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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.
Decreased or absent breath sounds
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Decreased or absent breath sounds
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.
Decreased or absent breath sounds
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Decreased or absent breath sounds
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.
Decreased or absent breath sounds
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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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Decreased vocal resonance
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.
Decreased vocal resonance
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Decreased vocal resonance
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.