Inquiry and general examination of a patient of pulmonological profile
Inquiry. Complaints. The main complaints typical for the respiratory system are dyspnoea, cough, bloody expectorations, and pain in the chest. Fever, asthenia, indisposition and loss of appetite are not infrequent.
Dyspnoea in its manifestation can be subjective, objective, or subjective and objective simultaneously. By subjective dyspnoea is understood the subjective feeling of difficult or laboured breathing. Objective dyspnoea is determined by objective examination and is characterized by changes in the respiration rate, depth, or rhythm, and also the duration of the inspiration or expiration.
Dyspnoea may be physiological (caused by heavy exercise) and pathological (associated with pathology of the respiratory organs, diseases of the cardiovascular and haemopoietic systems, and poisoning).
Dyspnoea associated with respiratory pathology may be of various aetiology. It can be caused by obstruction of the respiratory ducts, contraction of the respiratory surface of the lungs due to their compression by liquid or air accumulated in the pleural cavity, decreased pneumatization of the lung in pneumonia, atelectasis, infarction or decreased elasticity of the lungs.
A mechanical obstruction in the upper respiratory ducts (larynx, trachea) complicates and slows down passage of the air into the alveoli and causes inspiratory dyspnoea. When the trachea and a large bronchus are sharply contracted, both inspiration and expiration become difficult and noisy (stridulous respiration). Narrowed lumen in the fine bronchi and bronchioles due to inflammatory oedema and swelling of their mucosa, or else in spasms in the smooth muscles (bronchial asthma), interferes with normal air passage from the alveoli and the expiration becomes difficult. Cough is a complicated reflex act which is actually a defence reaction aimed at clearing the larynx, trachea, or bronchi from mucus or foreign material. An inflamed bronchial mucosa produces a secretion which acts on the sensitive reflexogenic zones in the respiratory mucosa to stimulate the nerve endings and to activate the coughing reflex.
Cough may be dry, without sputum, and moist which various amounts of sputum of different quality are expecced. Some diseases are attended only by dry cough, e.g. laryngitis, dry pleurisy or compression of the main bronchi by the bifurcation lymph nodes (tuberculosis, lym-phogranulomatosis, cancer metastases, etc.). Bronchitis, pulmonary tuberculosis, pneumosclerosis, abscess, or bronchogenic cancer of the lungs can be first attended by dry cough, which will then turn into moist one with expectoration of the sputum.
Haemoptysis is expectoration of blood with sputum during cough. The physician must determine the origin of haemoptysis and the amount and character of blood expectorated with sputum. Haemoptysis can develop in diseases of the lungs and air ways (bronchi, trachea or larynx), as well as in diseases of the cardiovascular system. Pulmonary tuberculosis and cancer, virus pneumonia, bronchiectasis, abscess and gangrene of the lung, ac-tinomycosis, tracheitis and laryngitis associated with virus influenza are often attended by haemoptysis. This symptom is also characteristic of some heart defects, thrombosis or embolism of the pulmonary arteries and subsequent pulmonary infarction.
The amount of blood expectorated with sputum is mostly scant. Blood appears in the form of thin streaks, or it may give diffuse colouration to the sputum, which can be jelly-like or foamy. Cavernous tuberculosis, bronchiectases, degrading tumour and pulmonary infarction may be attended by lung haemorrhage, which is usually accompanied with strong cough.
Blood expectorated with sputum can be fresh and scarlet, or altered. Scarlet blood in the sputum is characteristic of pulmonary tuberculosis, bronchogenic cancer, bronchiectasis, and actinomycosis of the lungs. Blood expectorated with sputum in acute lobar pneumonia (second stage) has the colour of rust (rusty sputum) due to decomposition of the red blood cells and formation of the pigment haemosiderin. Blood in the sputum is fresh and scarlet during the first 2-3 days in lung infarction while in subsequent 7-10 days it becomes altered.
Pain in the chest is classified by its location, origin, character, intensity, duration, and irradiation, by its connection with the respiratory movements, cough, and the posture. Pain may arise during the develop- ment of a pathological condition in the thoracic wall, the pleura, heart, and the aorta, and in diseases of the abdominal organs (by irradiation). Special clinical signs are characteristic of pain of any particular origin, and in this respect pain may have diagnostic value.
