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INTRODUCTION

•Diseases of the respiratory system

account for up to a third of deaths in most
countries and for a major proportion of
visits to the doctor and time away from
work or school.

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Locating Findings on the Chest

•Describe abnormalities of the chest in two

dimensions:

 along the vertical axis and

 around the circumference of the chest.

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Locations on the Chest.
Be familiar with general anatomic terms used ,
such as:

Supraclavicular—above the clavicles

Infraclavicular—below the clavicles

Interscapular—between the scapulae

Infrascapular—below the scapula

Bases of the lungs—the lowermost portions

Upper, middle, and lower lung fields

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5
 THE HISTORY
Common or Concerning
Symptoms

• Dyspnea (BREATHLESSNESS)

•Cough, sputum

•Hemoptysis

•Wheezing
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 Symptoms
BREATHLESSNESS
(Dyspnea)

•Breathlessness inappropriate to the level of

physical exertion, or even occurring at rest, is
called dyspnoea.
•Is the dyspnoea related only to exertion? How
far can the patient walk at a normal pace on
the level?
•Are there any times of day or night that are
usually worse than others? (Asthma is often
worse at night & in the early morning.)

•Is there variability in the symptom?

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 Symptoms

COUGH
•A cough may be dry or it may be productive of
sputum.
•How long has the cough been present?

•Is the cough worse at any time of day or night?

•Is the cough aggravated by anything, eg. dust,

pollen or cold air?

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 Symptoms cnd…

Hemoptysis -is the coughing up of blood from the

lungs;
it may vary from blood-streaked phlegm to frank blood.

assess the volume of blood produced

ask about the related setting & activity and any

associated sxs.

•Before using the term “hemoptysis,” try to confirm the

source of the bleeding by both Hx & physical
examination.

May originate in the mouth, pharynx, or GIT & is easily

mislabeled. 9
 Symptoms

Wheezes
are musical respiratory sounds that
may be audible both to the patient
and to others.
Wheezing suggests partial airway obstruction
from secretions, tissue inflammation, or a
foreign body.

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Symptoms
chest
The myocardium
pain Angina pectoris, MI
 The pericardium Pericarditis
 The aorta Dissecting aortic
 The trachea & large aneurysm
bronchi Bronchitis
 The parietal pleura Pericarditis, pneumonia
 The chest wall, including Costochondritis, herpes
the mss& skin zoster
 The esophagus Reflux esophagitis,
esophageal spasm
Extrathoracic structures Cervical arthritis, biliary
such as the neck, colic,gastritis
gallbladder, and stomach.

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 THE EXAMINATION

GENERAL ASSESSMENT

Points to note in a general assessment

• Physique
• Voice
• Breathlessness
• Clubbing
• Cyanosis or pallor
• Intercostal recession
• Use of accessory respiratory muscles
• Venous pulses
• Lymph nodes
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 TECHNIQUES OF
EXAMINATION
•Examine the posterior thorax while the patient is
sitting, and the anterior thorax with the patient
supine.

•Proceed in an orderly fashion:

inspect,
palpate,
percuss, and
auscultate.
•Compare one side with the other.

•Arrange the patient’s gown so that you can see the

chest fully.
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 TECHNIQUES OF EXAMINATION cnd…

•With the patient sitting, examine the posterior

chest.

•The patient’s arms should be folded across the chest

with hands resting, if possible, on the opposite
shoulders.

This position moves the scapulae partly out of the way

With
•and the patient
increases your supine, examine
access to the
the lung anterior chest.
fields.

•The supine position makes it easier to examine women

because the breasts can be gently displaced.

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 TECHNIQUES OF EXAMINATION cnd…

•For pts unable to sit up without aid, try to get help

so that you can examine the posterior chest in the
sitting position.

•If this is impossible, roll the pt to one side & then

to the other.

•Because ventilation is relatively greater in the

dependent lung, your chances of hearing wheezes
or crackles are greater on the dependent side.

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Initial Survey of Respiration and the Thorax

•Observe the rate, rhythm, depth, and effort of

breathing.

•A normal resting adult breathes quietly and

14 to 20 times a minute.
regularly about
•An occasional sigh is to be expected.

•Note whether expiration lasts longer than usual.

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 Initial Survey
Always inspect the pt for any signs of respiratory
difficulty.

•Assess the patient’s color for cyanosis.

• Listen to the patient’s breathing. Is there any

audible wheezing? If so, where does it fall in the
respiratory cycle?

• Inspect the neck. During inspiration, is there

contraction of the sternomastoid or other accessory
muscles, or supraclavicular retraction?

•Also observe the shape of the chest.

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 Examination of the Posterior
Chest
INSPECTION

•From a midline position behind the pt, note the

shape of the chest and the way in which it
moves, including:

Deformities or asymmetry
Abnormal retraction of the interspaces during
inspiration.
Impaired respiratory movement on one or both
sides or a unilateral lag (or delay) in movement.
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INSPECTION

Features to note in assessing the

shape of the chest

Kyphosis
Flattening
Scoliosis
Overinflation

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 Observing the chest

Rate of respiration
Rhythm of respiration
Chest expansion
Symmetry

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 PALPATION

Points to note on palpation of the chest

Swelling
Pain and tenderness
Tracheal position
Cardiac impulse
Asymmetry
Tactile vocal
fremitus

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 PALPATIO
N
•Feel for tactile fremitus.

