PHYSICAL DIAGNOSIS

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PHYSICAL DIAGNOSIS
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CHEST
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INTRODUCTION

• Though X-ray of the lungs has become wide-spread
  ,the physical examination of chest is still very
  important. A friction rub,rales, and wheezing
  cannot be seen on x-ray films and can be detected
  only by our senses.In fact,the findings on the
  x-ray film in many instances, can be interpreted
  intelligently only when coupled with the history
  and physical findings.Careful examination should
  enhance our ability to interpret the x-ray films
  and the chest film should serve as a check on the
  physical examination.

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INTRODUCTION

• Experience would indicate that the following
  order of procedure has much to recommend it
  (1)inspection,(2)palpation,(3)percussion,and
  (4)auscultation.The adoption of a systematic
  approach,in which each stage is performed in
  sequence,helps to prevent oversight of any
  important aspect of the examination.

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LINE LANDMARKS

• On the anterior surface
• Anterior midline (midsternal line)is located in
  the middle of the sternum
• Midclavicular line (left and right)runs di
  rectly downward from the midpoint of each
  clavicle

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LINE LANDMARKS

• On the anterior surface
• Sternal line(left and right)vertical line runs
  along the vertical edges of the sternum and
  parallels to the anterior midline.

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LINE LANDMARKS

• On the lateral wall of the chest
• the anterior axillary linedrawn downward from
  the origin of the anterior axillary fold along
  the anterolateral aspect of the chest
• the posterior axillary linea continuation of
  the posterior axillary fold running downward
  along the posterolateral wall of the thorax
• the midaxillary line midway between those two
  lines and running directly downward from the apex
  of the axilla

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LINE LANDMARKS

• On the posterior wall
• the midspinal line or posterior midline runs
  down the posterior spinous processes of the
  vertebrae
• the scapular line(left and right) runs parallel
  to the spine through the inferior angle of the
  scapula

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• For exact localization any abnormality should be
  described as being(1)how many centimeters medial
  or lateral to the lines of reference,or (2)in a
  specific interspace or interspaces.

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BONE LANDMARKS

• On the anterior thoracic wall
• the sternal angle is a help landmark.This is a
  visible angulation of the sternum that
  corresponds to the second rib and serves as a
  convenient starting point for counting ribs.It is
  also significant in that it indicates the
  location of other important structures within the
  thorax that normally lie at the same
  level(1)the fifth thoracic vertebra,(2)the
  bifurcation of the trachea,and (3)the upper level
  of the atria of the heart.

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BONE LANDMARKS

• Rib
• A total of 12 pairs.Each connects to the
  corresponding thoracic vertebra.The ribs run
  obliquely to the lateral and then to the anterior
  direction,with smaller oblique angle above and
  larger angle lower.

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BONE LANDMARKS

• Interspace
• The space between two adjacent ribs,used to mark
  the position of any lesion.
• Beneath the first rib is the first interspace,
  and so forth.

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BONE LANDMARKS

• On the posterior thorax
• the vertebra prominens (seventh cervical
  vertebra)is usually found with ease at the base
  of the neck and serves as a convenient landmark
  to help identify the thoracic vertebrae and
  posterior ribs.

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BONE LANDMARKS

• Scapula
• Its inferior end is called inferior angle. When
  the patient is in standing position with his arms
  hanging naturally, the inferior angle acts as the
  mark of the seventh rib,or the seventh interspace.

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• In additions,you must have exact knowledge of the
  location of the underlying thoracic structures
  and those in the upper abdomen.

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NATURAL FOSSA AND ANATOMIC REGION

• On the anterior thorax
• Suprasternal fossa,supraclavicular
  fossa(left,right),infraclavicular
  fossa(left,right)
• On the lateral wall of the chest
• Axillary fossa(left,right)
• On the posterior thorax
• Suprascapular region (left,right),infrascapular
  region (left,right),interscapular region

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The boundary of lung and pleura

• Trachea bifurcates into the left and the right
  primary bronchus at the sternal angle level,then
  enters into the left and right lungs.
• The right primary bronchuswider,shorter and
  steeper
• The left primary bronchusslender and oblique

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The boundary of lung and pleura

• The right lung 3 lobes (upper,middle
• and lower)
• the left lung 2 lobes(upper,lower)

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• The apices of the lungs extend for approximately
  3 cm above the clavicle on each side.
• Boundaries between lobes called fissure.On the
  right the fissure between the upper and middle
  lobes and the lower lobe is often called right
  oblique fissure,the fissure between the upper and
  middle lobes is often called the horizontal
  fissure.On the left the fissure between the upper
  and lower lobes is the left oblique fissure.

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• It will be seen that the anterior aspect of the
  right chest is composed principally of the upper
  and middle lobes,and the upper lobe lies beneath
  the major portion of the left anterior
  hemithorax.On both hemithoraces the lower lobes
  present only a small portion anterolaterally and
  inferiorly.Posteriorly a very large proportion of
  the thorax is occupied by the lower lobes with
  only a small area of the upper lobes presenting
  superiorly.