Pain in the chest in diseases of the respiratory organs depends on irrita¬tion of the pleura, especially of the costal and diaphragmal parts where sensitive nerve endings are found. (They are absent in the pulmonary tissue.) Pleura may be injured during its inflammation (dry pleurisy), in subpleural pneumonia (acute lobar pneumonia, lung abscess, pulmonary tuberculosis), in lung infarction, tumour metastasis into the pleura or development in it of the primary tumour, in injury (spontaneous pneumothorax, wound, rib fracture), in subdiaphragmal abscess, and in acute pancreatitis.
Pleural pain is often piercing, while in diaphragmal pleurisy and spontaneous pneumothorax it is acute and intense. Pain is intensified in deep breathing, coughing, or when the patient lies on the healthy side. The respiration movements in this position become more intense in the affected side of the chest to strengthen friction of the inflamed pleura (rough from deposited fibrin). Pain lessens when the patient lies on the affected side. Pleural pain is also lessened when the chest is compressed to decrease the respiratory excursions.
Data of objective examination of the patients with respiratory pathology.
The general configuration of the chest should first be estimated (position of the clavicles, supra- and subclavicular fossae, shoulder blades); the next step is to define the type, rhythm and frequency of breathing, respiratory movements of the left and right shoulder blades, and of the shoulder gir¬dle, and involvement of the accessory respiratory muscles in the breathing act. The patient should be better examined in the upright (standing or sitting) position with the chest being naked. Illumination of the body should be uniform.
The shape of the chest may be normal or pathological. A normal chest is characteristic of healthy persons with regular body built. Its right and left sides are symmetrical, the clavicles and the shoulder blades should be at one level and the supraclavicular fossae equally pronounced on both sides. Since all people with normal constitution are conventionally divided into three types, the chest has different shape in accordance with its constitu¬tional type. Pathological shape of the chest may be the result of congenital bone defects and of various chronic diseases (emphysema of the lungs, rickets, tuberculosis).
Normal form of the chest. 1. Normosthenic (conical) chest in subjects with normosthenic constitution resembles a truncated cone whose bottom is formed by well-developed muscles of the shoulder girdle and is directed upward. The anteroposterior (sterno vertebral) diameter of the chest is smaller than the lateral (transverse) one, and the supraclavicular fossae are slightly pronounced. There is a distinct angle between the sternum and the manubrium (angulus Ludowici); the epigastric angle nears 90°. The ribs are moderately inclined as viewed from the side; the shoulder blades closely fit to the chest and are at the same level; the chest is about the same height as the abdominal part of the trunk.
2. Hypersthenic chest in persons with hypersthenic constitution has the shape of a cylinder. The anteroposterior diameter is about the same as the transverse one; the supraclavicular fossae are absent (level with the chest). The manubriosternal angle is indistinct; the epigastric angle exceeds 90°;
the ribs in the lateral parts of the chest are nearly horizontal, the intercostal space is narrow, the shoulder blades closely fit to the chest, the thoradc part of the trunk is smaller than the abdominal one.
3. Asthenic chest in persons with asthenic constitution is elongated, narrow (both the anteroposterior and transverse diameters are smaller thaormal); the chest is flat. The supra- and subclavicular fossae are distinctly pronounced. There is no angle between the sternum and the manubrium: the sternal bone and the manubrium make a straight “plate”. The epigastric angle is less than 90°. The ribs are more vertical at the sides, the tenth ribs are not attached to the costal arch (costa decima fluctuens); the intercostal spaces are wide, the shoulder blades are winged (separated from the chest), the muscles of the shoulder girdle are underdeveloped, the shoulders are sloping, the chest is longer than the abdominal part of the trunk.
Pathological chest. 1. Emphysematous (barrel-like) chest resembles a hypersthenic chest in its shape, but differs from it by a barrel-like configuration, prominence of the chest wall, especially in the posterolateral regions, the intercostal spaces are enlarged. This type of chest is found in chronic emphysema of the lungs. Active participation of accessory respiratory muscles in the respiratory act (especially m. sternocleidomastoideus and m. trapezius), depression of the intercostal space, elevation of the entire chest during inspiration and relaxation of the respiratory muscles and lowering of the chest to the initial posi¬tion during expiration become evident during examination of emphysema patients.
