chest and lungs 1

8/4/2019 Chest and Lungs 1

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PHYSICAL DIAGNOSIS : Chest and Lungs | 1

PHYSICAL DIAGNOSIS

Chest and Lungs Examination

Lecturer: Dr. Feliciano

References: recording, 2010 ppt, Bates, google Sorry medyo mahaba sya ang dami kasi sinabi ni Dr. Feliciano.. Hi Mico haha! Yung iba jan peechures naman lang

so kering keri! Go!

OUTLINEI. CASE PRESENTATION

II. REVIEW OF ANATOMY

-Anterior

-Posterior

-Landmarks

-Lungs

III. PROPERLY POSITION THE PATIENT

IV. UNDRESS THE PATIENT PROPERLY :>

V. INSPECTION

-rate of breathing

-pattern of breathing

-position of the patient

- antero-posterior and lateral diameter of the chest

-chest and spine deformities

-Lung expansion

-extrapulmonary findings

VI. PALPATION

-lymph node

-trachea

-chest

-palpate for mass and tenderness

-assessing for asymmetry of lung expansion

-tactile fremitus

-unilateral diminished fremitus

-bilateral diminished fremitus

VII. PERCUSSION

-level of diaphragm

-differentiation of notes in percussion

VIII.CERTAIN DISEASES WITH USUAL FINDINGS

Next thing to do: AUSCULTATE, BP, general survey.

Above case is a veryincomplete history. Your physical

examination will depend on the history youll be able to get

from the patient. Remember your title as a clinician when

you are taking the history: You are the HISTORIAN that

means..

Whatever you write down is YOUR story. It is the analysis

of the case with the facts coming from the patient. Do not

just write down what the patient would tell you. You have

to give some of your inputs there and see what is

important/relevant to the assessment you are making.

Going back to the case, you would want to ask more..characterize cough MORE! What aggravates it? What

relieves it? When is the time predilection that the patient

would cough? Is it associated w/ hemoptysis? Fever?

Dyspnea.. How severe? Any medications? In pleuritic chest

pain.. is it localized?

Ask for more information.. sometimes the patient

wouldnt volunteer, then YOU WILL BE THE ONE TO ASK!

Ask forPast Medical History. The case above can manifest

a pulmonary disease as well as systemic disease (cardiac).

Family History. Ask if the patient smokes. Is he a smoker

w/ chronic cough? One of the differentials would be LUNG

CANCER. Ask for history of cancer or other pulmonary

disorder like asthma which can be genetically predisposed

to the patient. Ask Personal/Social History in terms of

occupation history as well.

Review of Anatomy

ANTERIOR

Suprasternal notch- point of reference where trachea

will pass through; where clavicle would attach to the

sternum.. the point where manubrium would start.

Angle of Louis -most prominent area next to

Suprasternal notch; where 2nd

rib would attach. In

tension pneumothorax (air in pleural space), if its too

large causing compression of cardiac

structurebradycarcardia, hypotension, cardiac arrest

Thats a medical emergency so you should

Immediately insert large core needle to release the air

and tension. Insert it at the 2nd INTERCOSTAL SPACE

midclavicular line. Or count 2 intercostals space below..

Case: 57 y/o, 50 pack year smoking

HPI: 1 year PTA- cough intermittent

2 mos PTA- persistent cough, whitish phlegm, anorexia, weight loss

Few days PTA- symptoms progressed, (+) dyspnea, (+) pleuritic chest pain

Transcriber: Peller and Jener

Editor: Cancanoo

Number of pages: 12


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at the level of 4th

rib/ nipple area(bifurcation of trachea to R and L main bronchus).

the clavicle would block the 1st

intercostals space.2

ndintercostal space-1

stsoft area that you will palpate.

In midclavicular line you could palpate up to 6th

intercostals space. Go obliquely on the lateralfor 7th

, 8th

, 9th

intercostals spaces.

Palpate Xiphoid-where the sternum would end and youll be able to delineate your lung during inhalation.

