Respiratory system examination by waheed

1. 1

2. • Upper respiratory tract and a lower respiratory tract.
• Conducting portion transports air.
– includes the nose, nasal cavity, pharynx, larynx, trachea,
and progressively smaller airways, from the primary
bronchi to the bronchioles
• Respiratory portion carries out gas exchange.
– composed of small airways called respiratory bronchioles
and alveolar ducts as well as air sacs called alveoli
2

3. Anatomy of the respiratory system
3

4. • A flexible, slightly rigid tubular organ
often referred to as the “windpipe.”
• Extends through the mediastinum and
lies immediately anterior to the
esophagus, inferior to the larynx, and
superior to the primary bronchi of the
lungs.
• Anterior and lateral walls of the
trachea are supported by 15 to 20 C-
shaped tracheal cartilages.
– cartilage rings reinforce and
provide some rigidity to the
tracheal wall to ensure that the
trachea remains open (patent) at all
times
– cartilage rings are connected by
elastic sheets called annular
ligaments
4

5. Cont..
• At the level of the sternal angle, the trachea bifurcates into two
smaller tubes, called the right and left primary bronchi.
• Each primary bronchus projects laterally toward each lung.
• The most inferior tracheal cartilage separates the primary
bronchi at their origin and forms an internal ridge called the
carina.
5

6. • A highly branched system of air-conducting passages that
originate from the left and right primary bronchi.
• Progressively branch into narrower tubes as they diverge
throughout the lungs before terminating in terminal
bronchioles.
• Incomplete rings of hyaline cartilage support the walls of the
primary bronchi to ensure that they remain open.
• Right primary bronchus is shorter, wider, and more vertically
oriented than the left primary bronchus.
• Foreign particles are more likely to lodge in the right
primary bronchus.
6

8. Cont…
• The primary bronchi enter the hilum of each lung together
with the pulmonary vessels, lymphatic vessels, and nerves.
• Each primary bronchus then branches into several secondary
bronchi (or lobar bronchi).
• The left lung has two secondary bronchi since it has two lobes.
• The right lung has three lobes and three secondary bronchi.
• They further divide into tertiary bronchi.
• The right lung is supplied by 10 tertiary bronchi, and the left
lung is supplied by 8 to 10 tertiary bronchi.
• Each tertiary bronchus is called a segmental bronchus because
it supplies a part of the lung called a broncho-pulmonary
segment.
8

9. • Contain small saccular out-pocketing called alveoli.
• An alveolus is about 0.25 to 0.5 millimeter in diameter.
• Its thin wall is specialized to promote diffusion of gases
between the alveolus and the blood in the pulmonary
capillaries.
• Gas exchange can take place in the respiratory bronchioles
and alveolar ducts as well as in the lungs, which contain
approximately 300–400 million alveoli.
• The spongy nature of the lung is due to the packing of
millions of alveoli together
9

11. Respiratory Bronchioles,
Alveolar Ducts & Alveoli
11

12. • Each lung has a conical shape.
• Its wide, concave base rests upon the muscular diaphragm.
• Its relatively blunt superior region, called the apex or (cupola),
projects superiorly to a point that is slightly superior and
posterior to the clavicle.
• Both lungs are bordered by the thoracic wall anteriorly,
laterally,
and posteriorly, and supported by the rib cage.
• Toward the midline, the lungs are separated from each other
by the mediastinum.
• The relatively broad, rounded surface in contact with the
thoracic wall is called the costal surface of the lung.
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13. 13

14. 14

15. 15

16. • The outer surface of each lung and the adjacent internal
thoracic wall are lined by a serous membrane called pleura,
which is formed from simple squamous epithelium.
• The outer surface of each lung is tightly covered by the
visceral pleura, while the internal thoracic walls, the lateral
surfaces of the mediastinum, and the superior surface of the
diaphragm are lined by the parietal pleura.
• The parietal and visceral pleural layers are continuous at the
hilum of each lung.
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17. 17