2. Paralytic chest resembles the asthenic chest. It is found in emaciated patients, in general asthenia and constitutional underdevelopment; it often occurs in grave chronic diseases, more commonly in pulmonary tuberculosis and pneumosclerosis. During examination of patients with paralytic chest, marked atrophy of the chest muscles and asymmetry of the clavicles and dissimilar depression of the supraclavicular fossae can be observed along with typical signs of aslhenic chest. The shoulder blades are not at one level either, and their movements during breathing are asynchronous.
3. Rachitic chest (keeled or pigeon chest). It is characterized by a markedly greater anteroposterior diameter (compared with the transverse diameter) due to the prominence of the sternum (which resembles the keel of a boat.) The anterolateral surfaces of the chest are as if pressed on both sides and therefore the ribs meet at an acute angle at the sternal bone, while the costal cartilages thicken like beads at points of their transition to bones (rachitic beads). As a rule, these beads can be palpated after rickets only in children and youths.
4. Funnel chest has a funnel-shaped depression in the lower part of the sternum. This deformity can be regarded as a result of abnormal development of the sternum or prolonged compressing effect. In older times this chest would be found in shoemaker adolescents.
5. Foveated chest is almost the same as the funnel chest except that the depression is found mostly in the upper and the middle parts of the anterior surface of the chest. This abnormality occurs in syringomyelia, a rare disease of the spinal cord.
The chest may be abnormal in subjects with various deformities of the spine which arise as a result of injuries, tuberculosis of the spine, rheumatoid arthritis (Bekhterev’s disease), etc. Four types of spine deformities are distinguished: lateral curvature of the spine, called scoliosis; excessive forward and backward curvature of the spine (gibbus and kyphosis, respectively); forward curvature of the spine, generally in the lumbar region (lordosis); combination of the lateral and forward curvature of the spine (kyphoscoliosis).
The shape of the chest can readily change due to enlargement or diminution of one half of the chest (asymmetry of the chest). These changes can be transient or permanent.
The enlargement of the volume of one half of the chest can be due to escape of considerable amounts of fluid as the result of accumulation of fluid in the pleural cavity, or due to penetration of air inside the chest in injuries (pneumothorax). Levelling or protrusion of the intercostal spaces, asymmetry of the clavicles and the shoulder blades and also unilateral thoracic lagging can be observed during examination of the enlarged part of the chest.
Respiratory movements of the chest should be examined during inspection of the patient. In physiological conditions they are performed by the contraction of the main respiratory muscles: intercostal muscles, muscles of the diaphragm, and partly the abdominal wall muscles. The so-called accessory respiratory muscles (mm. sternocleidomastoideus, trapezius, pectoralis major et minor, etc.) are actively involved in the respiratory movements in pathological conditions associated with difficult breathing.
The type, frequency, depth and rhythm of respiration can be determined by carefully observing the chest and the abdomen. Respiration can be costal (thoracic), abdominal, or mixed type.
Thoracic (costal) respiratio. Respiratory movements are carried out mainly by the contraction of the intercostal muscles. The chest markedly broadens and slightly rises during inspiration, while during expiration it narrows and slightly lowers. This type of breathing is known as costal and is mostly characteristic of women.
Abdominal respiration. Breathing is mainly accomplished by the diaphragmatic muscles; during the inspiration phase the diaphragm contracts and lowers to increase rarefaction in the chest and to suck in air into the lungs. The intra-abdominal pressure increases accordingly to displace anteriorly the abdominal wall. During expiration the muscles are relaxed, the diaphragm rises, and the abdominal wall returns to the initial position. This type of respiration is also called diaphragmatic and is mostly characteristic of men.
Respiration rate may be determined by counting the movements of the chest or the abdominal wall, while the patient is being unware of the procedure (during examination of his pulse, for example). Iorm the respiration rate is within 16-20 breathing movements a min. It is increased in dyspnea and rises in the case of inhibition of respiratory center.
Causes of alteration of the respiratory rate:
1) narrowing of the lumen of small bronchi due to spasms or diffuse inflammation of their mucosa (bronchiolitis occurring mostly in children), which interfere with normal passage of air into the lungs;
2) decreased respiratory surface of the lungs due to their inflammation and tuberculosis, in collapse or atelectasis of the lung due to its compression (pleuricy with rffusion, hydrothorax, pneumothorax, mediastinal tumor), in obstruction or compression of the main bronchus by a tumor etc;
3) insufficient depth of breathing.
Breathing through pursed lips, often seen in cases of emphysema.
