chest physical dx

8/14/2019 chest physical dx

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PHYSICAL

DIAGNOSIS


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CHEST


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INTRODUCTION

Though X-ray of the lungs has become

wide-spread ,the physical examination ofchest is still very important. A frictionrub,rales, and wheezing cannot be seen on

x-ray films and can be detected only by oursenses.In fact,the findings on the x-ray filmin many instances, can be interpretedintelligently only when coupled with the

history and physical findings.Carefulexamination should enhance our ability tointerpret the x-ray films and the chest filmshould serve as a check on the physical

examination.


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INTRODUCTION

Experience would indicate that thefollowing order of procedure has muchto recommend it:

(1)inspection,(2)palpation,(3)percussion,and (4)auscultation.The adoption of asystematic approach,in which each

stage is performed in sequence,helps toprevent oversight of any importantaspect of the examination.


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LINE LANDMARKS

On the anterior surface

Anterior midline (midsternal line):is located

in the middle of the sternum

Midclavicular line (left and right):runs di

rectly downward from the midpoint of each

clavicle


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LINE LANDMARKS

On the anterior surface

Sternal line(left and right):vertical line

runs along the vertical edges of thesternum and parallels to the anterior

midline.


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LINE LANDMARKS

On the lateral wall of the chest the anterior axillary line:drawn downward

from the origin of the anterior axillary fold

along the anterolateral aspect of the chest the posterior axillary line:a continuation of

the posterior axillary fold running downward

along the posterolateral wall of the thorax the midaxillary line:midway between those

two lines and running directly downward fromthe apex of the axilla


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LINE LANDMARKS

On the posterior wall

the midspinal line or posterior

midline: runs down the posteriorspinous processes of the vertebrae

the scapular line(left and right): runsparallel to the spine through theinferior angle of the scapula


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For exact localization any

abnormality should bedescribed as being:(1)how

many centimeters medial orlateral to the lines of

reference,or (2)in a specific

interspace or interspaces.


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BONE LANDMARKS

On the anterior thoracic wall the sternal angle is a help landmark.This is a

visible angulation of the sternum that

corresponds to the second rib and serves as aconvenient starting point for counting ribs.Itis also significant in that it indicates thelocation of other important structures withinthe thorax that normally lie at the samelevel:(1)the fifth thoracic vertebra,(2)the

bifurcation of the trachea,and (3)the upper

level of the atria of the heart.


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BONE LANDMARKS

Rib

A total of 12 pairs.Each connects tothe corresponding thoracic

vertebra.The ribs run obliquely to

the lateral and then to the anteriordirection,with smaller oblique angle

above and larger angle lower.


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BONE LANDMARKS

Interspace

The space between two adjacentribs,used to mark the position of any

lesion.

Beneath the first rib is the firstinterspace, and so forth.


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BONE LANDMARKS

On the posterior thorax

the vertebra prominens (seventhcervical vertebra)is usually found

with ease at the base of the neck and

serves as a convenient landmark tohelp identify the thoracic vertebrae

and posterior ribs.


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BONE LANDMARKS

Scapula

Its inferior end is called inferiorangle. When the patient is in

standing position with his arms

hanging naturally, the inferior angleacts as the mark of the seventh rib,or

the seventh interspace.


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In additions,you must have exact

knowledge of the location of theunderlying thoracic structures and

those in the upper abdomen.


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NATURAL FOSSA AND

ANATOMIC REGION

On the anterior thorax:

Suprasternal fossa,supraclavicular

fossa(left,right),infraclavicular fossa(left,right)On the lateral wall of the chest:

Axillary fossa(left,right)

On the posterior thorax:

Suprascapular region (left,right),infrascapular

region (left,right),interscapular region


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The boundary of lung and

pleuraThe right lung: 3 lobes (upper,middle

and lower)

the left lung: 2 lobes(upper,lower)


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The apices of the lungs extend forapproximately 3 cm above the clavicle on each

side.Boundaries between lobes called fissure.On

the right the fissure between the upper and

middle lobes and the lower lobe is often calledright oblique fissure,the fissure between theupper and middle lobes is often called the

horizontal fissure.On the left the fissurebetween the upper and lower lobes is the leftoblique fissure.


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It will be seen that the anterior aspect ofthe right chest is composed principally of

the upper and middle lobes,and the upperlobe lies beneath the major portion of theleft anterior hemithorax.On both

hemithoraces the lower lobes present onlya small portion anterolaterally andinferiorly.Posteriorly a very large

proportion of the thorax is occupied by thelower lobes with only a small area of theupper lobes presenting superiorly.