18. • Symptoms of the respiratory tract
• History of previous illness
• Family history
• Envoironmental exposure
• Cigarette smoking
• Occupational history
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19. • Cough
• Sputum
• Haemoptysis
• Dyspnea
• Chest pain
• Wheeze
19

20. • Anxious expression
• Suprasternal & intercostal retractions
• Nasal flaring
• Circumoral cyanosis
• Hyperexpanded chest
– ALWAYS REMEMBER YOUR ABCs

21. • It occurs when deep inspiration is followed by explosive
expiration
• Coughing enables the airways to be cleared of secretions and
foreign bodies
• The duration of a cough is important
– A cough of recent origin, particularly if associated with
fever and other symptoms of respiratory tract infection, may
be due to acute bronchitis or pneumonia
• Chronic cough associated with wheezing may be due to
asthma; or COPD.
21

22. Cont…
• An irritating chronic dry cough can result
– oesophageal reflux
– interstitial pulmonary fibrosis.
– angiotensin-converting enzyme (ACE) inhibitors-drugs
• Cough that wakes a patient from sleep may be a symptom of
cardiac failure or GERD
• A chronic cough that is productive of large volumes of purulent
sputum may be due to bronchiectasis.
• A change in the character of a chronic cough may indicate the
development of a new and serious underlying problem (e.g.
infection or lung cancer).
22

23. Cont…
• Patients' descriptions of their cough may be helpful. A cough
associated with inflammation of the
– Epiglottitis causes a Barking quality cough
– Tracheal compression by a tumor causes a Loud and Brassy
cough
– Cough associated with recurrent laryngeal nerve palsy has a
hollow sound because the vocal cords are unable to close
completely; this has been described as a Bovine cough.
– Cough that is worse at night is suggestive of asthma or heart
failure
– Coughing that comes on immediately after eating or
drinking may be due to a tracheo-oesophageal fistula or
oesophageal reflux.
23

24. • It is an important (though perhaps a somewhat unpleasant
task) to inquire about the type of sputum produced and then
to look at it, if it is available.
• A large volume of purulent (yellow or green) sputum
suggests the diagnosis of bronchiectasis or lobar pneumonia.
• Foul-smelling dark-coloured sputum may indicate the
presence of a lung abscess with anaerobic organisms.
• Pink frothy secretions from the trachea, which occur in
pulmonary oedema, should not be confused with sputum.
• Haemoptysis (coughing up of blood) can be a sinister sign of
lung disease and must always be investigated.
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25. • Bronchitis
• Bronchial carcinoma
• Bronchiectasis
• Pneumonia (The above four account for about 80% of cases)
• Pulmonary infarction
• Cystic fibrosis
• Lung abscess
• Tuberculosis
• Foreign body
• Goodpasture's syndrome
• Cardiovascular Mitral stenosis (severe), Acute left ventricular
failure
• Bleeding diatheses
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26. • The awareness that an abnormal amount of work is required
for breathing is called dyspnea. It can be due to respiratory or
cardiac disease .
• Careful questioning about the timing of onset, severity and
pattern of dyspnea is helpful in making the diagnosis. The
patient may be aware of this only on heavy exertion or have
much more limited exercise tolerance. Dyspnoea can be
graded from I to IV based on the New York Heart Association
classification:
– Class I - dyspnea only on heavy exertion
– Class II - dyspnea on moderate exertion
– Class III- dyspnea on minimal exertion
– Class IV- dyspnea at rest
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27. Cont…
• Dyspnea with wheeze suggests airways disease, which may be
due to asthma or chronic obstructive pulmonary disease.
• The duration and variability of the dyspnoea are important.
– Dyspnea that worsens progressively over a period of weeks,
months or years may be due to pulmonary fibrosis.
– Dyspnea of more rapid onset may be due to an acute
respiratory infection (including bronchopneumonia or lobar
pneumonia) or to pneumonitis (which may be infective or
secondary to a hypersensitivity reaction) or acute pulmonary
edema.
27

28. Cont…
• Dyspnea that varies from day to day or even from hour
to hour suggests a diagnosis of asthma.
• Dyspnea of very rapid onset associated with sharp chest
pain suggests a pneumothorax.
• Dyspnea that is described by the patient as inability to
take a breath big enough to fill the lungs and associated
with sighing suggests anxiety.
• Dyspnea that occurs on moderate exertion may be due
to the combination of obesity and a lack of physical
fitness (a not uncommon occurrence).