Ability to speak. At times, respiratory rates can be so high and/or work of breathing so great that patients are unable to speak in complete sentences. If this occurs, note how many words they can speak (i.e. the fewer words per breath, the worse the problem!).
Any audible noises associated with breathing as occasionally, wheezing or the gurgling caused by secretions in large airways are audible to the “naked” ear.
The direction of abdominal wall movement during inspiration. Normally, the descent of the diaphragm pushes intra-abdominal contents down and the wall outward. In cases of severe diaphragmatic flattening (e.g. emphysema) or paralysis, the abdominal wall may move inward during inspiration, referred to as paradoxical breathing. If you suspect this to be the case, place your hand on the patient’s abdomen as they breathe, which should accentuate its movement.
Any obvious chest or spine deformities. These may arise as a result of chronic lung disease (e.g. emphysema), occur congenitally, or be otherwise acquired. In any case, they can impair a patient’s ability to breathe normally. A few common variants include:
Pectus excavatum: Congenital posterior displacement of lower aspect of sternum. This gives the chest a somewhat “hollowed-out” appearance. The x-ray shows a subtle concave appearance of the lower sternum.
Barrel chest: Associated with emphysema and lung hyperinflation. Accompanying xray also demonstrates
increased anterior-posterior diameter as well as diaphragmatic flattening.
Spine abnormalities:
Kyphosis: Causes the patient to be bent forward. Accompanying X-Ray of same patient clearly demonstrates extreme curvature of the spine.
Scoliosis: Condition where the spine is curved to either the left or right. In the pictures below, scoliosis of the spine causes right shoulder area to appear somewhat higher than the left. Curvature is more pronounced on x-ray.
The sequence and technique of palpation of a chest
Palpation of the chest in user for determination of following:
To locate the pain in the chest and its irradiation – carefully press with your fingers along each intercostal space.
Resistance or elasticity of the chest – is determined by exerting preassure of the examining hands from the front to the sides and on the back and the , sternum and also by palpation of intercostal spaces.
The strengs of voice conduction to the chest surface (vocal fremitus) – The palms of the hands are placed on the symmetrical parts of the chest and the patient is asked to utter loudly words with the letter “r” in them.
Palpation as a method of examination
The sequence and technique of palpation of a chest
Palpation of the chest in user for determination of following:
To locate the pain in the chest and its irradiation – carefully press with your fingers along each intercostal space.
Resistance or elasticity of the chest – is determined by exerting preassure of the examining hands from the front to the sides and on the back and the , sternum and also by palpation of intercostal spaces.
The strengs of voice conduction to the chest surface (vocal fremitus) – The palms of the hands are placed on the symmetrical parts of the chest and the patient is asked to utter loudly words with the letter “r” in them.
Palpation is used as an additional means of examination to verify findings of inspection (the shape of the chest, its dimensions, respiratory movements(, for determining local or profuse tenderness of the chest, its elasticity (resilience), vocal fremitus, pleural friction and sounds of fluid in the pleural cavity.
Palpation should be done by placing the palms on the symmetrical (left and right) parts of the chest. This examination helps follow the respiratory excursions and deviation of the chest movements from their normal course. During respiration the hands will move with the chest wall. The doctor evaluates the amount and speed of respiratory excursion, noting any asymmetry of movement. Normally the amplitude of movements are equal on both chest parts..
The epigastric angle as determined by palpation as well. The thumbs should be pressed tightly against the costal arch, their tips resting against the xiphoid process (ensiform cartilage).
Palpation is used to locate pain in the chest and its irradiation. For example, in rib fracture, pain is located over a limited site, namely at the point of the fracture. Displacement (careful!) of bone fractures will be attended in this case by a specific sound (crunch). Inflammation of the intercostal nerves and muscles also causes pain, but it can be felt during palpation over the entire intercostal space. Such pain is called superficial. It is intensified during deep breathing, when the patient bends to the affected side, or lies on this side.
Resilience or elasticity of the chest is determined by exerting pressure of the examining hands from the front to the sides of the chest or on the back at the sternum, and also by palpation of the intercostal spaces. The chest of a healthy person is elastic, plaint and yields under the pressure. In the presence of pleurisy with effusion, or pleural tumour, the intercostal space over the affected site becomes rigid. Rigidity of the chest increases in general in the aged due to ossification of the costal cartilages, development the lung emphysema, and also with filling of both pleural cavities with fluid. Increased resistance of the chest can then be felt during examining the chest by compression in both the anteroposterior and lateral directions.