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The boundary of lung and pleura

• Pleura
• Visceral pleurathe pleura covering the surface
  of the lung
• Parietal pleura the pleura covering the inner
  surface of the chest wall,the diaphragm,and the
  mediastinum

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• On the right, the dome of the diaphragm is
  situated at a level approximating the fifth rib
  or fifth interspace at the midclavicular line.The
  dome of the left diaphragm is ordinarily about 1
  inch lower than the right.

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• THORAX AND LUNGS

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INSPECTION

• Inspection of the chest,productive of the
  maximum amount of information, requires the
  following
• 1. First and foremost,a definite desire to see
  and to appreciate every visible abnormality
• 2. The patient stripped to the waist
• 3. Good lighting

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INSPECTION

• 4. A thorough knowledge of topographic anatomy
• 5. The examiner and patient in a comfortable
  position throughout the examination. If either
  the physician or patient is uncomfortable,the
  examination may be hurried and consequently less
  thorough.
• It is important that the patient be
  absolutely straight,whether seated or supine.

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INSPECTION

• Normal thorax
• You should appreciate that in normal subjects
  there is a wide variation in the size and shape
  of the thorax.At times it is difficult to be
  certain where the normal variations and definite
  pathologic changes begin.

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INSPECTION

• Normal thorax
• The anteroposterior diameter of the thorax in
  the normal adult is definitely less than the
  transverse diameter.

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INSPECTION

• what to observe
• 1.First the general nutrition and
  musculoskeletal development 2.Next the skin and
  breasts
• 3.vein and subcutaneous emphysema

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INSPECTION

• 4.the anteroposterior diameter of the thorax
• persons with pulmonary emphysema --barrel
  chest
• 5.the general slope of the ribs
• normal 45 º degree angle
• patients with emphysema the ribs are
  nearly horizontal this angle becomes abnormally
  wide

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INSPECTION

• 6.retraction or bulging of interspaces
• Retraction of the interspaces obstruction of the
  respiratory tract
• Bulging of interspaces a massive pleural
  effusion,tension pneumothorax

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INSPECTION

• 7.the rate and depth of quiet breathing
• in the adult at rest the normal respiratory rate
  is approximately 16 to 18 breaths per minute and
  is quite regular in depth and rhythm
• increase in the respiratory rate fever

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INSPECTION

• 8.Alterations in shape of the thorax
• In the normal subject,the two sides of the chest
  move synchronously and expand equally
• Unilateral retraction of the thorax a thickened
  fibrotic pleura
• Pigeon chest
• Funnel chest

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INSPECTION

• 9.Types of respiration
• (1)Dyspnea difficulty or effort in breathing
  participation of the accessory respiratory
  muscles
• Inspiratory dyspnea obstruction of the trachea
  or major bronchi (tumor,laryngitis)
• Expiratory dyspnea obstruction in the
  bronchioles and smaller bronchi (asthma)

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INSPECTION

• 9.Types of respiration
• (2)Bradypnea abnormal slowing of respiration
• (3)Apnea temporary cessation of breathing
• (4)Tachypnea increased respiratory rate
• (5)Hyperpnea an increase in the depth of
  respiration
• (6)Hyperventilation an abnormal increase in both
  rate and depth of respiration (it is seen in
  diabetic acidosis and highly emotional states)

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INSPECTION

• 9.Types of respiration
• (7)Pleuritic or restrained breathing the
  inspiratory phase is suddenly interrupted as a
  result of pain associated with acute pleuritis
  The respirations are quite shallow but more
  rapid than normal

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INSPECTION

• 9.Types of respiration
• (8)tidal respiration is characterized by periods
  of rapidly increasing rate and depth of
  respiration, which within a matter of a few more
  respiratory cycles becomes shallower and
  shallower until respiration ceases.This is
  followed by a period of apnea,which may last a
  few seconds to as long as 30 seconds. periodic
  respiration may be present in many relatively
  severe disease states.

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INSPECTION

• 9.Types of respiration
• (9)Sighing respiration occurs when the normal
  respiratory rhythm is interrupted by a deep
  inspiration,which is followed by a prolonged
  expiration and ordinarily is accompanied by
  audible sighing. it is rarely associated with
  organic diseaseinstead it is almost always a
  manifestation of emotional tension.

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INSPECTION

• 9.Types of respiration
• (10)Ataxic breathing is characterized by
  unpredictable irregularity . Breaths may be
  shallow or deep,and stop for short periods.

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PALPATION

• Thoracic expansion
• Variations in expansion are more readily
  detectable on the anterior surface where there is
  greater range of motion.
• The examiner's hands should be placed over the
  lower anterolateral aspect of the chest.
• Expansion should be tested during both quiet and
  deep inspiration.

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PALPATION

• Thoracic expansion
• Expansion may be limited as the result of
  acute pleurisy,fibrous thickening of the pleura
  (fibrothorax),fractured ribs,or other trauma to
  the chest wall.