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The boundary of lung and

pleuraPleura

Visceral pleura:the pleura covering thesurface of the lung

Parietal pleura: the pleura covering theinner surface of the chest wall,the

diaphragm,and the mediastinum


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On the right, the dome of the

diaphragm is situated at a levelapproximating the fifth rib or fifth

interspace at the midclavicular

line.The dome of the leftdiaphragm is ordinarily about 1

inch lower than the right.


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THORAX

AND

LUNGS


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INSPECTION

Inspection of the chest,productive ofthe maximum amount of information,

requires the following:

1. First and foremost,a definite desire

to see and to appreciate every visible

abnormality

2.The patient stripped to the waist

3. Good lighting


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INSPECTION4. A thorough knowledge of topographic

anatomy5. The examiner and patient in a

comfortable position throughout the

examination. If either the physician orpatient is uncomfortable,the examinationmay be hurried and consequently less

thorough.It is important that the patient be

absolutely straight,whether seated or

supine.


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INSPECTION

Normal thorax

You should appreciate that in normal

subjects there is a wide variation in thesize and shape of the thorax.At times it

is difficult to be certain where the

normal variations and definitepathologic changes begin.


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INSPECTION

Normal thorax

The anteroposterior diameter ofthe thorax in the normal adult is

definitely less than the transverse

diameter.


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INSPECTION

what to observe

1.First: the general nutrition andmusculoskeletal development2.Next: the skin and breasts

3.vein and subcutaneousemphysema


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INSPECTION

4.the anteroposterior diameter ofthe thorax

persons with pulmonary emphysema --

barrel chest5.the general slope of the ribs

normal : 45 degree angle

patients with emphysema :the ribs arenearly horizontal ; this angle becomesabnormally wide


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INSPECTION

6.retraction or bulging of

interspaces

Retraction of the interspaces:

obstruction of the respiratory tract

Bulging of interspaces : a massivepleural effusion,tension pneumothorax


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INSPECTION

7.the rate and depth of quiet breathing

in the adult at rest the normal respiratory rateis approximately 16 to 18 breaths per minute

and is quite regular in depth and rhythm

increase in the respiratory rate :fever


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INSPECTION

8.Alterations in shape of the thoraxIn the normal subject,the two sides of

the chest move synchronously and

expand equally

Unilateral retraction of the thorax : a

thickened fibrotic pleuraPigeon chest

Funnel chest

INSPECTION


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INSPECTION

9.Types of respiration

(1)Dyspnea : difficulty or effort in breathing ;

participation of the accessory respiratory

musclesInspiratory dyspnea :obstruction of the

trachea or major bronchi (tumor,laryngitis)

Expiratory dyspnea :obstruction in thebronchioles and smaller bronchi (asthma)


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INSPECTION9.Types of respiration

(2)Bradypnea : abnormal slowing ofrespiration

(3)Apnea : temporary cessation of breathing

(4)Tachypnea : increased respiratory rate

(5)Hyperpnea : an increase in thedepthof

respiration (6)Hyperventilation :an abnormal increase inboth rate and depthof respiration(it is seen indiabetic acidosis and highly emotional states)


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INSPECTION

9.Types of respiration

(7)Pleuritic or restrained breathing :the

inspiratory phase is suddenly interrupted as a

result of pain associated with acute pleuritis ;

The respirations are quite shallow but morerapid than normal

S C O


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INSPECTION9.Types of respiration

(8)tidal respiration :is characterized by periods of

rapidly increasing rate and depth of respiration,

which within a matter of a few more respiratory

cycles becomes shallower and shallower untilrespiration ceases.This is followed by a period of

apnea,which may last a few seconds to as long as 30

seconds. periodic respiration may be present inmany relatively severe disease states.

INSPECTION


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INSPECTION

9.Types of respiration (9)Sighing respiration :occurs when the

normal respiratory rhythm is interrupted by a

deep inspiration,which is followed by aprolonged expiration and ordinarily is

accompanied by audible sighing. it is rarely

associated with organic disease;instead it isalmost always a manifestation of emotional

tension.


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INSPECTION

9.Types of respiration (10)Ataxic breathing: is characterized by

unpredictable irregularity . Breaths may be

shallow or deep,and stop for short periods.

PALPATION


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PALPATION

Thoracic expansion

Variations in expansion are more readily

detectable on the anterior surface where

there is greater range of motion.

The examiner's hands should be placed

over the lower anterolateral aspect of the

chest.Expansion should be tested during both

quiet and deep inspiration.


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PALPATION

Thoracic expansion

Expansion may be limited as the resultof acute pleurisy,fibrous thickening of

the pleura (fibrothorax),fractured

ribs,or other trauma to the chest wall.


