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PHYSICAL DIAGNOSIS. CHEST. INTRODUCTION.

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introduction
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.
introduction4
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.
line landmarks
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 landmarks6
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 landmarks8
LINE LANDMARKS
  • On the lateral wall of the chest
  • the 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 landmarks10
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
slide12
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
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 landmarks14
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 landmarks15
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 landmarks17
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.
bone landmarks18
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.
slide19
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
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
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 pleura24
The boundary of lung and pleura
  • The right lung: 3 lobes (upper,middle

and lower)

the left lung: 2 lobes(upper,lower)

slide25
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.
slide27
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 pleura28
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

slide29
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.
inspection
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
inspection33
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.

inspection34
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.

inspection35
INSPECTION

Normal thorax

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

inspection36
INSPECTION

what to observe

  • 1.First: the general nutrition and musculoskeletal development 2.Next: the skin and breasts
  • 3.vein and subcutaneous emphysema
inspection37
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

inspection38
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
inspection39
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
inspection40
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
inspection41
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)
inspection42
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 thedepth of respiration
  • (6)Hyperventilation :an abnormal increase in both rate and depth of respiration(it is seen in diabetic acidosis and highly emotional states)
inspection43
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
inspection44
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.
inspection45
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.
inspection46
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
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.
palpation49
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.
palpation50
PALPATION

Fremitus

  • Vocal fremitus :Vocal fremitus is a palpable vibration of the thoracic wall produced by phonation .
palpation51
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.

palpation52
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.

palpation53
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.
palpation54
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

palpation55
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.
palpation56
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.
palpation57
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
palpation58
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.
palpation59
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.
palpation60
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
PERCUSSION

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

percussion62
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.

percussion63
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.

percussion64
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.

percussion65
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.

percussion66
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.
percussion67
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.
percussion69
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.
percussion70
PERCUSSION
  • The percussion is continued downward, interspace by interspace,to the bases where the location and range of motion of each hemidiaphragm is ascertained.
percussion71
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.

percussion72
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.
percussion73
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.
percussion74
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.
percussion75
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.
percussion76
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.

percussion77
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 lessresonant (duller).

percussion78
PERCUSSION
  • Percussion sounds

It should be notedthat below the dome of the right diaphragm there is flatness because of the presenceof 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.

percussion79
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.

percussion80
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.

percussion81
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 .

percussion82
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.

percussion83
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.

percussion84
PERCUSSION

The lateral recumbent position causes the following changes:

percussion85
PERCUSSION
  • 1.Some curvature of the spine results,with awidening 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.
percussion86
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.
percussion87
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.
percussion88
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.
percussion89
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.
percussion91
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.
percussion92
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 ofmotion of the diaphragm .
percussion93
PERCUSSION
  • Diaphragmatic excursion
  • The normal diaphragmatic excursion is about 6to 8 cm.
  • It is decreased in patients with pleurisy and severe emphysema.
percussion95
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.
auscultation
AUSCULTATION
  • The patient should be instructed to breathe alittle 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.
auscultation97
AUSCULTATION

Breath sounds--normal

slide98
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.
slide99
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.
slide100
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.
slide101
Bronchovesicular
  • This type of breath sound isheard 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.
  • Whenheard in other locations, brochovesicular breathing isabnormal and is indicative of some disease process.
slide102
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.
slide103
Vesicular and bronchovesicular are the two types ofbreath sounds heard normally over the lungs.
auscultation104
AUSCULTATION

Breath sounds--abnormal

slide105
Bronchial breathing
  • Bronchial breath sounds are in general higher in pitch than vesicular or bronchovesicular sounds.
  • Expiration usually surpasses inspiration in length.
slide106
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.
slide107
Bronchovesicular breathing
  • Bronchovesicular breathing is abnormal when heard in any area of the lungs that normally have vesicular breath sounds.
  • An admixture of consolidated andaerated lung produces a mixture of bronchial and vesicular breathing--bronchovesicular breath sounds.
slide108
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
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.
slide110
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.
slide111
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.
slide112
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 .

slide113
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.
auscultation114
AUSCULTATION

voice sounds--normal

slide115
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.
auscultation116
AUSCULTATION

Voice sounds--abnormal

slide117
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.
slide118
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.
slide119
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.
slide120
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."
slide121
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.
slide122
Decreased vocal resonance
  • It should be noted that,although the vocal resonance and vocal fremitus are usually diminished over a pleural effusion, occasionally theymay 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.
auscultation123
AUSCULTATION

Adventitious sounds

slide124
The most common adventitious sounds are the various types of rales ,rhonchi and the pleural friction rub
slide125
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.
slide126
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.
slide127
Rales

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

slide128
Fine Rales
  • Fine rales have a fine,crackling quality.
  • They most commonly occur at the endof inspiration and are not cleared by coughing .
  • they are the result of moisture in the alveoli.
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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.
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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.
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Coarse rales
  • Coarse rales have their origin in the trachea, bronchi and some ofthe 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.
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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.
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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 .
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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.
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Sonorousrhonchi
  • Sonorousrhonchi are low pitched and often moaning or snoring in character.
  • They are produced by obstruction in the larger bronchi or trachea.
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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.
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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.
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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.
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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.
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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.
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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.
inspection144
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.
inspection145
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.
palpation146
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.
percussion147
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.
percussion148
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.
auscultation149
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.
auscultation150
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.
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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.

inspection154
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 .
palpation155
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.
percussion156
Percussion
  • In a lobar pneumonia the percussion note is dull or flat over the affected area.
auscultation157
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.
auscultation158
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.
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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.
inspection161
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.
palpation162
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.
percussion163
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.
auscultation164
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.
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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:
inspection167
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.
palpation168
Palpation
  • The tactile fremitus is usually decreased or absent over the affected side.
  • The trachea is deviated to the affected side.
percussion169
Percussion
  • Percussion shows that the heart is displaced toward the affected side.
  • The percussion note over the affected lung is usually dull.
auscultation170
Auscultation
  • The breath sounds are usually absent over the affected area.
  • Rales may not be present.
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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.
inspection173
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.
palpation174
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.
percussion175
Percussion
  • The percussion note over the affected side is usually hyperresonant or tympanic.
auscultation176
Auscultation
  • The vocal resonance is usually diminished.
  • The breath sound are markedly diminished on the affected side and exaggerated on the normal side.