POSTERIOR

-Spine

-Spinous Process(C7-the most prominent)

-Thoracic vertebrae

-Tip of Scapula(7th rib)

LANDMARKS- these are vertical lines used to locate findings around the circumference of the chest. The midsternal

and vertebral lines are precise; the others are estimated.

Anteriorly:Getthe midpoint of your sternum, draw a perpendicular line, to refer to your MIDSTERNAL LINE.

Approximate the midline of clavicle, draw a perpendicular line: MIDCLAVICULAR LINE.

Posteriorly: In your Spinous process, draw perpendicular line to refer to your MIDVERTEBRAL or SPINAL

LINE. In the lateral surface of scapula, you can have your MIDSCAPULAR LINE. In between your scapula, you

have your INTRASCAPULAR AREA. Below the scapula, is INFRASCAPULAR AREA.

Laterally:ANTERIOR AXILLARY LINE, POSTERIOR AXILLARY LINE , MID-AXILLARY LINE

The anterior and posterior axillary lines drop vertically from the anterior and posterior axillary folds, the

muscle masses that border the axilla. The midaxillary line drops from the apex of the axilla.

Posteriorly, the vertebral line overlies the spinous processes of the vertebrae. The scapular line drops

from the inferior angle of the scapula.

From Bates Note special landmarks: 2nd intercostal space for needle insertion for tensionpneumothorax; 4th intercostal space for chest tube insertion; T4 for lower margin of endotracheal tube

on chest x-ra .

From Bates

Note T7-8 interspace as landmark for thoracentesis.

When the neck is flexed forward, the most

protruding process is usually the vertebra ofC7. If

two processes are equally prominent, they are C7

and T1.


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LUNGS- divided into lobes. Each lobe is divided into segments.

RIGHT LUNG(3 lobes)

Right Upper Lobe: Apical, Anterior, Posterior

Middle Lobe: Medial, Lateral

Posterior Lobe: Superior basal, Antero-lateral

basal, Posterior basal, Medial basal

LEFT LUNG

Upper Lobe: Apicoposterior, Anterior, Superior and

Inferior Lingula

Lower lobe: Superior basal, anteromedial basal, lateral

basal, posterior basal

Figure 1. Anterior view

Anteriorly, the apex of each lung rises approximately 2

cm to 4 cm above the inner third of the clavicle. The

lower border of the lung crosses the 6th rib at the

midclavicular line and the 8th rib at the midaxillary line.

Posteriorly, the lower border of the lung lies at about

the level of the T10 spinous process. On inspiration, it

descends farther. See right figure

Each lung is divided roughly in half by an oblique (major)

fissure. This fissure may be approximated by a string that

runs from the T3 spinous process obliquely down and

around the chest to the 6th rib at the midclavicular line.

The right lung is further divided by the horizontal (minor)fissure. Anteriorly, this fissure runs close to the 4th rib

and meets the oblique fissure in the midaxillary line near

the 5th rib. The right lung is thus divided into upper,

middle, and lower lobes. The left lung has only two lobes,

upper and lower. See left figure


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You can identify problems on RIGHT UPPER LUNG(RUL) and RIGHT MIDDLE LOBE(RML), partly RIGHT LOWER LOBE(RLL) ; LEFT

UPPER LUNG and partly LEFT LOWER LUNG

Figure 2. Posterior view:

Partly Left Upper Lung and

Right Upper Lung; Better

appreciation of Left Lower

Lung and Right Lower Lung

Figure 3. Right Lateral view: Right Upper

Lung, Right Middle Lung, Right Lower Lung

divided by OBLIQUE and HORIZONTAL fissure

Figure 4. Left lateral view: LeftUpper lung and Left Lower

lung, divided by OBLIQUE FISSURE

PROPERLY POSITION THE PATIENT: might affect your findings so be cautious about it

Patient: SITTING OR STANDING - so you can examine the anterior and the back(posterior) of the patient

Babies: supine position

Doctors: do not stand in front of your patient! FOR YOUR OWN PROTECTION and HYGIENE PURPOSES. Also if the

patient is female, awkward if guy yung doctor tapos nasa harap dibuh (KINKY!)