Palpation is used for determining the strength of voice conduction to chest surface {fremitus vocalis s. pectoralis). Vocal fremitus depends on the conduction of voice sounds through the respiratory tract.
The palms of the hands placed on the symmetrical parts of the chest and the patient is asked to i loudly a few words (with the letter ‘r’ in them to intensify vibration). The doctor can ask the patient to repeat words, such as “ninety-nine”, “one, two, three,” “eee-eee”. The patient should speak the words with a voice of uniform intensity. The voice should be as low as possible since voice vibrations are better transmitted by the air column in the trachea and the bronchi to the chest wall in this case. Vibrations are felt as the hands move symmetrically on either side of the sternum and vertebral column.
Pathologic conditions will alter fremitus. In particular:
Lung consolidation: Consolidation occurs when the normally air filled lung parenchyma becomes engorged with fluid or tissue, most commonly in the setting of pneumonia. If a large enough segment of parenchyma is involved, it can alter the transmission of air and sound. In the presence of consolidation, fremitus becomes more pronounced.
Pleural fluid: Fluid, known as a pleural effusion, can collect in the potential space that exists between the lung and the chest wall, displacing the lung upwards. Fremitus over an effusion will be decreased.
In general, fremitus is a pretty subtle finding and should not be thought of as the primary means of identifying either consolidation or pleural fluid. It can, however, lend supporting evidence if other findings (see below) suggest the presence of either of these processes.
Effusions and infiltrates can perhaps be more easily understood using a sponge to represent the lung. In this model, an infiltrate is depicted by the blue coloration that has invaded the sponge itself (sponge on left). An effusion is depicted by the blue fluid upon which the lung is floating (sponge on right).
Investigating painful areas: If the patient complains of pain at a particular site it is obviously important to carefully palpate around that area. In addition, special situations (e.g. trauma) mandate careful palpation to look for evidence of rib fracture, subcutaneous air (feels like your pushing on Rice Krispies or bubble paper), etc.
Percussion of the chest
In comparative percussing the chest, the anterior lung is percussed from apex to base, usually with the patient in the supine or sitting position. Each side of the chest is percussed in sequence in order to compare the sounds, such as the dullness of the liver on the right side with the tympany of the stomach on the left side. When percussing the posterior lung, the procedure and sequence are the same, although the patient should be sitting. Normally only resonance is heard when percussing the posterior thorax from the shoulder to the eighth or tenth rib. At the base of the lungs dullness is heard as the diaphragm is percussed.
The rules and technique of comparative percussion
A certain sequence is followed in comparative percussion. Percussion sounds over the lung apices (in the front) on the symmetrical points of the chest are first compared; the pleximeter finger is placed parallel to the clavicle. The plexor finger is then used to strike the clavicle which is used as a pleximeter in this case. During percussion of the lungs below the clavicle, the pleximeter finger is placed in the interspace at the strictly symmetrical points of the left and right sides of the chest. The plexor finger is then used to strike the clavicle which is used as a pleximeter in this case. During percussion of the lungs below the clawicle, the pleximeter finger is placed in the interspace at the strictly symmetrical points of the left and right sides of the chest. The percussion sounds are compared only to the level of the 4th rib along the medioclavicular line (and medially). The heart lying below this level changes the percussion sound. For comparative percussion of the axillary region, the patient should raise his arms and clamp the hands at the back of the head. Comparative percussion of the lungs on the back begins with suprascapular areas. The pleximeter finger is placed horizontally, while during percussion of the regions between the scapulae, the pleximeter should be vertical. The patient should cross his arms on the chest to displace the scapulae anteriorly (away from the backbone). During percussion of the points lying below the scapulae, the pleximeter should again be horizontal; in the interspace it should be placed parallel to the ribs
Topographic percussion
In topographic percussing the chest, the doctor looks for the lungs’ borders in the main lines, the location of the apex of the lung and width of Kroenig’s areas.
In topographic percussion the margin of the lung is assessed from the side of resonance sound.
The upper margin of the lung (the location of the apex of the lung) is determined by percussions from the clavicle to the neck. The apex of each lung rises about 2 to 4 cmabove the inner third of the clavicles in front of the body At the back we examine the location of the apex of the lung by percussions from the scapula axis to the seventh cervical vertebra. Normally, the upper border of the lung is in the seventh cervical vertebra at the back.
