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`Signs of hypoxemla include cyanosis (bluish discoloration of the lips, face, or nail beds), which
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`signifies low arterial oxygen saturation (< 85%); the absence of cyanosis does not exclude the
`presence of hypoxemia.
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`Signs of respiratory difficulty include tachypnea, use of accessory respiratory muscles
`(sternocleidomastoids, intercostals, scalene) to breathe, lntercostal retractions, and paradoxical
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`breathing. Patients with COPD sometimes brace their arms against their legs or the examination
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`table while seated (ie, tripod position) in a subconscious effort to provide more leverage to
`accessory muscles and thereby enhance respiration. lntercostal retractions {inward movement of
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`the rib interspaces) are common among infants and older patients with severe airflow limitation.
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`Paradoxical breathing (inward motion of the abdomen during inspiration) signifies respiratory
`muscle fatigue or weakness.
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`Signs of possible chronic pulmonary disease include clubbing, barrel chest (the increased
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`anterior-posterior diameter of the chest present in some patients with emphysema), and pursed
`lip breathing. Clubbing is enlargement of the fingertips (or toes) due to proliferation of
`connective tissue between the fingernail and the bone. Diagnosis is based on an increase in the
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`profile angle of the nail as it exits the finger (to >176“) or on an increase in the phalangeal depth
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`ratio (to > 1—see Figure: Measuring finger clubbing). "Sponginess" of the nail bed beneath the
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`cuticle also suggests clubbing. Clubbing is most commonly observed in patients with lung cancer
`but is an important sign of chronic pulmonary disease, such as cystic fibrosis and idiopathic
`pulmonary fibrosis; it also occurs (but less commonly) in cyanotic heart disease, chronic infection
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`(eg, infective endocarditis), stroke, inflammatory bowel disease, and cirrhosis. Clubbing
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`occasionally occurs with osteoarthropathy and periostitis (primary or hereditary hypertrophic
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`osteoarthropathy): in this instance, clubbing may be accompanied by skin changes, such as
`hypertrophied skin on the dorsa of the hands (pachydermoperiostosis), seborrhea, and coarse
`facial features. Digital clubbing can also occur as a benign hereditary abnormality that can be
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`ht‘lpsziva.merckmanuals.oornrproiessionalipulmnary-disordersiapproach—Iothe-pulrnonary-paiientievaluaiionpf-flie-pulmonary-palient
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`Evaluation of the Pulmonary Patient - Pulmonary Disorders - Merck Manuals Professional Edilion
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`distinguished from pathologic clubbing by the absence of pulmonary symptoms or disease and
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`by the presence of clubbing from an early age (by patient report).
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`
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`Finger Clubbing
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`© Springer Science+Business Media
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`Measuring finger clubbing.
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`The ratio of the anteroposterior diameter of the finger at the nail bed (a—b) to that at the distal
`interphalangeal joint (c—d) is a simple measurement of finger clubbing. It can be obtained
`readily and reproducibly with calipers. if the ratio is > 1, clubbing is present. Finger clubbing is
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`also characterized by loss of the normal angle at the nail bed.
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`Normal linger
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`Clubbecl linger
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`160
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`{ 5160 \
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`Chest wall deformities. such as pectus excavatum (a sternal depression usually beginning over
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`the midportion of the manubrium and progressing inward through the xiphoid process} and
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`kyphoscoliosis, may restrict respirations and exacerbate symptoms of preexisting pulmonary
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`disease. These abnormalities can usually be observed during careful examination after the
`patient‘s shirt is removed. Inspection should also include an assessment of the abdomen and the
`extent of obesity. ascites. or other conditions that could affect abdominal compliance.
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`Abnormal breathing patterns cause fluctuations in respiratory rate so respiratory rate should
`be assessed and counted for 1 min.
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`Evaluation of the Pulmonary Patient - Pulmonary Disorders - Merck Manuals Professional Edilr'on
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`I Cheyne-Stokes respiration (periodic breathing) is a cyclic fluctuation of respiratory rate
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`and depth. From periods of brief apnea. patients breathe progressively faster and deeper
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`(hyperpnea), then slower and shallower until they become apneic and repeat the cycle.
`Cheyne~$tokes respiration is most often caused by heart failure. a neurologic disorder (eg.
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`stroke. advanced dementia), or drugs. The pattern in heart failure has been attributed to
`delays in cerebral circulation; respiratory centers lag in recognition of systemic
`acidosislhypoxia (causing hyperpnea) or alkalosis/hypocapnia (causing apnea).
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`o Blot respiration is an uncommon variant of Cheyne-Stokes respiration in which irregular
`periods of apnea alternate with periods in which 4 or 5 deep. equal breaths are taken. It
`differs from Cheyne-Stokes respiration in that it is characterized by abrupt starts and stops
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`and lacks periodicity. It results from injury to the CNS and occurs in such disorders as
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`meningitis.
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`- Kussmaul respirations are deep, regular respirations caused by metabolic acidosis.
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`Pulmonary hypertension, sometimes observed during inspection, indicates an increase in right
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`atrial and usually in right ventricular pressure. The elevated pressure is usually caused by left
`ventricular dysfunction. but it may also be due to a pulmonary disorder causing pulmonary
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`hypertension. The presence of jugular venous distension should prompt a search for other signs
`of cardiac disorder leg, 3rd heart sound [53] gallop, dependent edema).