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PALPATION

Fremitus

Vocal fremitus:Vocal fremitus is a

palpable vibration of the thoracic wallproduced by phonation .


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PALPATION

Vocal fremitus:

The sounds that arise in the larynx aretransmitted down along the air column of

the tracheobronchoalveolar system into thebronchi of each lung,on through thesmaller bronchi into the alveoli,setting in

motion the thoracic wall that acts as a largeresonator. Thus,vibrations are produced inthe chest wall that can be felt by the hand

of the examiner.

PALPATION


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PALPATION

Vocal fremitus:

In eliciting vocal fremitus the patient isdirected to count one,two,three---one,two,three,to repeat thewordsninety-nineninety-nine,or tosay e-e-e,e-e-e,e-e-e. The patient shouldspeak with a voice of uniform intensity

throughout the examination so that theexaminer can better compare thetransmission of the fremitus in different

areas of the chest.

PALPATION


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PALPATION

Vocal fremitus:

The vocal fremitus is perceived by placingthe palmar aspect of the fingers or ulnaraspect of the hand against the chestwall.Usually both hands are used,placingthem in corresponding areas so thatsimultaneous comparison of the two sides

can be made. If only one hand is used,itshould be moved from one place to thecorresponding area of the other side to

compare the transmission of sound.

PALPATION


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PALPATION

Normal variations of vocal fremitus.

The intensity of the vocal fremitus

perceived in the normal subject is governed

by the following:1.Intensity of the voice

2.Pitch of the voice

3.Varying relations of the bronchi to thechest wall

4.Varying thickness of the thoracic wall


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PALPATION

In general,vocal fremitus is most prominentin the regions of the thorax where the large

bronchi are the closest to the thoracic wall

and tends to become less intense as oneprogresses farther from the major bronchi.In

the normal person the fremitus is found at

maximum intensity over the upper thoraxboth anteriorly and posteriorly.It is least

intense at the bases.


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PALPATION

Also the intensity of the fremitus will varywith the thickness of the thoracic wall.In a

thin person the vibrations will be more

intense than in the normally developed orobese patient. There is considerable

variation from patient to patient.

PALPATION


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PALPATION

Alternations of vocal fremitus

increased vocal fremitus ----consolidation

of the lungs :lobar pneumonia

Decreased or absent fremitus ----fibrousthickening of the pleura: fluid in the pleural

space or pneumothorax

absent fremitus ---- major bronchus isobstructed :tumor


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PALPATION

pleural friction fremitus:As theresult of acute pleurisy,the inflamed

pleural surfaces rub against one

another,producing a pleural friction rub

that may be detected by the examining

hand.


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PALPATION

pleural friction fremitus

When present,it is palpable usually in

both phases of respiration.

Friction rubs most commonly are feltas well as heard in the inferior

anterolateral portion of the chest,thearea of greatest thoracic excursion.

PALPATION


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PALPATION

CrepitationCrepitation may be palpated when the sub

cutaneous tissues contain fine beads of air.

This condition is known as subcutaneousemphysema.

A somewhat similar sensation can be

produced by rolling a lock of hair between

the thumb and fingers.


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PERCUSSION

There are twoprincipal

methods that may be usedfor percussion of the thorax,

abdomen,or other structures.


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PERCUSSION

1. Mediate percussionis that in

which the examiner strikes the middle

finger of one hand held against the

thorax, thus producing a sound by

setting the chest wall and underlyingstructures in motion. This is the

method in almost universal use today.


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PERCUSSION

2. Immediate percussion may be

useful in demonstrating changes in

percussion note.This can be done

by striking the chest with the tips

of all of the fingers held firmlytogether.


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PERCUSSION

Practical experience has demonstratedthat useful sounds produced by

percussion probably do not penetrate

more than about 4 to 5cm below thesurface. Also a lesion must be at least 2

or 3cm in diameter to be detectable.

Thus,it is obvious that percussion willonly locate rather gross abnormalities.


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PERCUSSION

To obtain the maximum information frompercussion:

1. The distal phalanx of the pleximeter

finger must be pressed firmly on the chestwall;otherwise,a clear note is not obtained.

2. The plexor finger should strike thepleximeter finger only instantaneouslyand must be immediately withdrawn.


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PERCUSSION

Usually percussion is performed abovethe clavicles in the supraclavicular

spaces and downward.Next,each lateralwall is examined, beginning in theaxilla and working down to the coastal

margin. With the pleximeter fingeralways parallel to the ribs--never crossthem.


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PERCUSSION

In examining the back of the chest

the patient should have his head

inclined forward and the forearms

crossed comfortably at the waist to

move the scapulae as far laterallyas possible.


