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Physical examination of the chest The chest indicates the region that lies under the neck and

above the abdomen. Chest wall is composed of sternum, ribs, and vertebras. The anterior part is a little shorter than the posterior part. Chest examination includes many components: chest shape, chest wall, breasts, vessels, mediastinum, bronchus, lung, pleura, heart, and lymph nodes, etc. In addition to general physical examination, the following check methods have been widely used in clinical work: X-ray topography, lung function test, blood-gas analysis, aetiology, histology, and relevant bio-chemical tests. These methods can provide early stages of abnormality and pathogens, even give out exact diagnosis on pathology and pathogenesis, but, many changes in palpation, percussion and auscultation for all kinds of rales, can not be detected through these methods so they can’t completely replace the basic physical examinations till now. The basic physical examination has long been used clinically, which doesn’t need high-quality equippment, handy for use to provide important information and signs for the diagnosis of the chest diseases. Of course, a correct diagnosis depends not only on the basic physical examination, but also other supplementary examinations and the ill history should be emphasized in synthetical consideration. Traditional physical examination of the chest includes four methods, inspection, palpation, percussion and auscultation. The examination should be performed in warm circumstance with well light. The patient should expose the chest to the full, in sitting or supine position according to the need for the examination or the ill condition, and be examined thoroughly with the sequence of inspection, palpation, percussion and auscultation. In general, the anterior and the lateral part is examined first, then the posterior part, this may overcome the tendency that only percussion and auscultation be cared but inspection and palpation be overlooked and avoid omission of any significant sign. A.. Landmark on chest wall The chest contains important organs such as lung and heart. Examination of chest aims to determine the physiologic and pathophysiologic situations of these organs. The position of each organ inside the chest can be determined by examining the surface of the chest. To mark the underlying organ, and detect the position and range of the abnormalities, it is quite important to make well aquaintance with the natural landmarks and artificial lines, with which the underlying structure and abnormalities can be exactly located on the chest wall. I Bone landmark Suprasternal notch: Above the manubrium sterni. In normal condition trachea is in this notch. Manubrium sterni: a piece of hexagon bone at the top of the sternum. Its upper part connects bilaterally to the sternal end of each clavicula, while its base part connects to the sternum. Sternal angle: Also termed Louis angle. It is formed by the protrusion of the conjunction composed of sternum and manabrium sterni. It connects bilaterally to each of the right and left second costal cartilage. It acts as an important landmark for counting rib and interspace, and indicates the bifurcation of the trachea, the upper level of the atria of heart, the demarcation of upper and lower part of mediastinum, and the fifth thoracic vertebra as well. Suprabdominal angle: also termed infrasternal angle, denotes the angle formed by the bilateral rib rows (composed of the seventh to tenth costal cartilage joining bilaterally) which meet at the lower end of the sternum. It corresponds to the dome

part of the diaphragm. Normally this angle is approximately 70°- 110°,narrower in slender and wider in dumpy persons, and it also widens slightly during deep inspiration. The underlying region contains the left lobe of liver, stomach and pancreas. Xiphoid process: the protrusive triangular part of the lower end of the sternum with its base connects to the sternum. The length of xiphoid process in normal subject varies widely. Rib: a total of 12 pairs. Each connects to the corresponding thoracic vertebra with its posterior end. The ribs run obliquely to the lateral and then to the anterior direction, with smaller oblique angle above and larger angle lower. Each of the 1-10 rib connects to the relevant cartilage and the sternum, constructing the bony framework of the chest. The eleventh and the twelfth rib do not connect to the sternum and thus are called free ribs. Intercostal space (interspace): The space between two adjacent ribs, used to mark the position of any lesion. Beneath the first rib is the first interspace, beneath the second rib the second interspace, and so forth. Most ribs are palpable over the chest wall except for the first one because its anterior portion is overlapped by the clavicula and usually unpalpable. Scapula: lies between the second and the eighth rib on the posterior chest wall. The hillock and shoulder ridge of the scapula is palpated easily. Its inferior end is called inferior angle. When the patient is in standing position with his arms hanging naturally, the inferior angle acts as the mark of the seventh or the eighth rib, or corresponds to the eighth thoracic vertebra. Spinous process: marks the posterior midline. The seventh cervical spinal process at the base of the neck is most prominent, usually serves as the hallmark for counting the thoracic vertebrae which start just following it. Costolspinal angle: constructed by the twelfth rib and the spine. The kidney and ureter lies in the region in front of this angle. II Vertical line landmarks Anterior midline: namely midsternal line, a vertical line through the middle of the sternum running from its top at the middle point of the upper ridge of the manubrium sterni and running down vertically through the middle of the xiphoid process. Midclavicular line (left, right): vertical line drawn through the middle point of each clavicula, e.g. the vertical line running through the middle point of the clavicula between its shoulder end and sternal end. Sternal line (L, R): vertical line runs along the vertical edges of the sternum and parallels to the anterior midline. Parasternal line (L, R): Vertical line at the middle of sternal line and midclavicular line. Anterior axillary line (L, R): vertical line drawn downward through the anterior axillary fold along the anteriolateral aspect of the chest. Posterior axillary line (L, R): vertical line drawn through the posterior axillary fold along the posteriolateral wall of the chest. Midaxillary line (L, R): running downward vertically from the apex of the axillary and between anterior axillary line and posterior axillary line. Scapular line (L, R): vertical line drawn through the inferior angle as the arm hanging naturely, parallels to the spine. Posterior midline (L, R): namely midspinal line, running vertically downward through the posterior spinal process, or along the middle of spine. III Natural fossa and anatomic region Axillary fossa (L, R): the depressed region formed from the inside aspect of the