UNDRESS THE PATIENT PROPERLY (KINKIER!) narinig ko si Rayson at Mico nag-ohhhh

For Male patient, its not a problem

For some who do not want that, allow them to undress themselves and examine the chest directly WITHOUT their

clothes on. (DO NOT AUSCULTATE WITH THE PATIENTS CLOTHES ON.. Remove all obstructions)

In females, ask them to retract their breast (ask permission first) so you can auscultate the chest.

If patient is really that sick, examine them in SUPINE POSITION.

I. INSPECTION

1. Checking Respiratory rate

Dont stare at the patients chest (might be anxious and change his/her manner of breathing).

You can talk to the patient or get the pulse while counting the RR

RR Adults Normal RR - 16-20 breaths/min (Tachypnea-higher; Bradypnea-lower)

RR on Normal Pediatric patients - higher RR


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2. Pattern of Breathing

While the patient is standing/lying/seated upright at the end of the examing table or bed.

Usual pattern: diaphragm goes down, chest goes anteriorly and upward (inspiratory movement)

Normal Tidal volume(during resting respiration) on average is 500 mL(if patients 50 kg). Depends on the

weight. [TV= 10-15 ml/kg]

If the patient is smaller, smaller tidal volume

Hyperpnea rapid, deeper breathing metabolic acidosis, anxiety, excercise,hypoxia

Hypopnea shallow or less of breathing

Tachypnea Rapid, shallow, > 20/min Fever, pain, exertion, anemia, infection

Bradypnea slow breathing, < 12/min Uremia, diabetic coma, morphine andalcohol abuse

Kussmaul respiration hyperpneic breathing/polypnea; deep,regular, sighing respiration can be fast,normal or slow

Pneumonia, ESRD, Diabetic KETOacidosis,uremia)

Cheyne-Stokes -Regulary irregular: apnea(absence ofbreathing for more than 10 secs),

hypopnea, hyperpnea, hypopnea, apnea in

cycle;

**Trivia: Why Cheyne-Stokes? Best described by

Cheyne a kind of breathing pattern cease of 10

secs, became perceptible though very low, and

became hyperpnea, and gradually ceases

again(apnea)

-UREMIA

-Congestive heart failure(failing heart so

blood flow to brain is slower, then feedback

mechanism is affected and delayed kaya may

hypopnea, hyperpnea, hypopnea, hyperpnea

- brain injuries, metabolic encephalopathy

- common in children

Biots Breathing -Irregularly regular; Not periodic.-Sometimes slow, sometimes rapid.

Sometimes superficial. Sometimes deep;

without any constant relation of

succession between the two types; with

pauses following irregular interval

preceeded and often following by a sigh,

more or less prolonged;

-very irregular: hypopnea, hyperpnea,

hypopnea, hypopnea, hypopnea,

hyperpnea, apnea

-group of quick, shallow inspiration

followed by regular or iregular period of

apnea

MENINGITISCerbro vascular disease

Cranial tumors

generally indicates poor prognosis

Position of the Patient

Patient with COPD(problem with Expiration)- even they prolong the

expiratory phase, it stops because of bronchus closure. So theres incomplete

evacuation of air CO2 retention and hyperinflation; the air can get it but

once the patient exhales, it easily collapses blocking the exit of air

Di makalakad

Arms is resting on his legs: TRIPOD POSITION

Patients Lips: Pursed Lip Breathing(seen with patient w/ Obstructive Lung

Disease) they do not even know that this helps their breathing by creating

POSITIVE PRESSURE that would keep your airway open during expiration

phase; defense mechanism

Depression of supraclavicular fossa-very prominent in chronic lung disease(e.g. Asthma)

Retractions on Intercostal space

The patient is in respiratory distress(general survey), pursed lip breathing, supraclavicular fossa depression,

intercostals retraction, in a patient in Tripod position

3. Measure Antero-Posterior and Lateral Diameter of the Chest


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Normal ratioAP diameter: Lateral Diameter1:2 to 1:3(adults, bawal ang barrel chest); 1:1(pediatrics, ang

barrel chest okay lang sa baby)

Dont just say the patient is obese!!! Take note of the history! A patient with Bronchitis, AP diameter is 1:1 due to

bronchitis (not just due to obesity).

