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