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`Auscultation
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`Auscultation is arguably the most important component of the physical examination. All fields of
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`the chest should be listened to, including the flanks and the anterior chest, to detect
`abnormalities associated with each lobe of the lung. Features to listen for include
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`a Character and volume of breath sounds
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`0 Presence or absence of vocal sounds
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`a Pleural friction rubs
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`- Ratio of inspiration to expiration (I : E ratio)
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`Cardiac auscultation may reveal signs of pulmonary hypertension, such as a loud pulmonic 2nd
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`heart sound (P2), and of right heart failure, such as a right ventricular 4th heart sound (S4) and
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`tricuspid regurgitation.
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`The character and volume of breath sounds are useful in identifying pulmonary disorders.
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`Vesicular breath sounds are the normal sounds heard over most lung fields. Bronchial breath
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`sounds are slightly louder. harsher. and higher pitched; they normally can be heard over the
`trachea and over areas of lung consolidation, such as occur with pneumonia.
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`Typical breath sounds heard over most lung fields.
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`Evaluation oi the Pulmonary Patient - Pulmonary Disorders - Merck Manuals Professional Edilr'on
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`Normal Breath Sounds
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`Audio file courtesy of David W. Cugell, MD.
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`Typical breath sounds heard over the trachea and areas of lung consolidation.
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`Normal Bronchial Breath Sounds
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`Audio file courtesy of David W. Cugell. MD.
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`Crackles
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`Audio file courtesy of David W. Cugell. MD.
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`Prolonged expiratory phase with wheezing.
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`Wheezing
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`Audio file courtesy of David W. Cugell. MD.
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`Inspiratory Stridor in croup.
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`Stridor
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`Audio file courtesy of David W. Cugell. MD.
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`A leathery sound that fluctuates with the respiratory cycle.
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`Friction Rub
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`Audio file courtesy of David W. Cugell, MD.
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`Areas of consolidation cause a patient's vocalized "E" to sound like "A."
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`E to A Change
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`Audio file courtesy of David W. Cugell, MD.
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`Adventitious sounds are abnormal sounds, such as crackles, rhonchi, wheezes, and stridor.
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`Evaluation of the Pulmonary Patient - Pulmonary Disorders - Merck Manuals Professional Edilion
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`Crackles (previously called rales) are discontinuous adventitious breath sounds. Fine
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`crackles are short high-pitched sounds; coarse crackles are longer-lasting low-pitched
`sounds. Crackles have been compared to the sound of crinkling plastic wrap and can be
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`simulated by rubbing strands of hair together between 2 fingers near one's ear. They occur
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`most commonly with atelectasis. alveolar filling processes (eg, pulmonary edema). and
`interstitial lung disease (eg. pulmonary fibrosis); they signify opening of collapsed ainNays or
`alveoli.
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`Rhonchi are low-pitched respiratory sounds that can be heard during inspiration or
`expiration. They occur in various conditions, including chronic bronchitis. The mechanism
`may relate to variations in obstruction as airways distend with inhalation and narrow with
`exhalation.
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`Wheezes are whistling, musical breath sounds that are worse during expiration than
`inspiration. Wheezing can be a physical finding or a symptom and is usually associated with
`dyspnea.
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`Stridor is a high-pitched, predominantly inspiratory sound formed by extrathoracic upper
`airway obstruction. It usually can be heard without a stethoscope. Stridor is usually louder
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`than wheezing, is predominantly inspiratory, and is heard loudly over the larynx. It should
`trigger a concern for life-threatening upper airway obstruction.
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`Decreased breath sounds signify poor air movement in airways, as occurs with asthma
`and COPD where bronchospasm or other mechanisms limit airflow. Breath sounds may
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`also be decreased in the presence of a pleural effusion, pneumothorax, or obstructing
`endobronchial lesion.
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`Vocal sounds involve auscultation while patients vocalize.
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`Bronchophony and whispered pectoriloquy occur when the patient’s spoken or
`whispered voice is clearly transmitted through the chest wall. Voice transmission results
`from alveolar consolidation. as occurs with pneumonia.
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`Egophony (E to A change) is said to occur when, during auscultation. a patient says the
`letter "E" and the examiner hears the letter"A," again as occurs with pneumonia.
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`Friction rubs are grating or creaking sounds that fluctuate with the respiratory cycle and sound
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`like skin rubbing against wet leather. They are a sign of pleural inflammation and are heard in
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`patients with pleuritis or empyema and after thoracotomy.
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`|:E ratio is normally 1:2 but is prolonged to 2 1:3 when airflow is limited. such as in asthma and
`COPD. even in the absence of wheezing.
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`Percussion and palpation
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`Percussion is the primary physical maneuver used to detect the presence and level of pleural
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`effusion. Finding areas of dullness during percussion signifies underlying fluid or, less commonly,
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`consolidation.
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`Paipation includes tactile fremitus (vibration of the chest wall felt while a patient is speaking); it is
`decreased in pleural effusion and pneumothorax and increased in pulmonary consolidation leg,
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`lobar pneumonias). Point tenderness on palpation may signal underlying rib fracture or pleural
`inflammation.
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`In cor pulmonale. a right ventricular impulse at the left lower sternal border may become evident
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`and may be increased in amplitude and duration (right ventricular heave).
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`Last full review/revision August 2016 by Noah Lechtzin, MD, MHS
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`em
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`it.) 2018 Merck Sharp is Dohme Corp, a subsidiary ol Merck a Co. Inc,. Kcnilworlh, NJ, USA
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