Transcript PHYSICAL DIAGNOSIS

PHYSICAL
DIAGNOSIS
CHEST
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.
INTRODUCTION
 Experience
would indicate that the
following order of procedure has much
to
recommend
it:
(1)inspection,(2)palpation,(3)percussio
n,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.
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
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.
LINE LANDMARKS
 On
 the
the lateral wall of the chest
anterior axillary line:drawn downward
from the origin of the anterior axillary fold
along the anterolateral aspect of the chest
 the posterior axillary line:a 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
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
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.
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.
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.
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.
BONE LANDMARKS
 On
 the
the posterior thorax
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.
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.
 In
additions,you must have exact
knowledge of the location of the
underlying thoracic structures and
those in the upper abdomen.
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
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 bronchus:wider,shorter
and steeper
 The left primary bronchus:slender and
oblique
The boundary of lung and
pleura
 The
right lung: 3 lobes (upper,middle
and lower)
the left lung: 2 lobes(upper,lower)
 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.
 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.
The boundary of lung and
pleura
 Pleura
Visceral pleura:the pleura covering the
surface of the lung
Parietal pleura: the pleura covering the
inner surface of the chest wall,the
diaphragm,and the mediastinum
 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.
THORAX
AND
LUNGS
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
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.
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.
INSPECTION
Normal thorax
The anteroposterior diameter of
the thorax in the normal adult is
definitely less than the transverse
diameter.
INSPECTION
what to observe
1.First:
the general nutrition and
musculoskeletal development
2.Next: the skin and breasts
3.vein and subcutaneous
emphysema
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
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
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
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
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)
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)
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
INSPECTION
 9.Types
 (8)tidal
of respiration
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.
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 disease;instead it is
almost always a manifestation of emotional
tension.
INSPECTION
 9.Types
of respiration
 (10)Ataxic
breathing: is characterized by
unpredictable irregularity . Breaths may be
shallow or deep,and stop for short periods.
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.
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.
PALPATION
Fremitus
 Vocal
fremitus :Vocal fremitus is a
palpable vibration of the thoracic wall
produced by phonation .
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.
PALPATION
Vocal fremitus:
In eliciting vocal fremitus the patient is
directed to count “one,two,three”--“one,two,three”,to repeat the
words“ninety-nine”—“ninety-nine”,or 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.
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.
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
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.
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.
PALPATION
 Alternations
 increased
of vocal fremitus
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
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.
PALPATION
 pleural
 When
friction fremitus
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.
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.
PERCUSSION
There are two principal
methods that may be used
for percussion of the thorax,
abdomen,or other structures.
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.
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.
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.
PERCUSSION
 To
obtain the maximum information from
percussion:
1. The distal phalanx of the pleximeter
finger must be pressed firmly on the chest
wall;otherwise,a clear note is not ob
tained.
2. The plexor finger should strike the
pleximeter finger only instantaneously
and must be immediately withdrawn.
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.
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.
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.
PERCUSSION
 The
percussion is continued downward,
interspace by interspace,to the bases
where the location and range of motion
of each hemidiaphragm is ascertained.
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.
PERCUSSION
 Percussion
 1.
sounds
Resonance: the sounds heard
normally over lungs
 2. Hyperresonance: The hyperresonant
note in the adult is commonly the
result of emphysema and occasionally
pneumothorax.
PERCUSSION
 Percussion
 3. Tympany
sounds
: It never occurs in the
normal chest,except below the dome of
the left hemidiaphragm,where the
underlying stomach and bowel will
produce tympany.
PERCUSSION
 Percussion
 4.Dullness:
sounds
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.
PERCUSSION
 Percussion
 5.
sounds
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 airbearing lung to influence the sound.
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.
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).
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.
PERCUSSION
 Percussion
sounds
The change from resonance to
flatness on the right and from
resonance to tympany on the left is
not immediate;instead ,there is a
zone of transition.
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.
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 .
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.
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.
PERCUSSION
The lateral recumbent position
causes the following changes:
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 side;this curvature can be
counteracted to some degree if the
pillow is removed and the head is
allowed to the bed.
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.
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.
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.
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.
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.

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 .
PERCUSSION
Diaphragmatic excursion
 The
normal diaphragmatic excursion is
about 6 to 8 cm.
 It is decreased in patients with pleurisy
and severe emphysema.
.
PERCUSSION
 The
diaphragm is unusually high in any
condition that causes an increase in intraabdominal 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.
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.
AUSCULTATION
Breath sounds--normal
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 5:2.
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.
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.
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.
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.
Vesicular and bronchovesicular
are the two types of breath
sounds heard normally over the
lungs.
AUSCULTATION
Breath sounds--abnormal
Bronchial breathing
Bronchial breath sounds are in general
higher in pitch than vesicular or
bronchovesicular sounds.
 Expiration
usually
surpasses
inspiration in length.

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.
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.
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.
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.
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.
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.
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 .
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.
AUSCULTATION
voice sounds--normal
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.
AUSCULTATION
Voice sounds--abnormal
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.
Whispered pectoriloquy
To be of practical significance the sounds
must be actually whispered;softly 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.

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.
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."
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.
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.
AUSCULTATION
Adventitious sounds
The most common adventitious
sounds are the various types of
rales ,rhonchi and the pleural
friction rub
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.
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.
Rales
Rales may be divided roughly into
three categories: fine, medium, and
coarse.
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.

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.
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.
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.
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.
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 .
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.
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.
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.
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 causes:extrinsic
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.

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.
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,particularly at
the end.
 At times friction rubs are not heard during quiet
breathing but are only audible when the patient takes
a deeper breath.
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.
MAJOR
ALTERATIONS OF
THE LUNGS
Pleural effusion
 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.
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.
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.
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.
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.
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.
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.
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.
Pneumonia
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.
 The
signs of consolidation is commonly
found over lobar pneumonia.
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 .
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.
Percussion
 In
a lobar pneumonia the percussion
note is dull or flat over the affected
area.
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.
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.
Pulmonary emphysema
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.
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.
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.
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.
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.
Pulmonary atelectasis
 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:
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.
Palpation
 The
tactile fremitus is usually
decreased or absent over the affected
side.
 The trachea is deviated to the affected
side.
Percussion
 Percussion
shows that the heart is
displaced toward the affected side.
 The percussion note over the affected
lung is usually dull.
Auscultation
 The
breath sounds are usually absent
over the affected area.
 Rales may not be present.
Pneumothorax
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.
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.
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.
Percussion
 The
percussion note over the affected
side is usually hyperresonant or
tympanic.
Auscultation
 The
vocal resonance is usually
diminished.
 The breath sound are markedly
diminished on the affected side and
exaggerated on the normal side.