Check for defects or deformities

Pectus Excavatum funnel chest- Depression of lower aspect of the sternum;

common in shoemakers in olden times, they press the shoes in their chest;

abnormal in patients who had Rachitic Rosaryand Marfan Syndrome(congenital)

Rachitic Rosary: manifestaion of Vit D deficiency or problem with

the receptors of Vit D; nutritional in origin; prominence of

costosternal notch; bulging ear like beads thats why it is called

Rachitic rosary); seen in patient 1 to 2 years with Rickets

**Complication: Pectus Excavatum funnel chest

Marfan Syndrome(termed as arachnodactyly but not all patients manifest) long bones, long

skull with Pectus Excavatum; autosomal dominant genetic predisposition

Pectus Carinatum birds chest/pigeons breast/chicken

breast-

softened upper ribs bend inward, forcing the

sternum forward

complication of Rickets, Pagets Disease,

congenital Heart Diseases.

Can develop if epiphysis is still open, up to age

18(females) and 21(males)

Kyphosisexaggeration of the posterior curvature of the back.

Most common: osteoporosis

causes the patient to bend forward

Scoliosis

di pantay ang shoulders at fat fold. Ask the patient to bend

forward to really see (Adams Forward Test)

if you have Chronic Obstructive Lung Disease, this will

cause Restrictive Lung Diseases - lower Tidal Volume,

lower reserve volume, lower total lung capacity, all

inspiratory capacities will be low difficulty of breathingit can also compress cardiac structure cardiac

abnormalities.

Chondrosarcoma

malignancy of the rib or bone

more severe form

describe the lesion, measure the circumference

if it has ulceration(typical of malignancy)

Empyema necessitans - pus draining out of the chest wall;complication of tuberculosis

TB lymphadenitis Scrofula- TB of lymph node

4. Lung Expansion Flail chestdue to multiple rib fracture

common in patient with Atelectasis

when the patient inhales, the chest retracts. When the patient exhales, the chest bulges(opposite of normal)

abnormal pattern of breathing


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5. Observe Extrapulmonary findingsPuffy face-prominence of superficial vessels(due to obstruction of Superior Vena Cava associated with

lung mass, lymph node enlargement in mediastinal area, COPD patient)

Cyanosis-heart failure(congenital heart disease and patients with hypoxia); Hb level lower than 3 g/dl

Peripheral-most common etiology when you expose your hands to cold (Reynauds

phenomenon); common in patient with Connective Tissue diseases

Central

Clubbing of fingers-decrease in oxygenationneovascularization at the tip of fingertip; sign of chronic

illness due to cardiac or lung diseases, or even tumors.

II. PALPATION

Lymph node

One at a time only! You can kill the patient if

theres a problem in carotid artery and you

compress it

Guide: start with pre-auricular, post-auricular,

submandibular, submental, anterior and

posterior cervical, supraclavicular area or the

other way around.

Trachea

palpate the sides

It should be goind down straight.

If theres deviation, either contralaterally if

theres mass, effussion, or even pneumothorax.

Most common is goiter pushing the trachea on

the other side.

In Atelectasis, the trachea will deviate

ipsilaterally.

Chest

palpate anteriorly and posteriorly.

Check if theres a mass and tenderness.

Palpate the ribs and intercostal space

if you have any pleural involvement like in

pleurisy/pleuritis (inflammation of the pleura),

you can only elicit a pain whenever you try to

palpate the intercostal spaces

If you palpate on the rib and there is a pain on

the rib, then that would be due to a rib problem

and not necessarily a pulmonary problem. Do

this in front or at the back of your patient.

Assessing for Asymmetry of Lung Expansion

by checking respiratory excursion: best done at

the BACK of the patient.

place your hands at 10th

intercostal space

(3 intercostal spaces below the tip of the

scapula as your reference)

your thumb should be positioned in the

paravertebral area

You have to be on fold and ask the

patient to inhale, exhale(This is not the

proper way but a better way of doing it)

Let the patient move your hand. If there

is symmetry, then that is symmetrical

chest expansion.