 Refers to the palpable vibrations transmitted

through the bronchopulmonary tree to the chest wall
when the pt speaks.

To detect fremitus, use either the ball (the bony part
of the palm at the base of the fingers) or the ulnar
surface of your hand to optimize the vibratory
sensitivity of the bones in your hand.

Ask the pt to repeat the words “ninety-nine” or “one-

one-one.”
(44 – in Amharic)
 If fremitus is faint, ask the pt to speak more loudly 22
PALPATION

•Palpate and compare symmetric areas of

the lungs.

•Identify and locate any areas of increased,

decreased, or absent fremitus.

•Fremitus is more prominent in the

interscapular area than in the lower lung fields,
and on the right side than on the left.

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PALPATION

•Test chest expansion.

Place your thumbs at the level of the 10th ribs,

with your fingers loosely grasping & parallel to
the lateral rib cage.

Ask the patient to inhale deeply.

Watch the distance b\n your thumbs as they

move apart during inspiration, and feel for the
range and symmetry of the rib cage as it
expands and contracts. 25
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PERCUSSION

•Is one of the most important techniques of P\E.

•Helps you establish whether the underlying

tissues are air-filled, fluid-filled, or solid.

•It penetrates only about 5 cm to 7 cm into the

chest, however, and therefore will not help you
to detect deep-seated lesions.

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 PERCUSSION
• The key points for good
technique:

 Hyperextend the middle finger

of your left hand.

 Press its distal

interphalangeal joint firmly on
the surface to be percussed.

 Avoid surface contact by any

other part of the hand,
because this dampens out
vibrations.

 Note that the thumb, 2nd, 4th,

and 5th fingers are not 28
 PERCUSSION

Position your right

forearm quite close to
the surface, with the
hand cocked upward.

The middle finger

should be partially
flexed, relaxed, &
poised to strike.

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 PERCUSSION

• With a quick sharp but

relaxed wrist motion,
strike the pleximeter
finger with the right
middle finger.

• Aim at your distal

interphalangeal joint.

Strike using the tip of the

plexor finger, not the
finger pad.
Your finger should be at
right angles to the 30
 PERCUSSION

In summary, the movement is

at the wrist. It is directed,
brisk yet relaxed, and a bit
bouncy.

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 PERCUSSION

•While the patient keeps both arms crossed in front of

the chest, percuss the thorax in symmetric locations
from the apices to the lung bases.

•Percuss one side of the chest and then the other

at each level, as shown by the numbers below.

•Omit the areas over the scapulae—the thickness of

muscle
and bone alters the percussion notes over the lungs.

•Identify and locate the area and quality of any

abnormal percussion note.
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33
 PERCUSSION

Percussion Notes.
•Use the lightest percussion that produces a clear note.

•Percuss or strike twice in each location.

•Learn to identify five percussion notes.

These notes differ in their basic qualities of sound:

intensity, pitch, and duration.

•Normal lungs are resonant.

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 PERCUSSION

•Identify the descent of the diaphragms, or

diaphragmatic excursion.

•First, determine the level of diaphragmatic dullness

during quiet respiration.

•Holding the pleximeter finger above and parallel to the

expected level of dullness, percuss downward in
progressive steps until dullness clearly replaces
resonance.

•Confirm this level of change by percussion near the

middle of the hemithorax and also more laterally.

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 PERCUSSION

• You can infer the probable location of the diaphragm

from the level of dullness.

•Now, estimate the extent of diaphragmatic

excursion by determining the distance between
the level of dullness on full expiration and the
level of dullness on full inspiration, normally
about 5 cm or 6 cm.

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38
 AUSCULTATION
•Auscultation of the lungs is the most important
examining technique for assessing air flow through the
tracheobronchial tree.

•Auscultation involves
(1) listening to the sounds generated by breathing,
(2) listening for any adventitious (added)
sounds,and
(3) if abnormalities are suspected, listening to the
sounds of the patient’s spoken or whispered voice as
they are transmitted through the chest wall.

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 AUSCULTATION

Breath Sounds (Lung Sounds).

Identify patterns of breath sounds by their intensity,
their pitch, and the relative duration of their inspiratory
and expiratory phases.

Normal breath sounds are:

Vesicular, or soft and low pitched. They are heard
through inspiration, continue without pause through
expiration, and then fade away about one third of the
way through expiration.
 Bronchovesicular, with inspiratory and expiratory
sounds about equal in length, at times separated by a
silent interval.
Differences in pitch and intensity are often more easily
detected during expiration.
 Bronchial, or louder and higher in pitch, with a short
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 AUSCULTATION
TECHNIQUES OF EXAMINATION

•Listen to the breath sounds with the diaphragm of a

stethoscope after instructing the pt to breathe deeply
through an open mouth.