29. • Introduction, Patient Identification & Consent
• Infection Control Measures
Wash your hands and cleanse your stethoscope with
alcohol wipe.
• Patient Position
Have the patient undress to the waist, ideally sitting on
the edge of the bed.
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30. • Around the patients bed side:
– Is the patient using oxygen? Is there a nebulizer present? Do
you notice a sputum cup? What appearance does the sputum
have? Mucoid? Purulent? Mucopurulent? Blood stained?
• General patient observations:
– Does the patient look distressed? ( anxious, tachypneic,
diaphoretic)
– Are they using their accessory muscles of respiration?
(typically sternomastoids, platysma and strap muscles of the
neck)
– Are they breathing with pursed lips?
– Do they appear cachectic?
– Do they have signs of anaemia (a cause of shortness of breath)
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31. • Does the patient appear hoarse while talking?
– Commonest cause is laryngitis but may indicate in some
patients recurrent laryngeal nerve palsy associated with
lung carcinoma or vocal cord pathology
• Are they able to talk in full sentences or in short sentences due to
shortness of breath?
• Is there any Stridor present ?
– A rasping noise on inspiration ~ Usually signifies partial
obstruction of larynx, trachea or larger airways e.g. due to
infection / inflammation of the epiglottitis, foreign body in
the airway
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32. • Observe for finger clubbing:
• The normal angle between the nail and the cuticle immediately
proximal to the nail is around 140 degrees. The increase of this angle is
the cardinal feature of finger clubbing.
• Loss of the normal angle is often accompanied by sponginess of the
nail bed and increased longitudinal and lateral curvature of the nail
itself.
– In severe forms, the adjacent periosteum may also be involved, this
is known as hypertropic pulmonary osteoarthopathy (HPOA).
– Finger clubbing is commonly caused by intrathoracic disease (e.g.
Lung cancer, bronchiectasis, empyema, lung abcess, pulmonary
fibrosis, cystic fibrosis).
– Other systems can cause finger clubbing (e.g. Cardiovascular–
cyanotic congenital heart disease; Gastrointestinal–liver cirrhosis,
inflammatory bowel disease, coeliac disease
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33. • A patient with finger clubbing
due to pulmonary fibrosis
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o Nicotine staining on a patient
who smokes cigarettes

34. Cont…
• Small muscle wasting:
– Observe for any wasting of the small muscles of the hand.
– Compression on the brachial plexus by peripheral lung tumors may
result in wasting of the small muscles of hand
• Cyanosis:
– Cyanosis is a bluish coloration of the skin and mucous membranes. It
may be divided into central and peripheral.
• Central cyanosis
– Results from incomplete oxygenation of blood as in lung disease or
from the admixture of venous and arterial blood as in venous/arterial
shunts. In this case the cyanosis is general and the cyanosed extremities
warm.
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35. Cont…
• Peripheral cyanosis
– Results from the excess extraction of oxygen in the capillaries when
blood flow is slowed.
• This may happen on exposure to cold, with a low
cardiac output or with venous obstruction. The
cyanosed extremity will be cold.
• There must be a concentration of >5g/dl of
deoxygenated haemoglobin before cyanosis can be
appreciated.
• If there is anaemia, cyanosis may not be seen even in
severe hypoxia.
• The converse is true in polycythaemia.
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36. Cont…
• Tremor present?
– Ask the patient to put out their arms straight in front of them and fan
their fingers apart. Now ask them to dorsiflex their wrists and then
close their eyes. Do you notice any tremor?
– A fine tremor may indicate use of a beta 2 adrenoceptor agonist (e.g.
salbutamol )
– A flapping tremor may indicate CO2 retention (however this can be a
late and unreliable sign for CO2 retention)
• Pulse:
Increase rate (i.e. tachycardia) may indicate respiratory disease (e.g. in
severe asthma). Increased pulse volume may be present in CO2 retention.
Pulsus paradoxus present?
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37. Observe for central cyanosis: Look under the
tongue for a blue tinge
37