You can also do that in the anterior chest

usually at the level of 6th

intercostal

space. You do the same technique.

You can also do that on your upper chest

but do not press too much on your

brachial.

For the patient who cannot sit up, you

can also do that while your patient is on

supine position.

Asymmetrical Lung expansion

Problems on the side borders pathology

There would be a lag if there is a pleural

effusion, pneumothorax or large mass in

that area

If theres no mass, effusion nor

pneumothorax, possible cause is

In summarry for INSPECTION

Respiratory rate

Breathing pattern

(+)/(-)intercostal retractions/ use of accessory muscles

(+)/(-)Deformities or defects

(+)/(-)Mass or lesions

Symmetry in inhalation/expiration

Extra pulmonary findings- cyanosis, clubbing, increase vascularity of superficial veins, puffy face

Cyanosis is of two kinds, depending on the oxygen level in the arterial blood. If this level is low,

cyanosis is central. If it is normal, cyanosis is peripheral. Peripheral Cyanosis occurs when

cutaneous blood flow decreases and slows, and tissues extract more oxygen than usual from the

blood. Peripheral Cyanosis may be a normal response to anxiety or a cold environment.


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diaphragmatic paralysis (since diaphragm

is the major muscle in respiration).

Tactile Fremitus

The last you have to do with palpation

Ask the patient to say ninety-nine, tres, tres,

for as long as that the frequency of what you

would ask the patient to say is the same

frequency as the chest wall and the lungs.

For females with high frequency or high pitches,

expect that the fremitus might be decreased or

not appreciable at all. Ask the female to lower

down the pitch or voice to appreciate the lung

fremitus.

Certain points to consider:

Usually the first point of examination is your

supraclavicular area then down to your

intercostal space and then obliquely downward

to these points (zigzag pattern).

You can do it one at a time or at the same time

depending on your preference.

When examining the back, ask the patient to

place the hands on the shoulder to retract the

scapula so you would have more space to palpate,

percuss or auscultate. You have to place the baller

surface of palm or ulnar surface of your hands.

Best sensed by using the palmar bases of the

fingers applied on the chest wall

The intensity is dependent on tissue densityFeel for vibration. When you ask the patient to say

tres tres or ninety-nine, your vocal cords will

vibrate and will send vibrations towards your

bronchus, to your parenchyma and your chest

wall.

Remember your hand should be placed in the

intercostal space.

Normal is equal vocal fremitus.

Abnormality in fremitus can be seen in

consolidation that can be appreciated in patient

with Pneumonia because of increase in secretion

in alveoli due to the inflammatory mucus and cells

that would increase density of the lungs allowing a

better transmission of that vibration from your

lung parenchyma toward the chest wall. This is the

only one that can increase the fremitus.

The rest of the abnormality will diminish the

fremitus.

o Unilateral diminished fremitus

Pleural effusion of one side.

Fluid will block the transmission of

vibration from your lung parenchyma

towards your chest wall.

Same is true if there is a pleural

thickening or a big tumor with

obstruction. If you have only tumor and

the tumor is located 5-6cm away from

the chest wall, it might not manifest

with anything at all. it might notmanifest any physical findings.

Atelectasis (collapse of lung) will also

decrease the fremitus, as well as

pneumothorax.

o Bilateral diminished fremitus

You can probably appreciate among

the patient with excess fat tissues

(it is quite difficult to appreciate

fremitus) thats acceptable, report that

the fremitus cannot be appreciated or

diminished but be sure that this is dueto obesity or excessive fat tissues.

Air trapping which is common among

patients with COPD, asthma or any

obstructive lung disease, because of

that, there would be bilateral decrease

in fremitus as well.

III. PERCUSSION

use the dominant hand as a plexor if right

handed, use the right hand as a plexor

the other hand would be your pleximeter.