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PERCUSSION

Examination is started at the apices,where the percussion note as well as

the width of the isthmus of normal

resonance over the apex is determined .

Bounded medially by the neck muscles

and laterally by the shoulder girdle,thisband of resonance is normally about 5

cm wide.


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PERCUSSION

The percussion is continued downward,

interspace by interspace,to the bases

where the location and range of motion

of each hemidiaphragm is ascertained.

PERCUSSION


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PERCUSSION

Analysis of percussion tones

The sound waves produced by percussionare influenced more by the character of theimmediate underlying structures than bythose more distant.Consequently the tone

produced by percussion over the airfilledlung will be definitely different from the

tone heard over a solid structure,such as theheart or liver.This is the basis for thescientific application of percussion.


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PERCUSSION

Percussion sounds1. Resonance: the sounds heard

normally over lungs

2. Hyperresonance: The hyperresonant

note in the adult is commonly the

result of emphysema and occasionallypneumothorax.


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PERCUSSION

Percussion sounds

3. Tympany: It never occurs in the

normal chest,except below the dome of

the left hemidiaphragm,where the

underlying stomach and bowel will

produce tympany.

PERCUSSION


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PERCUSSION

Percussion sounds

4.Dullness: Dullness tends to occur when

there is considerable solid or liquid medium

present in the underlying lung in proportionto the amount of air in the lung tissue.

Thus,dullness will be found when there is

consolidation of lung,such as occurs inpneumonia,or when there is a moderate

amount of fluid in the pleural space with

some underlying air-containing lung.

PERCUSSION


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PERCUSSION

Percussion sounds5. Flatnessis the term used to describe the

percussion note when resonance is absent.

Flatness will be present when there is a verylarge fluid mass,such as in an extensive

pleura1 effusion with little underlying air-

bearing lung to influence the sound.

PERCUSSION


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PERCUSSION

Percussion soundsOver the apices,where there are large

amounts of muscle and bone with relatively

little underlying resonant lung,the note isless resonant than over the bases,where

there is a relatively greater amount of lung

with less thoracic wall and muscle.


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PERCUSSION

Percussion sounds

The development of the pectoral

muscles,the heavy muscles of the

back,the breasts,and the scapulae,all

tend to make the percussion note less

resonant (duller).

PERCUSSION


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PERCUSSION

Percussion soundsIt should be noted that below the dome of

the right diaphragm there is flatness

because of the presence of the liver.on the

left there is ordinarily a relatively

tympanic note that results from the

presence of the partially air-filled stomach

and bowel under the hemidiaphragm.


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PERCUSSION

Percussion sounds

The change from resonance to

flatness on the right and from

resonance to tympany on the left is

not immediate;instead ,there is azone of transition.


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PERCUSSION

Percussion sounds

Dullness from the liver is usually noted

at approximately the fifth interspace in

the midclavicular line,and this dullness

soon gives way to flatness as that part

of the liver not covered by the lung is

reached.


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PERCUSSION

Percussion soundsAlso the change from pulmonary

resonance to tympany over the leftlower chest at about the sixth rib in themidclavicular line has the same general

tendency to transition not an abruptchange .


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PERCUSSION

Percussion sounds

There is also dullness to the left of the

sternum,caused by the underlying heart,another solid organ in the left fifth

interspace. This dullness normally

extends to a point 1 or 2cm medial tothe midclavicular line.

PERCUSSION


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PERCUSSION

Effect of position on percussion soundOccasionally the patient is too ill to sit up to

permit percussion of the posterolateral

aspects of the chest.So the posterior andposterolateral thoracic wall must be

examined with the patient rolled on his

side.This is much less satisfactory than theupright position.


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PERCUSSION

The lateral recumbent position

causes the following changes:

PERCUSSION


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PERCUSSION

1 . Some curvature of the spineresults,with a widening of theintercostal spaces in that portion of the

thoracic wall that is against the bed anda narrowing of the interspaces on theupper side;this curvature can be

counteracted to some degree if thepillow is removed and the head isallowed to the bed.


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PERCUSSION

2. Disproportionate elevation of the

hemidiaphragm of the down side

results from the pressure of theabdominal viscera.

3. The surface of the bed affects the

percussion note by acting as a damper

for the sounds.


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PERCUSSION

As a result of these three

factors ,the following changes are

observed:

(1)there is an area of relative dullness

along the chest next to the bed.


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PERCUSSION

(2)above this area and at the base of

the lung there is a roughly triangular

area of dullness with the base towardthe bed and the apex approaching the

spine.


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PERCUSSION

(3)on the upper side there may be some

relative dullness at approximately the

tip of the scapula,which is caused bychanges in the lung as a result of the

crowding of the ribs.