The width of Kroenig’s areas is determined by percussions from the middle of muscle trapezium to each direction (to neck and shoulder) to disappearance of the resonance. Normally, the width of Kroenig’s areas is 3-
The excursion of the lung is the distance between the lower costal margin of the lungs in the maximum inspiration and maximum expirations. Normally, the excursion of the lung is 2-
The rules of the topographic percussion
During topographic percussion of lungs one should apply such rules as follows
– the finger-pleximeter should be placed parallel to the border of the organ one is seeking for;
– percussion should be carried out from resonans pulmonary sound to dull one.
– If the lungs’ borders has being determined, they should be marked on the edge of the finger-pleximeter from the side of resonans pulmonary sound.
Definition of height of the lungs’ apexes.
The lungs’ apexes should be determined on anterior and posterior surface of the chest. To find out the height of the lungs apexes anteriorly percuss from the midpoint of each clavicle parallel to their axis in progressive steps downwards as well as quite medially untill dull percussiootes will be heared. Posteriorly percussion should be carried out from the center of suprascapular area in direction to the point, placed on 3-4 cm laterally to the 7th cervical spinous processus. Iorm the apex of each lung rises anteriorly about 2-4 cm above the inner third of the clavicle, posteriorly – is placed approximately at the level of the 7th cervical spinous processus.
The upper border of the lung and width of the Kroenig’s area can vary depending on the amount of air in the apices. If the amount of air is high (for example, due to emphysema) the apices increase in size and move upwards. The Kroenig’s area widens accordingly. The presence of connective tissue in the lungs apex (which usually develops during inflammation as in tuberculosis or pneumonia or inflammatory infiltration) decreases the airness of the pulmonary tissue. The upper border of the lung lowers and the width of the Kroenig’s area decreases.
Determination of the lower lungs borders and their mobility
To determine the lower lungs borders one should held the pleximeter finger parallel to the expected border of diaphragmatic dullness, percuss in progressive steps downwards on parasternal, midclavicular, anterior axillary, midaxillary, posterior axillary, scapular and paravertebral lines from the right and left side. Identify the level of diaphragmatic dullness on each side during quiet respiration. This level is often slightly higher on the right. Anteriorly the low border of the left lung on parasternal and midclavicular lines is not distinguished because of heart dullness.
The lower border of the right lung is as a rule at the point of transition of the clear pulmonary resonance to dullness (lung-liver border). In exceptional cases, when air is present in the abdominal cavity (e.g. in perforation of gastric or duodenal ulcer), liver dullness may disappear. The clear pulmonary resonance will then convert to tympany. The lower border of the left lung by the anterior and midaxillary lines is determined by the transition of clear pulmonary resonance to dull tympany. This is explained by the contact between the lower surface of the lung (through the diaphragm) and a small airless organ, such as the spleen and the fundus of the stomach, which give tympany (Traube’s space).
The position of the lower border of the lungs can vary in various pathological conditions that develop in the lungs, the pleura, in diaphragm, and the abdominal viscera. The border can both rise and lower from the normal level. This displacement can be uni- or bilateral.
Bilateral lowering of the lower border of the lungs can occur in acute and chronic dilation of the lungs (attack of bronchial asthma and emphysema of the lungs, respectively) and also in sudden weakening of the tone of the abdominal muscles and lowering of the abdominal viscra (splanchnoptosis). Unilateral lowering of the lower border of the lungs can be due to vicarious (compensatory) emphysema of one lung with inactive tion of the other lung (pleurisy with effusion, hydrothorax, pneumothorax hemiparesis of the diaphragm).
The elevation of the lower border of the lungs is usually unilateral and I occurs in (1) shrivelling of the lung due to development of connective tissue (pneumosclerosis); (2) complete obstruction of the lower-lobe bronchus by a tumor which causes gradual collapse of the lung, atelectasis; (3) accumulation of fluid or air in the pleural cavity which displace the lung up wards and medially toward the root; (4) marked enlargement of the liver (cancer, echinococcosis), or of the spleen (chronic myeloleukaemia) Bilateral elevation of the lower borders of the lungs occurs in the presence I of large amounts of fluid (ascites) or air in the abdomen due to an acute perforation of gastric or duodenal ulcer, and also in meteorism.