So your pleximeter is usually your non-

dmoninant hand, you have to press it in the

intercostal space, and then you have to tap

it with your plexor.

the force should come from the wrist and

not from you elbow. You should do a 1-3strikes to appreciate the sounds created by

percussion.

The lung percussion note is resonance.

Heartand liveris dull. Stomach is tympanic.

Thigh is flat. Again, you have to do

percussion same as earlier (zigzag pattern).

Do not forget to percuss the lateral chest.

Be sure to cut your nails (long nails can be

painful in percussion).You can do it in supine position. But the

vibration might be dumped when doing in

supine. It is more audible when you do it in

a sitting position and there is a better

resonance on your apex rather than on the

base and it is highly appreciated on the

right intercostal area.


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At the back, you have to do that on your

vertebra and scapula, again, ask the patient

to retract the scapula (by putting his hands

on his shoulders).

To check the level of the diaphragm

o You can check it during the resting

expiration.

o Ask the patient to exhale, tap it quickly, and

note for resonance, and if there is dullness

you can appreciate, then that is the level of

your lung.

o And then ask the patient to inhale then tap

it again and you will expect it to go down.

o The difference should be around 4-6cm

thats the normal excursion of your lung.

You would also expect your right side to be

more elevated than your leftbecause of the

presence of the liver (they call this the Alley

of percussion)

Differentiation of notes in percussion (Technically)

The definitions of notes are arbitrary. But it can be

differentiated in terms ofpitch, intensity and quality

FLATNESS is usually high-pitched with soft intensity

and it is really dull (normally in thigh, sternum)

You can also appreciate if there is atelectasis or

pleural effusion.

DULLNESS has medium pitch and intensity and tad-

like quality. Normal in liver, cardiac and diaphragm.

Abnormal if you have pneumonia, tumor, Atelectasis

and even pleural effusion.

RESONANCE is the normal sound of your lung, it is

low, moderate to loud intensity and hallow in

quality. But you can also have hyperresonance as

normal sound among children or infants.

HYPERRESONANCE has lower pitch than resonance

sound, very loud intensity, booming in quality. In

abnormal diseases like pneumothorax, asthma,

chronic bronchitis and emphysema.

TYMPANIC SOUND is a high-pitched, loud intensity,

with drum-like or musical quality, well appreciated in

the asthma but it is also suggest a presence of

pneumothorax.

If you have difficulty in hearing the sound of

percussion, it is not the force of your plexor that

matters. You can actually apply more pressure with

your pleximeter before you try to percuss.

Certain Diseases with usual findings

Asthma

Reversible obstructive lung disease that is usually

caused by atopy or allergy or triggered by certain

allergens. And just like any obstructive lung disease, you would

expect to have air trapping thats why if you have

air-trapping, you have hyperinflation, you would

expect to have hyperresonance upon percussion.

In inspection, you would see the patient is dyspneic,

using of accessory muscles upon breathing, and

cyanosis.

On palpation, it is often normal but it might cause a

decrease in fremitus as well. Aside from being

hyperresonance, you will have a low lying diaphragm

as well.

Emphysema

Another obstructive lung disease.

You would expect to have increase in AP diameter,

use of accessory muscles, and the patient would

appear relatively thin. (LIKE ME :p)

Emphysema in chronic bronchitis is part of your

COPD (Chronic Obstructive Pulmonary Disease).

oThe only thing that we try to do is to probably

say that the COPD is predominantly emphysema

or predominantly bronchitic.

oMore often, both these things happen in a

patient with COPD.

The patient with emphysema would have decreased

fremitus, increase resonance, and decreased

excursion of the diaphragm.

Chronic Bronchitis

Present with cyanosis, they are short and stacky

Often with normal palpation and percussion.

Pneumothorax

Air in the pleural space.

Often normal or may have a lack on the affected

side.

It is normal if there is only minimal pneumothorax.

In summary, in percussion, you will report

the normal findings as resonance on all lungfield except on the area of cardiac dullness.

If you report otherwise, then it indicates

some other diseases.


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On palpation, there might be absent fremitus and if

there is tension pneumothorax, you will appreciate

deviation of your trachea to your contralateral side.