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PERCUSSION


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PERCUSSION

Diaphragmatic excursion

First,the patient is instructed to take a deep

inspiration and hold it.

Second, the lower margin of resonance(which represents the level of the

diaphragm)is determined by percussion

from the normal lung,moving downwarduntil a definite change in tonal quality is

heard.


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PERCUSSION

Diaphragmatic excursionThird,the patient is instructed to exhale

as far as possible and to hold his breath,and the percussion is repeated.

The distance between these levels

indicates the range of motion of thediaphragm .


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PERCUSSION

Diaphragmatic excursion

The normal diaphragmatic excursion is

about 6 to 8 cm.

It is decreased in patients with pleurisy

and severe emphysema.


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.

PERCUSSION


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PERCUSSION

The diaphragm is unusually high in anycondition that causes an increase in intra-

abdominal pressure, such as ascites or

pregnancy and lower than normal inpulmonary emphysema.

In the recumbent patient the level of the

diaphragm is approximately one interspacehigher than in the upright position.

AUSCULTATION


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AUSCULTATION

The patient should be instructed to breathe

a little deeper than usual with his mouth

open. Breathing through the open mouth

minimizes the sounds produced in the nose

and throat.

Corresponding areas of each side areauscultated as the examiner goes from top

to bottom, just as in percussion.


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AUSCULTATION

Breath sounds--normal

Vesicular


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The vesicular breath sound is believed to

be the result of movement of air in thebronchioles and alveoli.

Variously described as sighing or a gentle

rustling,vesicular breathing is a soft,

relatively low-pitched sound.

The normal vesicular respiration is longerin the inspiratory than in the expiratory

phase by a ratio of approximately 5:2.

Vesicular


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It should be emphasized that expiration as

heard in vesicular breathing is not actuallyshorter than inspiration --only that much of

expiration is not audible.

Inspiration is higher in pitch and louder than

expiration.In fact,expiration occasionally

may be inaudible.

Vesicular breath sounds heard from

normally over most of the lungs.

Bronchovesicular


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Bronchovesicular

In certain areas where the trachea andmajor bronchi are in proximity to the chest

wall,there is heard a mixture of both

tracheobronchial and vesicular elementsthat is termed bronchovesicular breath

sound.

Bronchovesicular


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This type of breath sound is heard normally

on each side of the sternum in the first andsecond interspaces,between the scapulae,

and over the apices anteriorly and

posteriorly,but are more prominent on theright than on the left.

When heard in other locations,

brochovesicular breathing is abnormal and

is indicative of some disease process.

Bronchovesicular


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In bronchovesicular breathing the

inspiratory phase resembles that of normalvesicular breathing,and the expiratory phaseresembles that of normal bronchial

breathing.A very brief pause may be noted between

inspiration and expiration. In essence,the

expiratory and inspiratory phases are verysimilar as to duration, pitch,intensity,andquality.


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Vesicular and bronchovesicular

are the two types of breath

sounds heard normally over thelungs.


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AUSCULTATION

Breath sounds--abnormal


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Bronchial breathing Bronchial breath sounds are in general

higher in pitch than vesicular or

bronchovesicular sounds.Expiration usually surpasses

inspiration in length.


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Bronchial breathing

Bronchial breathing is not normally

heard over the lungs. Therefore,its

presence over the lungs always

indicates disease.

It occurs only with pulmonary

consolidation, in other words,anincreased conducting mechanism.

B h i l b thi


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Bronchovesicular breathing

Bronchovesicular breathing is abnormalwhen heard in any area of the lungs that

normally have vesicular breath sounds.

An admixture of consolidated and aeratedlung produces a mixture of bronchial and

vesicular breathing--bronchovesicular

breath sounds.

El d i b h d


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Elongated expiratory breath sound

Occurs because of partial obstruction,spasmor stricture of the lower respiratory tract,

happening in bronchitis,bronchial asthma etc.

Because of lowering elasticity of pulmonary

tissue,happening in COPD etc.


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Hoarse breath sound

Due to smoothlessness or stricture

produced by mild bronchial

membranous edema or inflammation.Heard in the early stages of bronchial

or lung inflammations.


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Decreased or absent breath sounds

Breath sounds may be decreased in intensity

without change in fundamental type as theresult of several conditions.In some

instances the breath sounds may be entirely

absent.



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l.One of the most common causes is fluid inthe pleural space.Here the diminution in

breath sounds is the result of the interposed

liquid medium as well as a definite decreasein ventilation of the underlying lung.

2.In the same manner ,air in the pleural

space(pneumothorax)causes a diminution inthe breath sounds.



