PHYSICAL DIAGNOSIS

PHYSICAL PHYSICAL DIAGNOSISDIAGNOSIS

CHESTCHEST

INTRODUCTIONINTRODUCTIONThough 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.

INTRODUCTIONINTRODUCTIONExperience 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 LANDMARKSLINE LANDMARKS

On the anterior surfaceAnterior midline (midsternal line):is located

in the middle of the sternumMidclavicular line (left and right):runs di

rectly downward from the midpoint of each clavicle

LINE LANDMARKSLINE LANDMARKSOn the anterior surfaceSternal line(left and right):vertical line

runs along the vertical edges of the sternum and parallels to the anterior midline.

LINE LANDMARKSLINE LANDMARKSOn 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 LANDMARKSLINE 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 LANDMARKSBONE LANDMARKSOn 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 LANDMARKSBONE LANDMARKS

RibA 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.


InterspaceThe space between two adjacent ribs,

used to mark the position of any lesion.

Beneath the first rib is the first interspace, and so forth.


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.


ScapulaIts inferior end is called inferior angl

e. 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 NATURAL FOSSA AND ANATOMIC REGIONANATOMIC REGION

On the anterior thorax:Suprasternal fossa,supraclavicular fossa(left,right),i

nfraclavicular fossa(left,right)

On the lateral wall of the chest: Axillary fossa(left,right)On the posterior thorax:Suprascapular region (left,right),infrascapular regio

n (left,right),interscapular region

The boundary of lung and The boundary of lung and pleurapleura

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 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.


PleuraVisceral pleura:the pleura covering the s

urface of the lung Parietal pleura: the pleura covering the in

ner 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

INSPECTIONINSPECTION

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

INSPECTIONINSPECTION4. A thorough knowledge of topographic

anatomy5. 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.

INSPECTIONINSPECTIONNormal 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.


Normal thorax

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


what to observe

1.First: the general nutrition and musculoskeletal development 2.Next: the skin and breasts

3.vein and subcutaneous emphysema

INSPECTIONINSPECTION4.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


6.retraction or bulging of interspaces

• Retraction of the interspaces: obstruction of the respiratory tract

• Bulging of interspaces : a massive pleural effusion,tension pneumothorax


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

INSPECTIONINSPECTION8.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

INSPECTIONINSPECTION9.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)

INSPECTIONINSPECTION9.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)


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

INSPECTIONINSPECTION9.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.

INSPECTIONINSPECTION9.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.

INSPECTIONINSPECTION9.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

FremitusVocal 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.

PALPATIONNormal 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

PALPATIONIn 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.

PALPATIONAlso 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.

PALPATIONAlternations 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

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 friction fremitusWhen 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.

PALPATIONCrepitationCrepitation 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.

PERCUSSIONPERCUSSION

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


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.


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.

PERCUSSIONPERCUSSION 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.

PERCUSSIONPERCUSSIONTo 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.


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.


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.


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.


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

PERCUSSIONPERCUSSIONAnalysis 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.

PERCUSSIONPERCUSSIONPercussion sounds 1. Resonance: the sounds heard

normally over lungs2. Hyperresonance: The hyperresonant

note in the adult is commonly the result of emphysema and occasionally pneumothorax.


Percussion sounds3. 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.

PERCUSSIONPERCUSSIONPercussion sounds4.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.

PERCUSSIONPERCUSSIONPercussion sounds5. 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.

PERCUSSIONPERCUSSIONPercussion 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 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).

PERCUSSIONPERCUSSIONPercussion 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 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 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 sounds Also the change from pulmonary reso

nance 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 sounds There is also dullness to the left of the s

ternum,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.

PERCUSSIONPERCUSSION 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.


The lateral recumbent position causes the following changes:


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.


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.


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.


(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.


(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.

PERCUSSIONPERCUSSIONDiaphragmatic 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.


Diaphragmatic excursionThird,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 .


Diaphragmatic excursionThe normal diaphragmatic excursion is

about 6 to 8 cm. It is decreased in patients with pleurisy

and severe emphysema.

PERCUSSIONPERCUSSIONThe 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 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.

AUSCULTATIONAUSCULTATION

Breath sounds--normal

VesicularThe 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.

VesicularIt 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.

BronchovesicularIn 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.

BronchovesicularThis 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.

BronchovesicularIn bronchovesicular breathing the inspirator

y 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.


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 breathingBronchial 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 t

issue,happening in COPD etc.

Hoarse breath soundHoarse breath soundDue to smoothlessness or stricture prod

uced 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 soundsl.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 sounds3. If there is thickened pleura caused by fib

rosis -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 sounds4. 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.


voice sounds--normal

Vocal resonanceVocal 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.


Voice sounds--abnormal

BronchophonyBronchophony 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.

PectoriloquyAlthough 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.

EgophonyEgophony 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 resonanceVocal 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 resonanceIt 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.


Adventitious sounds

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

RalesThey 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.

RalesAccording 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 falesFine 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 ralesCoarse 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.

RhonchiRhonchi 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 rhonchiSibilant 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 rhonchiSonorous 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 rubThe 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 rubThe 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.

InspectionInspection

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.

InspectionInspectionIn large effusions the affected side app

ears 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 Palpation first confirms the observation mad

e 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.

PercussionPercussion

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.

PercussionPercussionWhen the effusion is on the right side, the d

ullness 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 Auscultation Early in the disease a friction rub may be he

ard, which, however, soon disappears. The breath sounds are diminished or absent

over the area of the effusion. Bronchovesicular breath sounds are often he

ard at the upper limit of the fluid, because of the compressed underlying lung.

AuscultationAuscultationThe vocal resonance is diminished or a

bsent over effusion. The whispered voice may be intensifi

ed ----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.


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 Palpation The diminished respiratory movements on t

he 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.


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

AuscultationAuscultationIn the early stages of lobar pneumonia, the bre

ath 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.

AuscultationAuscultationDuring resolution ,the cyanosis and tachypne

a 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.


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.

PalpationPalpation

The trachea is in the midline position. The tactile fremitus is diminished over

both side of the chest. The chest movement is restricted but e

qual bilaterally. The apex beat cannot be felt.


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 e

xpiration, percussion over the bases of the lung in the back shows little change in the lower limits of lung resonance.

AuscultationAuscultation

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 Inspection The chest on the affected side looks fla

t, the intercostal spaces narrowed and depressed.

The respiratory movements are markedly diminished, while there is increased expansion over the normal side.

PalpationPalpation

The tactile fremitus is usually decreased or absent over the affected side.

The trachea is deviated to the affected side.


Percussion shows that the heart is displaced toward the affected side.

The percussion note over the affected lung is usually dull.


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.


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.

PalpationPalpation

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 Percussion The percussion note over the affected s

ide is usually hyperresonant or tympanic.


The vocal resonance is usually diminished.

The breath sound are markedly diminished on the affected side and exaggerated on the normal side.

PHYSICAL DIAGNOSIS

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