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PALPATION

• Fremitus
• Vocal fremitus Vocal fremitus is a palpable
  vibration of the thoracic wall produced by
  phonation .

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PALPATION

• Vocal fremitus
• The sounds that arise in the larynx are
  transmitted down along the air column of the
  tracheobronchoalveolar system into the bronchi of
  each lung,on through the smaller bronchi into the
  alveoli,setting in motion the thoracic wall that
  acts as a large resonator. Thus,vibrations are
  produced in the chest wall that can be felt by
  the hand of the examiner.

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PALPATION

• Vocal fremitus
• In eliciting vocal fremitus the patient is
  directed to count one,two,three---one,two,three
  ,to repeat the wordsninety-nineninety-nine,o
  r to say e-e-e,e-e-e,e-e-e. The patient should
  speak with a voice of uniform intensity
  throughout the examination so that the examiner
  can better compare the transmission of the
  fremitus in different areas of the chest.

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PALPATION

• Vocal fremitus
• The vocal fremitus is perceived by placing the
  palmar aspect of the fingers or ulnar aspect of
  the hand against the chest wall.Usually both
  hands are used,placing them in corresponding
  areas so that simultaneous comparison of the two
  sides can be made. If only one hand is used,it
  should be moved from one place to the
  corresponding area of the other side to compare
  the transmission of sound.

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PALPATION

• Normal variations of vocal fremitus.
• The intensity of the vocal fremitus perceived in
  the normal subject is governed by the following
• 1.Intensity of the voice
• 2.Pitch of the voice
• 3.Varying relations of the bronchi to the chest
  wall
• 4.Varying thickness of the thoracic wall

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PALPATION

• In general,vocal fremitus is most prominent in
  the regions of the thorax where the large bronchi
  are the closest to the thoracic wall and tends to
  become less intense as one progresses farther
  from the major bronchi.In the normal person the
  fremitus is found at maximum intensity over the
  upper thorax both anteriorly and posteriorly.It
  is least intense at the bases.

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PALPATION

• Also the intensity of the fremitus will vary with
  the thickness of the thoracic wall.In a thin
  person the vibrations will be more intense than
  in the normally developed or obese patient. There
  is considerable variation from patient to
  patient.

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PALPATION

• Alternations of vocal fremitus
• increased vocal fremitus ----consolidation of the
  lungs lobar pneumonia
• Decreased or absent fremitus ----fibrous
  thickening of the pleura fluid in the pleural
  space or pneumothorax
• absent fremitus ---- major bronchus is obstructed
  tumor

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PALPATION

• pleural friction fremitus As the result of acute
  pleurisy,the inflamed pleural surfaces rub
  against one another,producing a pleural friction
  rub that may be detected by the examining hand.

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PALPATION

• pleural friction fremitus
• When present,it is palpable usually in both
  phases of respiration.
• Friction rubs most commonly are felt as well as
  heard in the inferior anterolateral portion of
  the chest,the area of greatest thoracic
  excursion.

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PALPATION

• Crepitation
• Crepitation may be palpated when the sub
  cutaneous tissues contain fine beads of air.
• This condition is known as subcutaneous
  emphysema.
• A somewhat similar sensation can be produced by
  rolling a lock of hair between the thumb and
  fingers.

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PERCUSSION

• There are two principal methods that may be
  used for percussion of the thorax, abdomen,or
  other structures.

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PERCUSSION

• 1. Mediate percussion is that in which the
  examiner strikes the middle finger of one hand
  held against the thorax, thus producing a sound
  by setting the chest wall and underlying
  structures in motion. This is the method in
  almost universal use today.

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PERCUSSION

• 2. Immediate percussion may be useful in
  demonstrating changes in percussion note.This can
  be done by striking the chest with the tips of
  all of the fingers held firmly together.

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PERCUSSION

• Practical experience has demonstrated that
  useful sounds produced by percussion probably do
  not penetrate more than about 4 to 5cm below the
  surface. Also a lesion must be at least 2 or 3cm
  in diameter to be detectable. Thus,it is obvious
  that percussion will only locate rather gross
  abnormalities.

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PERCUSSION

• To obtain the maximum information from
  percussion
• 1. The distal phalanx of the pleximeter finger
  must be pressed firmly on the chest
  wallotherwise,a clear note is not ob tained.
• 2. The plexor finger should strike the
  pleximeter finger only instantaneously and must
  be immediately withdrawn.

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PERCUSSION

• Usually percussion is performed above the
  clavicles in the supraclavicular spaces and
  downward.Next,each lateral wall is examined,
  beginning in the axilla and working down to the
  coastal margin. With the pleximeter finger always
  parallel to the ribs--never cross them.

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PERCUSSION

• In examining the back of the chest the patient
  should have his head inclined forward and the
  forearms crossed comfortably at the waist to move
  the scapulae as far laterally as possible.