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3. If there is thickened pleura caused byfibrosis -which may followeffusion,hemothorax, and empyema-or byactual tumor involvement of the

pleura,decrease in breath sounds is noted.

Whether fluid,air,or solid in the pleuralspace,all interfere with the conduction of

breath sounds so that they are decreased oreven absent.



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4. Breath sounds are commonly decreased in

emphysema because of the decreased airvelocity and sound conduction.

5. Breath sounds are markedly diminished or

absent in complete bronchial obstruction.6.If there is definite decrease in expansion,

such as that commonly noted in painful

pleurisy with its attendant shallowbreathing,the breath sounds are diminishedbecause of the decreased ventilation.


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AUSCULTATION

voice sounds--normal

Vocal resonance


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Vocal resonance

Vocal resonance is produced in the same

fashion as vocal fremitus.The spoken

voice as heard over the normal lung is

termed vocal resonance. Vocal resonance varies in exactly the

same fashion as does vocal fremitus.It is

heard loudest near the trachea and majorbronchi and is less intense at the extreme

bases.


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AUSCULTATION

Voice sounds--abnormal

Bronchophony


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p y

Bronchophony indicates vocal resonance

that is increased both in intensity and

clarity.

It is usually associated with increased vocalfremitus ,dullness to percussion,and

bronchial breathing,and as a rule indicates

the presence of pulmonary consolidation.

Whispered pectoriloquy


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To be of practical significance the sounds

must be actually whispered;softly spokenwords that require the use of the vocal cords

are not suitable.

In the normal subject the whispered voice is

heard only faintly and indistinctly throughout

the chest except anteriorly and posterior1y in

the regions overlying the trachea and primary

bronchi.At the bases the whispered voice

may be entirely inaudible.

P t il


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Pectoriloquy

Although pectoriloquy is only a form ofexaggerated bronchophony, at times it is

more easily detected than bronchophony.

Pectoriloquy is never normal,and itspresence always indicates consolidation of

the lung.

Egophony


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Egophony is a modified form of bronchophony in

which there is not only an increase in intensity ofthe spoken voice but its character is altered so thatthere is a definite nasal or "bleating" quality.

It is occasionally heard over an area of

consolidation,over the upper portion of a pleuraleffusion,or where there is a small amount of fluidin association with pneumonic consolidation.

It is most readily elicited by having the patientsay"e-e - e."If egophony is present,the spoken"eeee"will sound as though the patient is saying"aaaa."

Decreased vocal resonance


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Vocal resonance is decreased under the

same circumstances that the vocal fremitus

and the breath sounds are decreased or

absent-where there is interference in theconduction of vibrations produced in the

thorax,such as is found with pleural

thickening , pleural fluid , pneumothorax,adiposity,or complete bronchial obstruction.



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It should be noted that,although the vocal

resonance and vocal fremitus are usually

diminished over a pleural effusion,

occasionally they may actually be increasedat the upper level of the fluid as the result of

compression of the lung or if there is

pneumonic consolidation of the underlyinglobe.


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AUSCULTATION

Adventitious sounds


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The most common adventitioussounds are the various types of

rales,rhonchi and the pleuralfriction rub

Rales


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They result from the passage of air

through secretions in the respiratory

tract and from reinflation of the

alveoli and bronchioles, the walls ofwhich have become adherent as the

result of moisture.Rales,therefore,are

produced by air flow plus abnormalmoisture.

RalesAccording to the size of the air chamber


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According to the size of the air chamberinvolved (trachea,bronchi,bronchioles,and

alveoli)and the character of the exudate,ralesvary in their size,intensity,distribution, and

persistence.

Rales are most often heard in the terminalphase of inspiration and are more pronouncedwhen the patient is instructed to breathe

deeply.Rales are very similar to the sound heard over

a recently opened carbonated drink.


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Rales

Rales may be divided roughly into

three categories: fine, medium, and

coarse.

Fine Rales


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Fine rales have a fine,crackling quality.

They most commonly occur at the end

of inspiration and are not cleared by

coughing .they are the result of moisture in the

alveoli.

Fine fales


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Fine fales

Fine rales indicate inflammation orcongestion involving the alveoli and

bronchioles. Consequently they may

be heard in pneumonia, pulmonary

congestion, and many other diseases.

Medium rales

M di l t d ti


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Medium rales represent a gradation

between coarse and fine rales.They may be simulated by rolling a dry

cigar between the fingers.

They tend to be the result of the passage ofair through mucus in the bronchioles andsmall bronchi or the separation of the walls

of these structures that have becomeadherent because of exudate.