upper arm connecting to the chest wall. Suprasternal fossa: a depressed region above the manubrium sterni, behind it lies the trachea in normal condition. Supraclavicular fossa (L, R): the depressed region above the clavicula, corresponds to the upper part of each lung apex. Infraclavicular fossa (L, R): a depressed region beneath the claviculae with its lower margin at the third rib, corresponds to the lower part of each lung apex. Suprascapular region (L, R): the region above the scapular hillock with the upper lateral margin at the ridge of the trapezius, corresponds to the lower part of the lung apex. Infrascapular region (L, R): the region that between the line through two inferior angles and the horizontal line through the twelfth thoracic vertebra. The posteriormidline departs it into two parts. Interscapular region (L, R): The region between the inside ridges of both scapulae, is departed by the posteriormidline into two parts.` IV The boundary of lung and pleura Trachea runs down along the anterior part of the neck into the thorax at the front of esophagus, bifurcates into the left and the right primary bronchus at the sternal angle level, then enters into the left and right lungs, respectively. The right primary bronchus is wider, shorter and steeper, while the left one is slender and oblique. Right primary bronchus departs into three branches, enter the upper, middle, and lower lobe of the right lung, respectively. Left primary bronchus bifurcates and enters the upper and lower lobes, respectively. Two lungs resemble in shape, except for that the anterior part of the left lung is occupied by the heart. Each lobe has a topographic position on chest wall. To know the topographic position is of importance for location diagnosis of lung diseases. Lung apex: protrudes about 3 cm above the upper edge of the clavicula with its apex point near the sternal end of the clavicula, approaches the level of the first thoracic vertibra. Upper boundary of the lung: its projection on the anterior chest wall forms an upward arc. It begins at sternal-clavicular junction, runs upward and outward to the level of the first thoracic vertebra, then downward and outwardly, ends at the border point of middle and inner one third of the clavicula. Outer boundary of the lung: runs downward from the upper boundary, quite approaches the inner surface of lateral chest wall. Inner boundary of the lung: runs down from the sternal-clavicuar junction, the two sides nearly meet each other at the sternal angle, then runs down along each side of the anterior midline, then separates at the fourth costal cartilage level. The right boundary continues almost vertically downward, turns rightward at the sixth costal cartilage, runs down to meet the lower boundary. The left boundary turns leftward to the anterior end of the fourth rib, along the anterior ends of 4-6 ribs downward, then turns left again to meet the lower boundary. Lower boundary: two sides of the lower boundary are in analogy position. The anterior part begins from the sixth rib, runs downward and laterally to the midclavicuar line at the level of the sixth interspace, and to the midaxillary line at the level of the eighth interspace. The posterior part of the lower boundary approaches horizontal at the tenth rib level by the inferior angle line. Boundaries between lobes: called fissure. Lobes of the two lungs are separated by visceral pleura between lobes. The fissure between the upper lobe and the middle and lower lobes of the right lung, and that between the upper and lower lobe of the left lung, is called oblique or diagonal fissure. Both begin from the third thoracic vertebra