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PERCUSSION

• Examination is started at the apices, where the
  percussion note as well as the width of the
  isthmus of normal resonance over the apex is
  determined . Bounded medially by the neck muscles
  and laterally by the shoulder girdle,this band of
  resonance is normally about 5 cm wide.

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PERCUSSION

• The percussion is continued downward, interspace
  by interspace,to the bases where the location and
  range of motion of each hemidiaphragm is
  ascertained.

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PERCUSSION

• Analysis of percussion tones
• The sound waves produced by percussion are
  influenced more by the character of the immediate
  underlying structures than by those more
  distant.Consequently the tone produced by
  percussion over the airfilled lung will be
  definitely different from the tone heard over a
  solid structure,such as the heart or liver.This
  is the basis for the scientific application of
  percussion.

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PERCUSSION

• Percussion sounds
• 1. Resonance the sounds heard normally over
  lungs
• 2. Hyperresonance The hyperresonant note in the
  adult is commonly the result of emphysema and
  occasionally pneumothorax.

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PERCUSSION

• Percussion sounds
• 3. Tympany It never occurs in the normal
  chest,except below the dome of the left
  hemidiaphragm,where the underlying stomach and
  bowel will produce tympany.

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PERCUSSION

• Percussion sounds
• 4.Dullness Dullness tends to occur when there is
  considerable solid or liquid medium present in
  the underlying lung in proportion to the amount
  of air in the lung tissue. Thus,dullness will be
  found when there is consolidation of lung,such as
  occurs in pneumonia,or when there is a moderate
  amount of fluid in the pleural space with some
  underlying air-containing lung.

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PERCUSSION

• Percussion sounds
• 5. Flatness is the term used to describe the
  percussion note when resonance is absent.
  Flatness will be present when there is a very
  large fluid mass,such as in an extensive pleura1
  effusion with little underlying air-bearing lung
  to influence the sound.

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PERCUSSION

• Percussion sounds
• Over the apices,where there are large amounts
  of muscle and bone with relatively little
  underlying resonant lung,the note is less
  resonant than over the bases,where there is a
  relatively greater amount of lung with less
  thoracic wall and muscle.

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PERCUSSION

• Percussion sounds
• The development of the pectoral muscles,the
  heavy muscles of the back,the breasts,and the
  scapulae,all tend to make the percussion note
  less resonant (duller).

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PERCUSSION

• Percussion sounds
• It should be noted that below the dome of the
  right diaphragm there is flatness because of the
  presence of the liver.on the left there is
  ordinarily a relatively tympanic note that
  results from the presence of the partially
  air-filled stomach and bowel under the
  hemidiaphragm.

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PERCUSSION

• Percussion sounds
• The change from resonance to flatness on the
  right and from resonance to tympany on the left
  is not immediateinstead ,there is a zone of
  transition.

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PERCUSSION

• Percussion sounds
• Dullness from the liver is usually noted at
  approximately the fifth interspace in the
  midclavicular line,and this dullness soon gives
  way to flatness as that part of the liver not
  covered by the lung is reached.

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PERCUSSION

• Percussion sounds
• Also the change from pulmonary resonance to
  tympany over the left lower chest at about the
  sixth rib in the midclavicular line has the same
  general tendency to transition not an abrupt
  change .

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PERCUSSION

• Percussion sounds
• There is also dullness to the left of the
  sternum,caused by the underlying heart, another
  solid organ in the left fifth interspace. This
  dullness normally extends to a point 1 or 2cm
  medial to the midclavicular line.

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PERCUSSION

• Effect of position on percussion sound
• Occasionally the patient is too ill to sit up
  to permit percussion of the posterolateral
  aspects of the chest.So the posterior and
  posterolateral thoracic wall must be examined
  with the patient rolled on his side.This is much
  less satisfactory than the upright position.

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PERCUSSION

• The lateral recumbent position causes the
  following changes

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PERCUSSION

• 1.Some curvature of the spine results,with a
  widening of the intercostal spaces in that
  portion of the thoracic wall that is against the
  bed and a narrowing of the interspaces on the
  upper sidethis curvature can be counteracted to
  some degree if the pillow is removed and the head
  is allowed to the bed.

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PERCUSSION

• 2. Disproportionate elevation of the
  hemidiaphragm of the down side results from the
  pressure of the abdominal viscera.
• 3. The surface of the bed affects the
  percussion note by acting as a damper for the
  sounds.

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PERCUSSION

• As a result of these three factors ,the following
  changes are observed
• (1)there is an area of relative dullness along
  the chest next to the bed.

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PERCUSSION

• (2)above this area and at the base of the lung
  there is a roughly triangular area of dullness
  with the base toward the bed and the apex
  approaching the spine.

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PERCUSSION

• (3)on the upper side there may be some relative
  dullness at approximately the tip of the
  scapula,which is caused by changes in the lung as
  a result of the crowding of the ribs.