Medium and coarse rales tend to occur

earlier in respiration than do fine rales

Coarse rales Coarse rales have their origin in the trachea, bronchi


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g ,and some of the smaller bronchi.

They are produced by the passage of air throughexudate.Often they will clear,at least in part,as theresult of a vigorous cough.

They may be heard during the resolution of an acutepneumonia,at which time there is the production ofrelatively large amounts of thick exudate.

In the moribund patient who has a definite

depression of his cough reflex,there is often anaccumulation of thick secretions,producing verycoarse rales.

Rhonchi

Rh hi diff f d t ll f


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Rhonchi differ very fundamentally from

rales in that the former are continuoussounds,similar to the sound produced byplaying a violin.

Rhonchi are continuous sounds producedby the passage of air through the trachea,

bronchi,and bronchioles that have beennarrowed,irrespective of the cause. As longas air passes the obstruction,the sound will

be produced.

Rhonchi


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Rhonchi

Rhonchi in general are more prominentduring expiration than inspiration,

although they are frequently audible

during inspiration.Based primarily on the pitch,rhonchi

are classified as sibilant or sonorous .

Sibilant rhonchi


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Sibilant rhonchi

Sibilant rhonchi are high pitched,wheezing, squeaking,or musical in

character.The wheezing quality often

can be accentuated by forcedexpiration.

They have their origin in bronchioles

and smaller bronchi.


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Sonorous rhonchiSonorous rhonchi are low pitched and

often moaning or snoring in character.

They are produced by obstruction inthe larger bronchi or trachea.


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Rhonchi tend to vary greatly inintensity and character from time

to time.In some instances they can

be cleared,or partially so,by

coughing.

Rhonchi are produced as air enters the areaof obstruction and again as it leaves.


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The underlying obstruction or narrowing

may be the result of variety of causes:extrinsiccompression as by enlarged lymph nodes ormediastinal tumor or by intrinsic narrowing as

in bronchogenic carcinoma,exudate,mucosalinflammation or edema,and bronchiolarspasm(asthma).

In each instance there are narrowing andirregularity in the tracheobronchial tree,withresultant turbulence of the air producing thesound.

pleural friction rub


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Normally the visceral and parietal surfaces

of the pleura glide noiselessly over oneanother during respiration.

However,when these surfaces become

inflamed,as the result of pleurisy,

pulmonary infarct, or underlying

pneumonia,the rubbing of the roughened

surfaces during respiration produces a very

characteristic sound that is known as the

pleural friction rub.


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pleural friction rub


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The most common site for a friction rub to be

heard is the lower anterolateral chest wall, the

area of greatest thoracic mobility.

It does not disappear with coughing as coarse

rales will often do,and that cough is usually

attended by discomfort.

Furthermore,an increase in the intensity of thefriction rub may be noted with arm pressure of

the stethoscope over the thoracic wall.


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MAJOR

ALTERATIONS OFTHE LUNGS


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Pleural effusion

A collection of fluid in the pleural


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space is called pleural effusion.

Pleural effusion is a sign of disease

and not a diagnosis in itself.

The physical sign of a pleuraleffusion are the same whether it is

serious, hemorrhagic, or purulent

in character.

Inspection


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The patient usually lies on the affected side,thus allowing free expansion of the normal

lung.

If the amount of the effusion is large, thepatient may show marked dyspnea.

The movements of the chest during

respiration are diminished on the affected

side.

Inspection


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Inspection

In large effusions the affected side

appears much fuller than the normal

one, and the intercostal spaces mayactually bulge.

When the effusion is on the right side,

the cardiac impulse may be displacedbeyond the left midclavicular line.

Palpation


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Palpation first confirms the observation

made on inspection; decreased mobilitywith bulging of the intercostal spaces on the

affected side and displacement of the

cardiac impulse.

The trachea is deviated away from the

diseased side. The vocal fremitus is absent or markedly

diminished over the effusion.

Percussion


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Percussion

In small effusions and in early stages

of any pleural effusion, the percussion

note may be unchanged.As more fluid accumulates, the

percussion note becomes less and less

resonant, and finally becomes dull toflat.

Percussionh h ff i i h i h id h


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When the effusion is on the right side, the

dullness extends into and cannot bedemarcated from the liver dullness.

A right side plural effusion displaces the

heart to the left, and the cardiac dullnesstoward the left axilla.

In a left sided plural effusion the dullness

extends into that of the cardiac dullness, andpercussion of the left cardiac border may beimpossible.

Auscultation


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Early in the disease a friction rub may beheard, which, however, soon disappears.

The breath sounds are diminished or absent

over the area of the effusion.Bronchovesicular breath sounds are often

heard at the upper limit of the fluid, because

of the compressed underlying lung.