38. – Palpate the trachea to assess for possible deviation.
From in front of the patient gently place the index
and middle fingers on either side of the trachea in
the suprasternal notch
– In a normal patient the trachea will be placed in the
centre. If there is deviation to one side there will be
a bigger gap on one side compared to the other
– Reduction in the normal three to four fingers' width
from the suprasternal notch to cricoid cartilage
suggests over inflation of the chest.
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39. • Causes of Tracheal
displacement:
• TOWARDS THE SIDE OF
THE LUNG LESION
– Upper lobe collapse
– Fibrosis
• AWAY FROM THE SIDE
OF THE LUNG LESION
– Pleural effusion
– Tension pneumothorax
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40. • Inspect the neck for asymmetry, scars, or other lesions.
• Palpate the neck to detect areas of tenderness, deformity, or
masses.
• Systematically palpate with the pads of your index and middle
fingers for the various lymph node groups.
– Preauricular - In front of the ear
– Postauricular - Behind the ear
– Occipital - At the base of the skull
– Tonsillar - At the angle of the jaw
– Submandibular - Under the jaw on the side
– Submental - Under the jaw in the midline
– Superficial (Anterior) Cervical - Over and in front of the
sternomastoid muscle
– Supraclavicular - In the angle of the sternomastoid and the
clavicle
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41. Cont…
• The deep cervical chain of lymph nodes lies below the
sternomastoid and cannot be palpated without getting
underneath the muscle:
– Inform the patient that this procedure will cause some
discomfort.
– Hook your fingers under the anterior edge of the
sternomastoid muscle.
– Ask the patient to bend their neck toward the side you are
examining.
– Move the muscle backward and palpate for the deep nodes
underneath.
• Note the size and location of any palpable nodes and whether
they were soft or hard, non-tender or tender, and mobile or
fixed.

42. Lymph nodes

43.  Inspect the neck looking for the
thyroid gland. Note whether it is
visible and symmetrical. A visibly
enlarged thyroid gland is called a
goiter.
 Move to a position behind the
patient.
 Identify the cricoid cartilage with
the fingers of both hands
 Move downward two or three
tracheal rings while palpating for
the isthmus
 Move laterally from the midline
while palpating for the lobes of the
thyroid
 Note the size, symmetry, and
position of the lobes, as well as the
presence of any nodules. The
normal gland is often not palpable
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44. • A raised jugular venous pressure (JVP) may indicate right
heart problems secondary to chronic lung disease or
pulmonary embolism. In patients with airflow obstruction
the high pressure changes in the thorax often make it
difficult to assess jugular venous pressure. A fixed and
non-pulsatile pressure could be due to obstruction of the
superior vena cava, usually caused by tumour in the
mediastinum.
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45. • Are there any chest wall
deformities? (e.g.
pectus excavatum /
pectus carinatum)
• Does the chest appear
over expanded? (i.e.
Barrel shaped chest )
• Is there any Kyphosis or
Scoliosis present?
• Abnormal retraction
• Impaired movement
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PECTUS EXCAVATUM
PECTUS CARINATUM (PEGION CHEST)

46. Barrel Chest

47. Bony Thoracic cage

48. Posterior thorax

49. • Often when you tell a patient that you are measuring
their respiratory rate they often tend to breath slower
or faster.
• Therefore respiratory rate is often measured
surreptitiously by observing the respiratory
movements of the chest wall, while placing you
fingers over the patient's radial pulse and telling them
that you are “Taking their pulse” where as in fact you
are measuring their respiratory rate!
• The normal respiratory rate in an adult is 12 breaths
per minute. A raised respiratory rate is called
tachypnea
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50. • Palpate for any mass,
tenderness, crepitus
• Apex beat:
The apex beat is often
impalpable in a chest which is
hyper-expanded secondary to
chronic airflow obstruction.
– Movement of the apex beat
from one side to the other
may be caused by several
conditions including
pleural effusion, tension
pneumothorax
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Location of the apex beat