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PERCUSSION

• Diaphragmatic excursion
• First,the patient is instructed to take a deep
  inspiration and hold it.
• Second, the lower margin of resonance (which
  represents the level of the diaphragm)is
  determined by percussion from the normal
  lung,moving downward until a definite change in
  tonal quality is heard.

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PERCUSSION

• Diaphragmatic excursion
• Third,the patient is instructed to exhale as far
  as possible and to hold his breath, and the
  percussion is repeated.
• The distance between these levels indicates the
  range of motion of the diaphragm .

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PERCUSSION

• Diaphragmatic excursion
• The normal diaphragmatic excursion is about 6 to
  8 cm.
• It is decreased in patients with pleurisy and
  severe emphysema.

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• .

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PERCUSSION

• The diaphragm is unusually high in any condition
  that causes an increase in intra-abdominal
  pressure, such as ascites or pregnancy and lower
  than normal in pulmonary emphysema.
• In the recumbent patient the level of the
  diaphragm is approximately one interspace higher
  than in the upright position.

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AUSCULTATION

• The patient should be instructed to breathe a
  little deeper than usual with his mouth open.
  Breathing through the open mouth minimizes the
  sounds produced in the nose and throat.
• Corresponding areas of each side are auscultated
  as the examiner goes from top to bottom, just as
  in percussion.

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AUSCULTATION

• Breath sounds--normal

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• Vesicular
• The vesicular breath sound is believed to be the
  result of movement of air in the bronchioles and
  alveoli.
• Variously described as sighing or a gentle
  rustling,vesicular breathing is a soft,
  relatively low-pitched sound.
• The normal vesicular respiration is longer in the
  inspiratory than in the expiratory phase by a
  ratio of approximately 52.

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• Vesicular
• It should be emphasized that expiration as heard
  in vesicular breathing is not actually shorter
  than inspiration --only that much of expiration
  is not audible.
• Inspiration is higher in pitch and louder than
  expiration.In fact,expiration occasionally may be
  inaudible.
• Vesicular breath sounds heard from normally over
  most of the lungs.

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• Bronchovesicular
• In certain areas where the trachea and major
  bronchi are in proximity to the chest wall,there
  is heard a mixture of both tracheobronchial and
  vesicular elements that is termed
  bronchovesicular breath sound.

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• Bronchovesicular
• This type of breath sound is heard normally on
  each side of the sternum in the first and second
  interspaces,between the scapulae, and over the
  apices anteriorly and posteriorly,but are more
  prominent on the right than on the left.
• When heard in other locations, brochovesicular
  breathing is abnormal and is indicative of some
  disease process.

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• Bronchovesicular
• In bronchovesicular breathing the inspiratory
  phase resembles that of normal vesicular
  breathing,and the expiratory phase resembles that
  of normal bronchial breathing.
• A very brief pause may be noted between
  inspiration and expiration. In essence,the
  expiratory and inspiratory phases are very
  similar as to duration, pitch,intensity,and
  quality.

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• Vesicular and bronchovesicular are the two
  types of breath sounds heard normally over the
  lungs.

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AUSCULTATION

• Breath sounds--abnormal

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• Bronchial breathing
• Bronchial breath sounds are in general higher in
  pitch than vesicular or bronchovesicular sounds.
• Expiration usually surpasses inspiration in
  length.

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• Bronchial breathing
• Bronchial breathing is not normally heard over
  the lungs. Therefore,its presence over the lungs
  always indicates disease.
• It occurs only with pulmonary consolidation, in
  other words,an increased conducting mechanism.

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• Bronchovesicular breathing
• Bronchovesicular breathing is abnormal when heard
  in any area of the lungs that normally have
  vesicular breath sounds.
• An admixture of consolidated and aerated lung
  produces a mixture of bronchial and vesicular
  breathing--bronchovesicular breath sounds.

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• Elongated expiratory breath sound
• Occurs because of partial obstruction,spasm or
  stricture of the lower respiratory tract,
• happening in bronchitis,bronchial asthma etc.
• Because of lowering elasticity of pulmonary
  tissue,happening in COPD etc.

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Hoarse breath sound

• Due to smoothlessness or stricture produced by
  mild bronchial membranous edema or inflammation.
• Heard in the early stages of bronchial or lung
  inflammations.

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• Decreased or absent breath sounds
• Breath sounds may be decreased in intensity
  without change in fundamental type as the result
  of several conditions.In some instances the
  breath sounds may be entirely absent.

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• Decreased or absent breath sounds
• l.One of the most common causes is fluid in the
  pleural space.Here the diminution in breath
  sounds is the result of the interposed liquid
  medium as well as a definite decrease in
  ventilation of the underlying lung.
• 2.In the same manner ,air in the pleural
  space(pneumothorax)causes a diminution in the
  breath sounds.

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• Decreased or absent breath sounds
• 3. If there is thickened pleura caused by
  fibrosis -which may follow effusion,hemothorax,
  and empyema-or by actual tumor involvement of the
  pleura,decrease in breath sounds is noted.
• Whether fluid,air,or solid in the pleural
  space,all interfere with the conduction of breath
  sounds so that they are decreased or even absent .

