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Review of Physical Examination of the Chest

Instructions: There are hyperlinks within the text that will take you to a website where additional information is presented.  You will need Real Player to view the streaming PowerPoint presentations, or you may read the text version.  To get Real Player, follow this link and click on "Free RealOne Player" in the top right corner, then click "download free player" at the bottom of the next page.

Introduction: This information is presented as a review for students in RSPT 2201.  Words in italics are basic vocabulary that you should know.  If you are not familiar with these terms, you need to look them up in your text or a medical dictionary.  After you take the pretest, continue with the review.

 Examination of the thorax includes 4 parts; inspection, palpation, percussion and auscultation.  Each of these 4 areas is heavily tested on the NBRC examinations. We will review each of these areas separately.   Prior to beginning this section, the student should have a good understanding of  cardiac and pulmonary anatomy and physiology, so take some time to review your A&P, then quiz yourself. 

Prior to the 4 specific evaluations you will make, you should notice some general characteristics about the patient.  You can start making observations as soon as you enter the room, as you introduce yourself to the patient and take their medical history. You should notice the patient's face.  Do they look cachectic or emaciated?  That could be a sign of chronic disease.  Are they diaphoretic?  That could be a sign of fear, pain or anxiety.  You will need to determine the cause during your evaluation.  Evaluate the patient's level of consciousness. Are they oriented X 3?  If they are not, you need to find out why. Once you have reviewed the patient's chart, taken or read their history and made your general assessment, you are ready to begin with inspection.

Inspection: For a streaming PowerPoint presentation, click Inspection  or read on for the text version.  Inspection involves things you can see.  You do not need to touch the patient to gather this information.   It is a good idea to use a form or a specific routine to ensure you perform a thorough inspection.  You should evaluate:

• Thoracic formation.  Normally the chest is wider than it is deep.  In chronic pulmonary disease, the chest becomes more round in shape, which we refer to as an increased AP diameter or barrel chest.  Deformities of the chest should also be noted; such as pectus carinatum, kyphosis etc

• Breathing pattern, rate and effort.  Normal rate for adults is between 12 and 18 breaths per minute.  Tachypnea may be caused by exertion, fever, hypoxia or pain.  Bradypnea may be caused by hypothermia or medication effect. Evaluate the patient for dyspnea. Breathing should not be a strenuous activity.  If you note use of accessory muscles or retractions during breathing, that means the patient has an increased WOB.  Normally we spend 1/3 of the breathing cycle in inspiration, 2/3 in exhalation for an I:E ratio of 1:2.  Longer expiratory times are associated with chronic pulmonary disease.

Palpation: Palpation involves touching the patient's chest wall to evaluate the quality of breathing.  

•  Activity: Touch your chest wall now as you breath. You feel the chest move but there should be no vibration.  Keep touching your chest wall and say "ninety-nine".  You should feel a slight vibration. 

• Fremitus: In health, the lungs are filled with air.  As the lung tissue becomes more consolidated in diseases such as pneumonia, the vibrations with speech become stronger, we call that vocal fremitus.  If there are large amounts of secretions in the airways, you may even feel vibrations with breathing, we call that rhonchal fremitus. If something separates the lung from the chest wall it acts as insulation and decreases the vibration of the chest wall.  A pneumothorax or pleural effusion would decrease fremitus. 

• Thoracic expansion: Both sides of the chest should expand equally.  If you place one hand on either side of the patient's chest and ask them to inhale, you can determine the amount and symmetry of chest expansion.

• Skin & subcutaneous tissue: You should evaluate the skin for temperature and integrity.  A crackling or paper like sound or feeling of the skin over the chest may be due to pulmonary air leak.  You should note any subcutaneous emphysema and determine it's cause.

Percussion: Percussion involves tapping on the patient's chest wall to create a vibration/sound. This is the same concept as finding a stud in the wall to hang a picture.

• Activity: Place the middle finger of your non-dominant hand between 2 of the patient's ribs.  Now tap on the last joint of your finger with your other middle or index finger.  Feel the vibration and listen for the sound.

• Resonance: Resonance is a ringing quality of the sound that is created with percussion.  There are 3 types of percussion notes. Normal lung tissue is fairly hollow and air filled.  The normal percussion note is called resonant.  If there is air trapping or hyperinflation of the lung, the percussion note is hyperresonant; it is a lower pitched note and longer in duration. If there is consolidation the percussion note will be dull or flat.  It is higher pitched and short in duration, like tapping on a wall over a stud. 

Auscultation: Auscultation is listening to breathing sounds with a stethoscope.  There are normal breath sounds and adventitious or abnormal breath sounds.  

• Technique: The diaphragm of the stethoscope should be placed firmly against the chest wall while listening to breath sounds.  External noise, such as TV, should be eliminated during auscultation. You should begin at the base of the lung, posteriorly and listen bilaterally, moving systematically up the chest, comparing both sides and lower and upper sounds.

• Normal Breath Sounds: Bronchial or tracheal sounds are loud, tubular sounds that are high-pitched with an expiratory component that is equal to the inspiratory component.  These sounds are normally heard over the upper and larger airways.  Vesicular sounds are softer, lower pitched sounds that are whispery in nature.  They are heard softly on inspiration and fade away after 1/3 of exhalation.  Vesicular sounds are normally heard over the periphery of the lung.  These sounds are only normal when heard in the correct location.  If bronchial sounds are heard in the periphery, that would indicate consolidation.  If vesicular sounds are heard in the trachea, that would indicate seriously diminished airflow.

• Intensity: Another important feature of breath sounds is the intensity or loudness of the sound.  Respiratory disease may alter the intensity of breath sounds.  A sound that is decreased in intensity may be caused by reduced airflow or shallow breathing.  A sound that is increased in intensity is referred to as harsh.  Harsh breath sounds have an increased expiratory component and may be described as bronchial. Harsh breath sounds may be heard in the periphery of the lung when there is consolidation.

• Adventitious sounds: Adventitious sounds are abnormal anywhere and anytime they are heard.

• Crackles can be loud or soft, scanty or profuse, on inhalation or exhalation but are always discontinuous.  The old name for crackles is rales.  Crackles may be associated with excess fluid or secretions in the lung or with collapsed bronchioles and alveoli.

• Rhonchi are loud low-pitched continuous bubbling sounds heard due to large amounts of secretions in the airways.

• Wheezes are loud high-pitched continuous sounds heard due to partial occlusion of the airways.  

• Stridor is a loud continuous harsh sound created in the upper airway due to partial obstruction. 

Voice Sounds: For a streaming PowerPoint presentation click here or read the text version.   To evaluate voice sounds, you have the patient speak and listen for changes from normal voice transmission.  These tests become abnormal when there is excess fluid in the lung.  Follow this link for more on Voice Sounds.

When you have finished this review, re-read the assigned chapters in your texts and review your notes, then try my Physical Examination on-line Quiz , a copy of your results will be emailed to you.   Look up and review any answers you got wrong on the quiz, then try filling in the worksheet.  We will review worksheet answers in class.

If you have questions about this review email me.