On percussion, it is hyperresonant.

Pneumonia

Common infection of the lung parenchyma.

The patient may present with possible cyanosis, and

splinting on the affected side, increased fremitus,

dullness on percussion.

Theres a special resonance that can be appreciated

(also in patient with pneumohydrothorax) skodaic

resonance or tympany.

o you would have dullness in the area and

have consolidation but just above it you

would appreciate hyperresonance or almost

tympany.

o It can also appreciated inpneumohydrothorax where you have both

air and fluid in the pleura.

In the area where you have fluid,

you have dullness. The area where

you have air in the pleura, you will

have hyperresonance or tympany

upon percussion.

Pleural Effusion

Usually present with lag on affected side or if it is

minimal it can have normal lung expansion.

On palpation, you would have a decrease infremitus, and the trachea is shifted to the

contralateral side.

On percussion, it would be dull.

Atelectasis

It can be normal if there is only a segmental

atelectasis but if it is a lobar atelectasis or atelectasis

of the whole lung then you would expect lag on the

affected side, decrease in fremitus and shifting of

the trachea to the affected side or ipsilaterally.

There is dullness on percussion.

Acute Respiratory Distress Syndrome (ARDS)

Upon inspection, the patient is using accessory

muscles upon breathing and cyanosis, but the

percussion and palpation may be normal.

Pulmonary Embolism

normal physical examination. You would need to

have a good clinical eye. Probably look for risk

factors. And have a high index of suspicion before

you make a diagnosis of pulmonary embolism.

Pulmonary edema or congestion

It might also have inspection but in severe

congestion you might have dyspnea.

Upon palpation and percussion it would be normal.

There might have fine crackles when you have

congestion.

On the left, anterior sequence of percussing the chest while on

the right picture shows posterior examination of the chest

Relativeintensity

Relativepitch

Relativeduration

location Examples

Flatness Soft high Short Thigh Pleural effusion

Dullness Medium Medium Medium Liver Lobar

pneumonia

Resonance Loud Low Long Normal lung Chronic

bronchitis

Hyperresonance Very loud Lower longer None Emphysema,

pneumothorax

tympany loud High Gastric air

bubble

Large

pneumothorax


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Differentiation of Common Pulmonary Conditions

Condition Inspection Palpation Percussion Auscultation

Asthma Dyspnea; use of

accessory muscles;

poss. Cyanosis;

hyperinflation

Often normal,

decreased fremitus

Often normal;

hyperresonant; low

diaphragm.

Prolonged

expiration; wheezes;

decreased lung

sounds

Emphysema Increased AP

diameter; use of

accessory muscles;

thin

Decreased fremitus Increased

resonance;

decreased excursion

of diaphragm

Decreased lung

sounds and vocal

fremitus

Chronic Bronchitis Poss. Cyanosis;short, stocky

Often normal Often normal Early crackles;rhonchi

Pneumothorax Often normal; lag on

affected side

Absent fremitus;

trachea shifted to

contralateral

Hyperresonant Absent breath

sounds

Pneumonia Poss. Cyanosis and

splinting on affected

side

Increased fremitus Dull Late crackles;

bronchial breath

sounds

Pleural Effusion Often normal; lag on

affected side

Decreased fremitus;

trachea shifted to

contralateral

Dull Absent breath

sounds

Atelectasis Often normal; lag on

affected side

Decreased fremitus;

trachea shifted to

ipsilateral

Dull Absent breath

sounds

ARDS Use of accessory

muscles; cyanosis

Usually normal Often normal Normal initially;

crackles and

decreased lung

sounds

Pulmonary

Embolism

Often normal Usually normal Usually normal Usually normal

Pulmonary Edema Often normal Often normal Often normal Early crackles;

wheezes

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Hi batchmates! Galingan natin!

Thank you Jener sa pagtulong sakin sa last 20 mins of recording.. Nakakapagod tranx na to hmp!

Pag may tanong kayo guys, or tingin nyo na mali sabihin nyo lang.. or dedma haha! Goodluck satin!

Number of noh?: 133

chest and lungs 1

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