•Use the pattern suggested for percussion, moving from

one side to the other and comparing symmetric areas of
the lungs.

•If you hear or suspect abnormal sounds, auscultate

adjacent areas so that you can fully describe the extent
of any abnormality.

•Listen to at least one full breath in each location.

•Be alert for patient discomfort due to hyperventilation

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42
 AUSCULTATION

Adventitious (Added) Sounds.

•Listen for any added, or adventitious, sounds that are
superimposed on the usual breath sounds.

• crackles (rales), wheezes, and rhonchi.

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 AUSCULTATION

If you hear crackles, especially those that do not clear

after cough, listen carefully for the following
characteristics. These are clues to the underlying
condition:

 Loudness, pitch, and duration (summarized as fine or

coarse crackles)
Number (few to many) Timing in the respiratory cycle

Location on the chest wall

Persistence of their pattern from breath to breath

Any change after a cough or a change in the patient’s

position 45
 AUSCULTATION

•In some normal people, crackles may be heard at the

lung bases anteriorly after maximal expiration.

•Crackles in dependent portions of the lungs may also

occur after prolonged recumbency.

•If you hear wheezes or rhonchi, note their timing and

location.

•Do they change with deep breathing or coughing?

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 AUSCULTATION

Transmitted Voice Sounds.

•Listen in symmetric areas over the chest wall as you:

Ask the patient to say “ninety-nine.”

Normally the sounds transmitted through the chest
wall are muffled and indistinct.

 Ask the pt to say “ee.”

You will normally hear a muffled long E sound.

Ask the pt to whisper “ninety-nine” or “one-two-three.”

The whispered voice is normally heard faintly &
indistinctly,if at all.
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Examination of the Anterior Chest

•The patient, when examined in the supine position,

should lie comfortably with arms somewhat abducted.

•A patient who is having difficulty breathing should be

examined in the sitting position or with the head of the
bed elevated to a comfortable level.

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INSPECTION
Observe the shape of the patient’s chest and
the movement of the chest wall.

Note:

Deformities or asymmetry

Abnormal retraction of the lower interspaces

during inspiration

Local lag or impairment in respiratory

movement 49
PALPATION

Palpation has four potential uses:

 Identification of tender areas

Assessment of observed abnormalities

Further assessment of chest expansion.

 Assessment of tactile fremitus.

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PERCUSSION

•Percuss the anterior and lateral chest, again

comparing both sides.
•The heart normally produces an area of dullness to the
left of the sternum from the 3rd to the 5th interspaces.

•Percuss the left lung lateral to it.

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 PERCUSSION

•With your pleximeter finger above and parallel to the

expected upper border of liver dullness, percuss in
progressive steps downward in the right midclavicular
line.

•Identify the upper border of liver dullness.

•Later, during the abdominal examination, you will use

this method to estimate the size of the liver.

•As you percuss down the chest on the left, the

resonance of normal lung usually changes to the
tympany of the gastric air bubble.

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57
AUSCULTATION

•Listen to the chest anteriorly and laterally as the

patient breathes with mouth open, somewhat more
deeply than normal.

•Compare symmetric areas of the lungs.

•Listen to the breath sounds.

•Identify any adventitious sounds.

•Listen for transmitted voice sounds.

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Recording the Physical Examination

•“Chest is symmetric with good expansion. Lungs

resonant. Breath sounds vesicular; no rales, wheezes,
or rhonchi. Diaphragms descend 4 cm bilaterally.”
OR
•“Chest symmetric with moderate kyphosis and
increased AP diameter, decreased expansion. Lungs
are hyperresonant. Breath sounds distant with delayed
expiratory phase and scattered expiratory wheezes.
Fremitus decreased; no bronchophony, egophony, or
whispered pectoriloquy. Diaphragms descend 2 cm
bilaterally.”

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 Summary
Observe the patient generally, and the
surroundings.
Ask the patient's permission for the examination,
and ensure they are lying back comfortably at 45°.
Examine the hands.
Check the face for anaemia or cyanosis.
Observe the respiratory rate.
Inspect the chest movements and the anterior
chest wall.
Feel the position of the trachea, & check for
lymphadenopathy.
Feel the position of the apex beat.
Check the symmetry of the chest movements by
palpation. 60
 Summary

Sit the patient forward

Inspect the posterior chest wall.

Percuss the back of the chest.
Listen to the breath sounds.
Check the vocal resonance.
Check the tactile vocal fremitus.

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 Summary
lying the patient back again

Listen to the breath sounds on the front

of the chest.
Check the vocal resonance.
Check the tactile vocal fremitus.

Stand back for a moment and reflect upon

whether you have omitted anything

Thank the patient and ensure they are

dressed or appropriately covered.
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Tachypnoea
Cyanosis
Use of respiratory accessory
muscles
Inter costal retractions
Flaring of alae nasae.

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Components of the Health History

Identifying Data
Reliability
Chief Complaint(s)
Present Illness
Past History
Family History
Personal and Social
History
Review of Systems 65
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