Chest Year 1 Year 2 Year 3 Do Do Know 1. Inspection: • Assess for diaphragmatic excursion if atelectasis, • Bronchial (or tubular) breath sounds are • With patient seated observe posture, respiratory diaphragmatic paralysis is suspected abnormal, high pitched sounds heard over rate, depth and effort and look for • If consolidation is suspected clinically assess for consolidated lung connected to a patent presence/absence of distress such as grunting , vocal resonance in addition to tactile vocal fremitus bronchus. Consolidated lung increases nasal flaring and pursed lip breathing. by asking the patient to say “E” and auscultate over transmission of airway sounds. • Observe shape of chest, (spine, ribs and sternum) suspected consolidation. “E” will sound like “A”. • Adventitial breath sounds are abnormal and symmetry of chest movement, paying Know -Crackles (historically “rales”): attention to asynchronous contraction of the • Patients with respiratory distress may have accessory Fine- like fine hairs being rubbed, occurs when diaphragm and intercostals (paradoxical muscle use, nasal flaring, intercostals retractions or partially collapsed airways open during respiration). paradoxical abdominal movements. This is detected inspiration. Collapse may be caused by • Observe abnormalities of the chest by inspection. scarring, pus (pneumonia), blood (alveolar surface.(pigmentation, collateral circulation. Skin • Tracheal deviations occur with tumors, pleural hemorrhage), fluid (pulmonary edema). lesions, etc). effusions or tension pneumothorax. -Wheezes: high pitched, musical sounds caused • • Tactile fremitus is vibration felt by the clinician’s by airflow through tightly constricted airways 2. Palpation: hand when the patient speaks. (eg. asthma, tumor obstruction) • Confirm trachea midline position • Asymmetric areas of increased tactile fremitus -Rhonchi: low pitched “snoring” sounds • Place hands on posterior chest wall to confirm (vibration) occurs with consolidation caused by partial airway obstruction from equal expansion. Ask the patient to exhale • Asymmetric areas of decreased tactile fremitus mucus or foreign body, or endobronchial completely, closing in with both hands and occurs with pleural effusion, pneumothorax or large tumors. juxtaposed thumbs, then take a deep breath. pulmonary blebs. -Pleural rubs: loud, creaky “sandpaper” • Assess vocal tactile fremitus by placing hands • Dullness to percussion occurs when normal lung is sounds caused by inflamed visceral and parietal sequentially over various areas of the chest and filled with or displaced by fluid or solid tissue (eg pleura rubbing together. ask patient to say, “99” or 1-2-2 or Eeeee. Check effusion, pneumonia, tumor, pleural thickening) -Stridor: Whistling or shrieking sounds caused by upper airway partial obstruction. Inspiratory if asymmetric breath sounds are present. • Hyperresonance to percussion occurs when normal • Explore supraclavicular and axillary fossae for lung is replaced by air (eg. pneumothorax or stridor is caused by upper airway obstruction enlarged lymph nodes. emphysema) and expiratory stridor is caused by lower airway obstruction (eg. aspiration). 3. Percussion: • A barrel shaped chest may be seen in Chronic • Percuss anteriorly and posteriorly at each level Obstructive Pulmonary Disease from apices to bases comparing sides. The pleximeter finger should be firmly in the intercostal space, with the other fingers providing support. The percussing finger should strike the distal interphalangeal joint. • Percuss spine and costovertebral angle for tenderness 4. Auscultation • Auscultate with diaphragm firmly on bare skin listening to chest for a full inhalation and exhalation,comparing right and left at each level (posteriorly in 6 areas, laterally in mid-axillary line from apex to base, and anteriorly at apex and base) Know • Normal lung is resonant to percussion • Vesicular breath sounds are normal