51. • By assessing chest expansion the examiner aims to assess
the range and symmetry of chest wall movements.
• Place your hands firmly on the chest wall, with your thumbs
slightly lifted off the chest so that they are free to move with
respiration (placing your thumbs up provides the examiner
with a visible marker to assess the range and symmetry of
chest wall movements).
• Ask the patient to take a deep breath in and observe the
range and symmetry of movement.
• Reduced expansion on one side indicates a lesion on that
side. This should be performed on the front and the back of
the patient’s chest
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52. Assessment of chest
wall expansion
52

53. 53
Assessment of posterior
chest wall expansion

54. • Palpable vibrations transmitted through the broncho-
pulmonary tree to the chest wall when the patient
speaks.
• Ask the patient to repeat ‘99” or “1,1,1” while placing
the ball of your hand or the ulnar surface of your hand
on symmetrical parts of the chest
• Increased in consolidation
• Decreased in pneumothorax, pleural effusion, pleural
thickening, emphysema
54

55. • By percussing the patients chest wall will provide the
examiner with useful information about the patients lungs.
• Students often find difficulty performing percussion for the
first time - but with practice it will improve.
• It is important to note that the examiners finger nails need to
be short to avoid self injury!
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56. • Place you hand on the
patients chest wall with the
fingers slightly separated
and aligned with the ribs
and pressing the middle
finger firmly against the
chest.
56

57. Cont…
• With the other hand (usually
the middle finger) strike
firmly the middle phalanx of
the middle finger that is on
the patients chest wall.
• The percussing finger is
removed quickly – therefore
not to dampen the generated
noise.
• The percussing finger should
be held partly flexed and a
loose swinging motion should
come form the wrist
57

58. Cont…
• When percussing the
anterior chest wall start in
the supraclavicular area
• Percuss the clavicle directly
with the percussing finger
• Then the rest of the anterior
chest wall
• Do not forget to percuss the
axilla.
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Areas to percuss in the
anterior chest wall

60. Cont…
• When percussing the
posterior aspect of the chest,
the scapula should be
moved out of the way.
• Therefore ask the patient to
move their arms forward –
by doing this will rotate
their scapula anterioly.
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Areas to percuss in the
posterior chest wall

61. • “Resonant”
– When percussing a normal chest the noise generated should be
resonant.
• “Dull”
– when percussing over a solid structure (such as the liver or a
consolidated lung) produces a dull note.
• “Stony dull”
– Percussion over a fluid filled area such as a pleural effusion produces a
stony dull note.
• “Hyper-resonant”
– Percussion over hollow structures (e.g. pneumothorax) may produce a
hyper-resonant note – such as a pneumothorax.
• “Tympanatic”
– High pitched sound while percussing gastric air bubble
61

62. Diaphragmatic Excursion
• Reason for Assessing Diaphragmatic Excursion-to determine
the movement of diaphragm that occurs during inspiration.
Possible reasons for decreased descent include: atelectasis of
lower lobes, emphysema, pleural effusion, pain, abdominal
changes such as tumors and extreme ascites.
• Normal range of diaphragm movement: 3-5cm but may be up
to 7-8cm in well conditioned people.
Procedure:
1. First, ask the person to take "exhale and hold it" while you
percuss down the left scapular line until the sound changes
from resonant to dull. Mark the area. This estimates the level
of the diaphragm separating the lungs from the abdominal
viscera.

63. Cont…
2. Allow the patient to take a few normal breaths. Then, ask the
person to "take a deep breath and hold it." Continue
percussing down from the first mark to the level where the
sound changes to dull. Mark the area.
3. Measure the two marks. Repeat the same procedure on the
right side. It should be equal bilaterally and measure about 3-
5 cm. in adults. It may be up to 7-8 cm. in well-conditioned
people.
4. Level of the diaphragm may be higher on the right side
because of the liver.

