CASE 3

PLEURISY
 DEFINITION

Pain from the pleura w/c is usually on

one side of the chest only
it is identified because it is worse on
inspiration
usually described as sharp or knife-like
It can be severe
Its onset can be sudden (especially
when due to pneumothorax or
pulmonary embolism) or slow
(infection)
 DEFINITION

Pleurisy can result from direct trauma to

the chest wall, but it most commonly
occurs from extension of localized disease
of the lung (pneumonia), mediastinum
(esophageal rupture), pericardium
(pericarditis), or abdomen (subphrenic
abscess), or from systemic disease (lupus
erythematosus)
Patients who present with pleurisy
usually have an associated pleural
effusion; the presence or absence of
pleural fluid may be a helpful differential
finding
 DEFINITION

Pleuritic pain can often be

identified because it is associated
with symptoms of lung disease such
as:
Breathlessness
Cough
sputum production
hemoptysis
 PATHOPHYSIOLOGY

A scant nerve supply exists in the lung

distal to the bronchi, primarily
composed of efferent twigs of
sympathetic and vagal origin
stimulation of the visceral pleura and lung
usually does not produce pain
The parietal pleura, in contrast, is a
highly sensitive surface, supplied
extensively with sensory afferents
from intercostal, sympathetic, phrenic,
and vagus nerves
 PATHOPHYSIOLOGY

Injury to the costal parietal pleura

produces sharp, localized pain at the
site of irritation
Inflammation of the peripheral
diaphragmatic pleura also results in
localized pain but tends to extend over
a greater area of the chest wall, back,
or abdomen
The area of perceived pain expands in
relation to the intensity of the injury
 PATHOPHYSIOLOGY

Irritation of the central portion of the

diaphragmatic pleura does not elicit
pain in the immediate area but results
in referred pain to the ipsilateral
posterior neck, shoulder, and trapezius
muscle
Stimulation of the mediastinal parietal
pleura over the pericardium also may
result in pain referred to the neck
most of the sensory fibers of the phrenic
nerve enter at the C4 level of the spinal
cord, the usual entry point of sensation
from the shoulder
 CLINICAL MANIFESTATIONS
sudden (pneumothorax or pulmonary
Onset embolism) or slow (infection)

Precipitating exacerbated by deep breathing, coughing,

factors sneezing, or even talking

Quality/ stabbing or shooting, or as a stitch in the

Quantity side; often severe

Relieving relieved by manual pressure against the

chest wall that causes splinting, lying on the
factors involved side

Signs/ dyspnea, associated tenderness to deep

palpation; associated s/s of underlying
symptoms illness

Timing persistent
CLINICAL MANIFESTATIONS

PHYSICAL EXAMINATION

Inspection

Px has shallow and rapid

breathing and ipsilateral
restriction of chest wall motion,
and often lies on the affected
side to limit chest expansion
CLINICAL MANIFESTATIONS
Palpation

verifies the limited ipsilateral

movement of the hemithorax
and rarely demonstrates a
friction rub
fremitus may be increased or
diminished, depending on the
presence or absence of
consolidation
CLINICAL MANIFESTATIONS

Percussion

percussion note may be

flat owing to underlying
consolidation or pleural
effusion
CLINICAL MANIFESTATIONS
Auscultation

pleural friction rub confirms the diagnosis of

pleurisy
often evanescent, can vary in intensity from a
faint scratchy sound to a loud creak that is
appreciated close to the ear
audible during both phases of respiration but is
best heard at or near the end of inspiration; the
rub disappears with breath holding, in contrast
to a pericardial rub
may be localized or heard over a wide area
mostly appreciated over the lateral and
posterior regions of the inferior thorax
rarely heard over the upper thorax and apex
because of limited movement of the lung in the
apexes relative to the bases
CLINICAL MANIFESTATIONS

In acute pleurisy, splinting diminishes

the friction rub; only when the patient is
encouraged to take a deep breath is the
rub discovered by the clinician
The clinician may hear a FALSE
FRICTION RUB if the stethoscope is
allowed to slide over the skin; firm
pressure eliminates this problem and
increases the intensity of the rub
It is sometimes difficult to differentiate
crackles from a friction rub; cough may
diminish or ablate crackles but has no
effect on the rub
References

Oxford Textbook of Medicine 4th

edition
Kelley's Textbook of Internal
Medicine 4th edition