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• Decreased or absent breath sounds
• 4. Breath sounds are commonly decreased in
  emphysema because of the decreased air velocity
  and sound conduction.
• 5. Breath sounds are markedly diminished or
  absent in complete bronchial obstruction.
• 6.If there is definite decrease in expansion,
  such as that commonly noted in painful pleurisy
  with its attendant shallow breathing,the breath
  sounds are diminished because of the decreased
  ventilation.

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AUSCULTATION

• voice sounds--normal

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• Vocal resonance
• Vocal resonance is produced in the same fashion
  as vocal fremitus.The spoken voice as heard over
  the normal lung is termed vocal resonance.
• Vocal resonance varies in exactly the same
  fashion as does vocal fremitus.It is heard
  loudest near the trachea and major bronchi and is
  less intense at the extreme bases.

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AUSCULTATION

• Voice sounds--abnormal

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• Bronchophony
• Bronchophony indicates vocal resonance that is
  increased both in intensity and clarity.
• It is usually associated with increased vocal
  fremitus ,dullness to percussion,and bronchial
  breathing,and as a rule indicates the presence of
  pulmonary consolidation.

118

• Whispered pectoriloquy
• To be of practical significance the sounds must
  be actually whisperedsoftly spoken words that
  require the use of the vocal cords are not
  suitable.
• In the normal subject the whispered voice is
  heard only faintly and indistinctly throughout
  the chest except anteriorly and posterior1y in
  the regions overlying the trachea and primary
  bronchi.At the bases the whispered voice may be
  entirely inaudible.

119

• Pectoriloquy
• Although pectoriloquy is only a form of
  exaggerated bronchophony, at times it is more
  easily detected than bronchophony.
• Pectoriloquy is never normal,and its presence
  always indicates consolidation of the lung.

120

• Egophony
• Egophony is a modified form of bronchophony in
  which there is not only an increase in intensity
  of the spoken voice but its character is altered
  so that there is a definite nasal or "bleating"
  quality.
• It is occasionally heard over an area of
  consolidation,over the upper portion of a pleural
  effusion,or where there is a small amount of
  fluid in association with pneumonic
  consolidation.
• It is most readily elicited by having the patient
  say"e-e - e."If egophony is present,the spoken
  "eeee"will sound as though the patient is saying
  "aaaa."

121

• Decreased vocal resonance
• Vocal resonance is decreased under the same
  circumstances that the vocal fremitus and the
  breath sounds are decreased or absent-where there
  is interference in the conduction of vibrations
  produced in the thorax,such as is found with
  pleural thickening , pleural fluid ,
  pneumothorax, adiposity,or complete bronchial
  obstruction.

122

• Decreased vocal resonance
• It should be noted that,although the vocal
  resonance and vocal fremitus are usually
  diminished over a pleural effusion, occasionally
  they may actually be increased at the upper level
  of the fluid as the result of compression of the
  lung or if there is pneumonic consolidation of
  the underlying lobe.

123
AUSCULTATION

• Adventitious sounds

124

• The most common adventitious sounds are the
  various types of rales ,rhonchi and the pleural
  friction rub

125

• Rales
• They result from the passage of air through
  secretions in the respiratory tract and from
  reinflation of the alveoli and bronchioles, the
  walls of which have become adherent as the result
  of moisture.Rales,therefore,are produced by air
  flow plus abnormal moisture.

126

• Rales
• According to the size of the air chamber involved
  (trachea,bronchi,bronchioles,and alveoli)and the
  character of the exudate,rales vary in their
  size,intensity,distribution, and persistence.
• Rales are most often heard in the terminal phase
  of inspiration and are more pronounced when the
  patient is instructed to breathe deeply.
• Rales are very similar to the sound heard over a
  recently opened carbonated drink.

127

• Rales
• Rales may be divided roughly into three
  categories fine, medium, and coarse.

128

• Fine Rales
• Fine rales have a fine,crackling quality.
• They most commonly occur at the end of
  inspiration and are not cleared by coughing .
• they are the result of moisture in the alveoli.

129

• Fine fales
• Fine rales indicate inflammation or congestion
  involving the alveoli and bronchioles.
  Consequently they may be heard in pneumonia,
  pulmonary congestion, and many other diseases.

130

• Medium rales
• Medium rales represent a gradation between coarse
  and fine rales.
• They may be simulated by rolling a dry cigar
  between the fingers.
• They tend to be the result of the passage of air
  through mucus in the bronchioles and small
  bronchi or the separation of the walls of these
  structures that have become adherent because of
  exudate.
• Medium and coarse rales tend to occur earlier in
  respiration than do fine rales.