Auscultation


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Auscultation

The vocal resonance is diminished or

absent over effusion.

The whispered voice may beintensified ----bronchophony,

especially just above the level of the

effusion.


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Pneumonia

Any lung infection that involves the alveoli

and causes then to fill with exudate or


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inflammatory secretion is calledpneumonia.

Pneumonias usually sudden, often coughing

is usually present. It may be severe andassociated with sharp pain in the affected

side.

The sputum at first is mucoid, but laterbecomes bright red and then rusty brown.


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The signs of consolidation is commonly

found over lobar pneumonia.

Inspection


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Dyspnea is almost invariably present andthe respiratory rate is increases.

In severe cases, cyanosis of the tip of the

noses, ears and fingertips is commonlypresent, and movements are decreased on

the affected side and increased on the

normal side .

Palpation


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The diminished respiratory movements onthe affected side are often better felt then

seen.

A pleural friction fremitus may be feltbecause of a coexisting acute pleuritis.

The vocal fremitus is greatly increased

over the pneumonic area.


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Percussion

In a lobar pneumonia the percussion

note is dull or flat over the affectedarea.

Auscultation


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In the early stages of lobar pneumonia, the

breath sounds may be diminished or

suppressed. Fine crepitant rales may be heard.

With the development of frank consolidation,the crepitant rales disappears, the breath

sounds become tubular .

The vocal resonance is increased and the voicesounds may have a curious nasal tone ----the

egophony.

Auscultation


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Auscultation

During resolution ,the cyanosis and

tachypnea disappear, the areas of auscultation

numerous small and large moist rales areheard in increasing numbers, while the harsh

tubular breathing gradually disappears and

normal vesicular breathing reappears.


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Pulmonary emphysema

By definition emphysema refers


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By definition emphysema refers

to the presence of an abnormallylarge amount of air within portions

of the lung distal to the terminal

bronchioles. The history is often

progressive dyspnea, starting after

cough, sputum for many years.

Inspection


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A barrel chest deformity is

frequently present.

The chest is on an inspiratory position,with the ribs horizontal.

The apex beat of the heart is not visible.

Palpation


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Palpation

The trachea is in the midline position.

The tactile fremitus is diminished over

both side of the chest.The chest movement is restricted but

equal bilaterally.

The apex beat cannot be felt.

Percussion


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there is hyperresonance throughout both

sides of the chest.

the area of cardiac dullness is diminished.

The upper limit of liver dullness is lowered.After deep inspiration followed by forced

expiration, percussion over the bases of the

lung in the back shows little change in thelower limits of lung resonance.

Auscultation


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Auscultation

On auscultation the breath sounds arevesicular and generally diminished inintensity or almost inaudible.

Expiration is commonly prolonged.

Rhonchi are normally widespread, but

may be most marked at the bases of thelung.


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Pulmonary atelectasis

Atelectasis occurs when an area of lung

tissue is not ventilated The signs and


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tissue is not ventilated. The signs and

symptoms that follow depend upon theamount of lung tissue involved and vary

from an asymptomatic shadow on an X-ray

to acute respiratory distress.When a sufficient amount of lung is

involved, there are signs of respiratory

distress, and the physical findings are as

following:

Inspection


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Inspection

The chest on the affected side looks

flat, the intercostal spaces narrowed

and depressed.The respiratory movements are

markedly diminished, while there is

increased expansion over the normalside.

Palpation


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Palpation

The tactile fremitus is usually

decreased or absent over the affected

side.The trachea is deviated to the affected

side.

Percussion


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e cuss o

Percussion shows that the heart is

displaced toward the affected side.

The percussion note over the affectedlung is usually dull.

Auscultation


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The breath sounds are usually absent

over the affected area.

Rales may not be present.


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Pneumothorax

An acc m lation of air in the ple ral


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An accumulation of air in the pleural

space is called pneumothorax. Inacute spontaneous pneumothorax the

patient show sudden dyspnea, cyanosisand chest pain. If the pneumothorax issmall,the alterations may be minor oreven absent.

Inspection


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p

Unilateral diminishing of movement

may be present in variable degree.

The cardiac impulse is displaced to theleft in a right pneumothorax, and to the

right in a left pneumothorax.

Palpation


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p

Tracheal deviation away from the

affected side can be find, if the

pneumothorax is large. The vocal fremitus is diminished or

abolished over the affected side.

Percussion


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The percussion note over the affected

side is usually hyperresonant or

tympanic.

Auscultation


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The vocal resonance is usually

diminished.

The breath sound are markedlydiminished on the affected side and

exaggerated on the normal side.

chest physical dx

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