64. • When listening to the patients chest the diaphragm component of
the stethoscope is usually used
• Instruct the patient to breath in and out with an open mouth every
time you move the stethoscope
• Listen both to the supraclavicular areas, anterior, axillary and
posterior aspects of the chest
• Remember to compare left with right at each level
• Auscultation of the lungs allows an appreciation of the intensity
and quality of breath sounds and the presence of additional
sounds best described as crackles, wheezes, and rubs.
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65. Areas to auscultate in the anterior chest wall
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66. Areas to auscultate in the posterior chest wall
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67. • Breath sounds are produced by vibrations due to turbulent airflow
through out the airways. These sounds are transmitted through the
smaller airways and lungs to the chest wall
• Vesicular breath sounds :
– The intensity of the sounds increase during inspiration
and then fade away during the first third of expiration.
– Low pitched
67

68. Cont…
• Bronchial breath sounds:
– Expiration is longer than inspiration. They result from
enhanced transmission of higher frequency sounds through
solid lung tissue as in consolidation, pulmonary edema
• Bronchovescicular:
– Inspiration and expiration are equal. Typically heard in the
1st
and the 2nd
interspaces and between the scapulae
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69. Cont…
• Intensity of the breath sounds:
– Usually described as being normal, reduced or absent. It is
important to compare air entry in all areas of the chest. For
example breath sounds may be absent locally over a
pneumothorax or a pleural effusion.
69

70. • Wheeze (also known as rhonchi)
– Musical sounds produced by the passage of air
through narrowed airways (e.g. when there is spasm
of the bronchi in asthma)
– Polyphonic wheezes in expiration are heard in
asthma and chronic obstructive pulmonary disease.
– A focal monophonic wheeze in inspiration,
expiration, or both suggests a localised area of large
airway narrowing caused by a foreign body or
possibly a tumor.
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71. Cont…
• Crepitations (also known as crackles)
– Crackles are non-musical sounds which derive from the
sudden opening of collapsed airways. Crackles that clear
on coughing are usually not significant.
• Early inspiratory crackles are heard most often in chronic
bronchitis and emphysema, are fairly coarse, and change with
coughing.
• Late inspiratory crackles occur as fine runs at the end of
inspiration; they are found at the lung bases in restrictive
conditions such as fibrosing alveolitis and pulmonary oedema.
• Mid inspiratory and expiratory crackles are heard in
bronchiectasis
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72. Cont…
• Mediastinal Crunch: A series of crackles
synchronous with the heart beat, not with respiration
– Best heard in the left lateral position
– Due to pneumomediastinum
• Pleural rub: A pleural rub is a ‘leathery’ noise produced
when inflamed or abnormal layers of pleura move over each
other. It is often likened to the squeaking noise when walking
in fresh snow
– Usually confined to a small area of the chest wall
– Heard in both phases of respiration
72

73. • Auscultation of the chest while the patient speaks can
provide extra information about the patient’s lungs.
– Bronchophony: Ask the patient to say "99" every time
you change your stethoscope position over the patients
chest wall. Vocal resonance is increased over solid areas
of lung with open airways - for example, consolidation;
and decreased by pleural fluid.
– Egophony: Ask the patient to say “ee”, normally a
muffled long E sound comes; in consolidation a nasal
“ay” sound is heard
– Whispered Pectoriloquy: Ask the patient to whisper “99”
or “1,2,3”. Normally faint sound is heard. In consolidation
a loud and clear sound is heard
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74. Reference
• World Wide Web page Richard. R, Physical
examination of Chest [online] May 1, 1996
[cited 2000 Dec 19]. Available from: URL:
http://medinfo.ufl.edu/year1/bcs/clist/chest.html
• Bickly L.S, B.(2011) Bates guide to physical
examination and history taking (10th
ed).Philadelphia: J.B.Lippincott
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