131

• Coarse rales
• Coarse rales have their origin in the trachea,
  bronchi and some of the smaller bronchi.
• They are produced by the passage of air through
  exudate.Often they will clear,at least in part,as
  the result of a vigorous cough.
• They may be heard during the resolution of an
  acute pneumonia,at which time there is the
  production of relatively large amounts of thick
  exudate.
• In the moribund patient who has a definite
  depression of his cough reflex,there is often an
  accumulation of thick secretions,producing very
  coarse rales.

132

• Rhonchi
• Rhonchi differ very fundamentally from rales in
  that the former are continuous sounds,similar to
  the sound produced by playing a violin.
• Rhonchi are continuous sounds produced by the
  passage of air through the trachea, bronchi,and
  bronchioles that have been narrowed,irrespective
  of the cause. As long as air passes the
  obstruction,the sound will be produced.

133

• Rhonchi
• Rhonchi in general are more prominent during
  expiration than inspiration, although they are
  frequently audible during inspiration.
• Based primarily on the pitch,rhonchi are
  classified as sibilant or sonorous .

134

• Sibilant rhonchi
• Sibilant rhonchi are high pitched, wheezing,
  squeaking,or musical in character.The wheezing
  quality often can be accentuated by forced
  expiration.
• They have their origin in bronchioles and smaller
  bronchi.

135

• Sonorous rhonchi
• Sonorous rhonchi are low pitched and often
  moaning or snoring in character.
• They are produced by obstruction in the larger
  bronchi or trachea.

136

• Rhonchi tend to vary greatly in intensity and
  character from time to time.In some instances
  they can be cleared,or partially so,by coughing.

137

• Rhonchi are produced as air enters the area
  of obstruction and again as it leaves.
• The underlying obstruction or narrowing may
  be the result of variety of causesextrinsic
  compression as by enlarged lymph nodes or
  mediastinal tumor or by intrinsic narrowing as in
  bronchogenic carcinoma,exudate,mucosal
  inflammation or edema,and bronchiolar
  spasm(asthma).
• In each instance there are narrowing and
  irregularity in the tracheobronchial tree,with
  resultant turbulence of the air producing the
  sound.

138

• pleural friction rub
• Normally the visceral and parietal surfaces of
  the pleura glide noiselessly over one another
  during respiration.
• However,when these surfaces become inflamed,as
  the result of pleurisy, pulmonary infarct, or
  underlying pneumonia,the rubbing of the roughened
  surfaces during respiration produces a very
  characteristic sound that is known as the pleural
  friction rub.

139

• pleural friction rub
• The characteristics of a friction rub can be
  imitated by pressing the palm of one hand over
  the ear and then lightly and slowly rubbing the
  back of the hand with the fingers of the other
  hand.
• It is usually heard during both phases of
  respiration.If audible in only one phase,it is
  most commonly heard during inspiration,particularl
  y at the end.
• At times friction rubs are not heard during quiet
  breathing but are only audible when the patient
  takes a deeper breath.

140

• pleural friction rub
• The most common site for a friction rub to be
  heard is the lower anterolateral chest wall, the
  area of greatest thoracic mobility.
• It does not disappear with coughing as coarse
  rales will often do,and that cough is usually
  attended by discomfort.
• Furthermore,an increase in the intensity of the
  friction rub may be noted with arm pressure of
  the stethoscope over the thoracic wall.

141

• MAJOR ALTERATIONS OF THE LUNGS

142

• Pleural effusion

143

• A collection of fluid in the pleural space is
  called pleural effusion. Pleural effusion is a
  sign of disease and not a diagnosis in itself.
• The physical sign of a pleural effusion are the
  same whether it is serious, hemorrhagic, or
  purulent in character.

144
Inspection

• The patient usually lies on the affected side,
  thus allowing free expansion of the normal lung.
  
• If the amount of the effusion is large, the
  patient may show marked dyspnea.
• The movements of the chest during respiration are
  diminished on the affected side.

145
Inspection

• In large effusions the affected side appears much
  fuller than the normal one, and the intercostal
  spaces may actually bulge.
• When the effusion is on the right side, the
  cardiac impulse may be displaced beyond the left
  midclavicular line.

146
Palpation

• Palpation first confirms the observation made on
  inspection decreased mobility with bulging of
  the intercostal spaces on the affected side and
  displacement of the cardiac impulse.
• The trachea is deviated away from the diseased
  side.
• The vocal fremitus is absent or markedly
  diminished over the effusion.

147
Percussion

• In small effusions and in early stages of any
  pleural effusion, the percussion note may be
  unchanged.
• As more fluid accumulates, the percussion note
  becomes less and less resonant, and finally
  becomes dull to flat.

148
Percussion

• When the effusion is on the right side, the
  dullness extends into and cannot be demarcated
  from the liver dullness.
• A right side plural effusion displaces the heart
  to the left, and the cardiac dullness toward the
  left axilla.
• In a left sided plural effusion the dullness
  extends into that of the cardiac dullness, and
  percussion of the left cardiac border may be
  impossible.

