The document provides a framework for assessing clinical conditions of the chest through percussion notes, adventitious sounds, tactile fremitus and transmitted voice sounds, and breath sounds. It compares these findings for normal lungs versus conditions such as chronic bronchitis, left-sided heart failure, consolidation, atelectasis, pleural effusion, pneumothorax, chronic obstructive pulmonary disease, and asthma. The table acts as a guide for how physical exam findings may change with different chest disorders and their locations and severity.

1. The black boxes in this table suggest a framework for clinical assessment. Start with
the three boxes under Percussion Note: resonant, dull, and hyperresonant. Then
move from each of these to other boxes that emphasize some of the key differences
among various conditions. The changes described vary with the extent and severity
Condition
Normal
BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
The tracheobronchial tree and
alveoli are clear; pleurae are
thin and close together;
mobility of the chest wall
is unimpaired.
Chronic Bronchitis
The bronchi are chronically
inflamed and a productive
cough is present. Airway
obstruction may develop.
Left-Sided Heart Failure
(Early)
Increased pressure in the
pulmonary veins causes
congestion and interstitial
edema (around the alveoli);
bronchial mucosa may become
edematous.
Consolidation
Alveoli fill with fluid or blood
cells, as in pneumonia,
pulmonary edema, or
pulmonary hemorrhage.
Percussion
Note
of the disorder. Abnormalities deep in the chest usually produce fewer signs than
superficial ones, and may cause no signs at all. Use the table for the direction of
typical changes, not for absolute distinctions.
Adventitious
Sounds
Tactile Fremitus
and Transmitted
Voice Sounds
Trachea
Breath Sounds
Resonant
Midline
Vesicular, except perhaps
bronchovesicular and
bronchial sounds over
the large bronchi and
trachea respectively
None, except perhaps
a few transient inspiratory
crackles at the bases of the
lungs
Normal
Resonant
Midline
Vesicular (normal)
None; or scattered coarse
crackles in early inspiration
and perhaps expiration; or
wheezes or rhonchi
Normal
Resonant
Midline
Vesicular
Late inspiratory crackles in
the dependent portions of
the lungs; possibly wheezes
Normal
Dull over the
airless area
Midline
Bronchial over the
involved area
Late inspiratory crackles
over the involved area
Increased over the
involved area, with
bronchophony,
egophony, and
whispered
pectoriloquy
TABLE 6-7 I Physical Findings in Selected Chest Disorders
242
TABLE 6-7 I Physical Findings in Selected Chest Disorders

2. CHAPTER 6
Atelectasis
(Lobar Obstruction)
I
THE THORAX AND LUNGS
When a plug in a mainstem
bronchus (as from mucus or a
foreign object) obstructs air
flow, affected lung tissue
collapses into an airless state.
Pleural Effusion
Fluid accumulates in the
pleural space, separates airfilled lung from the chest wall,
blocking the transmission of
sound.
Pneumothorax
Chronic Obstructive
Pulmonary Disease
(COPD)
Slowly progressive disorder in
which the distal air spaces
enlarge and lungs become
hyperinflated. Chronic
bronchitis is often associated.
Asthma
Widespread narrowing of the
tracheobronchial tree
diminishes airflow to a
fluctuating degree. During
attacks, airflow decreases
further and lungs hyperinflate.
May be shifted
toward involved
side
Usually absent when
bronchial plug persists.
Exceptions include right
upper lobe atelectasis,
where adjacent tracheal
sounds may be
transmitted.
None
Usually absent when
the bronchial plug
persists. In
exceptions, e.g.,
right upper lobe
atelectasis, may be
increased
Dull to flat
over the fluid
Shifted toward
opposite side in a
large effusion
Decreased to absent, but
bronchial breath sounds
may be heard near top of
large effusion.
None, except a possible
pleural rub
Decreased to absent,
but may be increased
toward the top of a
large effusion
Hyperresonant
or tympanitic
over the pleural
air
Shifted toward
opposite side if
much air
Decreased to absent over
the pleural air
None, except a possible
pleural rub
Decreased to absent
over the pleural air
Diffusely
hyperresonant
Midline
Decreased to absent
None, or the crackles,
wheezes, and rhonchi of
associated chronic
bronchitis
Decreased
Resonant to
diffusely
hyperresonant
Midline
Often obscured by wheezes
Wheezes, possibly crackles
Decreased
243
TABLE 6-7 I Physical Findings in Selected Chest Disorders
When air leaks into the pleural
space, usually unilaterally, the
lung recoils from the chest
wall. Pleural air blocks
transmission of sound.
Dull over the
airless area