149
Auscultation

• Early in the disease a friction rub may be heard,
  which, however, soon disappears.
• The breath sounds are diminished or absent over
  the area of the effusion.
• Bronchovesicular breath sounds are often heard at
  the upper limit of the fluid, because of the
  compressed underlying lung.

150
Auscultation

• The vocal resonance is diminished or absent over
  effusion.
• The whispered voice may be intensified
  ----bronchophony, especially just above the level
  of the effusion.

151

• Pneumonia

152

• Any lung infection that involves the alveoli
  and causes then to fill with exudate or
  inflammatory secretion is called pneumonia.
• Pneumonias usually sudden, often coughing is
  usually present. It may be severe and
  associated with sharp pain in the affected side.
  
• The sputum at first is mucoid, but later
  becomes bright red and then rusty brown.

153

• The signs of consolidation is commonly found over
  lobar pneumonia.

154
Inspection

• Dyspnea is almost invariably present and the
  respiratory rate is increases.
• In severe cases, cyanosis of the tip of the
  noses, ears and fingertips is commonly present,
  and movements are decreased on the affected side
  and increased on the normal side .

155
Palpation

• The diminished respiratory movements on the
  affected side are often better felt then seen.
• A pleural friction fremitus may be felt because
  of a coexisting acute pleuritis.
• The vocal fremitus is greatly increased over the
  pneumonic area.

156
Percussion

• In a lobar pneumonia the percussion note is
  dull or flat over the affected area.

157
Auscultation

• In the early stages of lobar pneumonia, the
  breath sounds may be diminished or suppressed.
  Fine crepitant rales may be heard.
• With the development of frank consolidation, the
  crepitant rales disappears, the breath sounds
  become tubular .
• The vocal resonance is increased and the voice
  sounds may have a curious nasal tone ----the
  egophony.

158
Auscultation

• During resolution ,the cyanosis and tachypnea
  disappear, the areas of auscultation numerous
  small and large moist rales are heard in
  increasing numbers, while the harsh tubular
  breathing gradually disappears and normal
  vesicular breathing reappears.

159

• Pulmonary emphysema

160

• By definition emphysema refers to the
  presence of an abnormally large amount of air
  within portions of the lung distal to the
  terminal bronchioles. The history is often
  progressive dyspnea, starting after cough, sputum
  for many years.

161
Inspection

• A barrel chest deformity is frequently present.
  
• The chest is on an inspiratory position, with
  the ribs horizontal.
• The apex beat of the heart is not visible.

162
Palpation

• The trachea is in the midline position.
• The tactile fremitus is diminished over both side
  of the chest.
• The chest movement is restricted but equal
  bilaterally.
• The apex beat cannot be felt.

163
Percussion

• there is hyperresonance throughout both sides of
  the chest.
• the area of cardiac dullness is diminished.
• The upper limit of liver dullness is lowered.
• After deep inspiration followed by forced
  expiration, percussion over the bases of the lung
  in the back shows little change in the lower
  limits of lung resonance.

164
Auscultation

• On auscultation the breath sounds are vesicular
  and generally diminished in intensity or almost
  inaudible.
• Expiration is commonly prolonged.
• Rhonchi are normally widespread, but may be most
  marked at the bases of the lung.

165

• Pulmonary atelectasis

166

• Atelectasis occurs when an area of lung tissue is
  not ventilated. The signs and symptoms that
  follow depend upon the amount of lung tissue
  involved and vary from an asymptomatic shadow on
  an X-ray to acute respiratory distress.
• When a sufficient amount of lung is involved,
  there are signs of respiratory distress, and the
  physical findings are as following

167
Inspection

• The chest on the affected side looks flat, the
  intercostal spaces narrowed and depressed.
• The respiratory movements are markedly
  diminished, while there is increased expansion
  over the normal side.

168
Palpation

• The tactile fremitus is usually decreased or
  absent over the affected side.
• The trachea is deviated to the affected side.

169
Percussion

• Percussion shows that the heart is displaced
  toward the affected side.
• The percussion note over the affected lung is
  usually dull.

170
Auscultation

• The breath sounds are usually absent over the
  affected area.
• Rales may not be present.

171

• Pneumothorax

172

• An accumulation of air in the pleural space is
  called pneumothorax. In acute spontaneous
  pneumothorax the patient show sudden dyspnea,
  cyanosis and chest pain. If the pneumothorax is
  small,the alterations may be minor or even
  absent.

173
Inspection

• Unilateral diminishing of movement may be present
  in variable degree.
• The cardiac impulse is displaced to the left in a
  right pneumothorax, and to the right in a left
  pneumothorax.

174
Palpation

• Tracheal deviation away from the affected side
  can be find, if the pneumothorax is large.
• The vocal fremitus is diminished or abolished
  over the affected side.

175
Percussion

• The percussion note over the affected side is
  usually hyperresonant or tympanic.

176
Auscultation

• The vocal resonance is usually diminished.
• The breath sound are markedly diminished on the
  affected side and exaggerated on the normal side.