Tenderness and pain on percussion on sternum usually exist in leukemia patients when myelodysplasia occurs. When superior or inferior vena cava and their branches are blocked. skin. collateral circulation will be built up. Bulging of interspaces may be seen in patients with massive pleural effusion. the costal part and the diaphragmatic part of the parietal pleura beneath the lower boundary of lung turns over and compose a place about 2-3 interspace height. Pleura: the pleura covering the surface of the lung is termed visceral pleura. Chest wall. a sensation like rolling a lock of hair between the thumb and fingers or grasping snow. When pressing the stethoscope on the involved skin. abdomen and other position of subcutaneous tissues. II Chest framwork In normal posterior midline. and the development of skeleton muscle: 1. ends at the right edge of sternum at the level of the third interspace. and breast I Chest wall In examining chest wall. begins from the forth rib at posterior axillary line. 4. forming a latent cavity. Subcutaneous emphysema: Indicates the condition when air enters and stores in subcutaneous tissue. end at the sixth chondrocostal junction. and upward when inferior vein obstructed. or marked cardiac enlargement in infancy and childhood. . even at deep inspiration. In the cavity there is a little plasma. the sound can be heard that resemble to rolling hair. 3. present elliptical shape. aortic aneurysm. The visceral part and the parietal part of pleura turn over each other successively. Occasionally subcutaneous emphysema can be caused by local infection of bacillus aerogenes. In intercostal neuritis. tension pneumothorax. or severe emphysema. called horizontal fissure. chest wall soft tissue inflammation and rib fractures. Vein: Normally the vein on chest wall is not obvious. At each side. lymph nodes. is called parietal pleura. In general. trachea or pleura. Subcutaneous emphysema at chest is commonly the result of injuries of lung. The blood flow in the varicose vein is downward when superior vein is obstructed. meet the fourth rib at posterioraxillary line. veins on chest wall become full form varicose. it can't be brimmed by the expanded lung. chest framwork. In addition. Because of its lowest position. there is some variation in size and shape of the thorax. free air escapes from injured part into subcutaneous tissues. costal cartilagitis. the involved portion may be tender. which makes the two layer of pleura adhere closely together. called crepitus. Intrathoracic pressure is negative. Retraction of the interspace during inspiration indicates the obstruction of free air flowing into the respiratory tract.Interspace: It must be mentioned whether there is any retraction or bulging of interspace. run outward and downward. and the mediastinum. the examiner should pay attention to the following aspects in addition to the nutrition.Tenderness: Normally there is no tenderness on chest wall. The anterior upper aspect of the right lower lobe attaches to the lower aspect of the middle lobe. then run downward anteriorly. which lessons the rub between pleura during respiration. B. and produce crepitation. the two halves of the thorax are grossly symmetric. the corresponding interspace bulging may be noted in the thoracic wall as the result of tumor. and that covering the inner surface of the chest wall. make up the right and the left thoracic cavity two wholly closed spaces. 2. In severe cases air may spread to neck. Pressing the skin with fingers will lead to motion of stored air in the subcutaneous tissues. the diaphragm. The boundary between the upper and middle lobe is horizontal. called sinus phrenicocostalis.

In normal female the breast begins to develop during adolescence. Barrel chest: The AP diameter is increased to as large as. form a sulciform band. Normally the first step is . If the AP diameter is a little longer than the transverse diameter. 3. 1. pneumothorax. the lower part of the sternum bulges. the part of chest wall attaching with diaphragm depress. called Harrison groove. Though. etc. The oblique degree of the rib becomes small. and plenty of light is essential. the AP diameter is less than half of the transverse diameter. the resultant deformed chest is called pigeon chest. In adult. termed rachitic rosary. the latter often reveals severe pain as the chest wall being pressed. the AP diameter is a little shorter than or nearly equals to the transverse diameter. Rachitic chest: a deformed chest caused by rachitis. or unilateral severe compensatory emphysema. aortic aneurysm and tumors inside or on the chest wall. seen mostly in childhood. Unilateral deformation of the thorax: Bulging of hemithorax is noted most in massive effusion. The infrasternal angle becomes wider with less respiratory variation. Besides. 5. the deformed thorax may cause respiratory and circulatory dysfunction. makes the thorax cylindric. with widened or narrowed interspaces. The nipple also develops to cylidric shape. Local bulge of chest wall: Seen in obvious heart enlargement.5. The opposite would apply for those who are lefthanded. 6. with the nipple located in the fourth interspace at midclavicular line. can lead to asymmetric thorax. 2. The lower anterior part of ribs turns outward. This can be seen in slender adult. Breast examination should be conducted in systemic sequence rather than only the position complained by patient. and the adjacent ribs depress. or even greater than the transverse diameter. Along each side of the sternum. or protrusion of spine. resulting in cylindric thorax. The patient is usually in sitting or supine position. Thoracic deformation caused by deformed spine: Severe kyphoscoliosis. the rib angle with spine is larger than 45°. This is common in spinal tuberculosis. bulging can also be noted in costal cartilagitis and rib fracture. making the thorax funnel-like. lest any misdiagnosis. such as tuberculosis. The xiphoid process is depressed. pulmonary fibrosis. 4. kyphosis. Interspace becomes wider and full. This situation can be seen in severe emphysema patient. called funnel chest. the anterioposterior(AP) diameter of the thorax is shorter than the transverse diameter. the patient should stripped to waist for adequate exposure of the chest. massive pericardial effusion. extensive thickening fibrotic pleura. or elderly or obese subject. Unilateral flat or retraction of the thorax is usually seen in atelectasis. in right-handed person. the lymphatic drainage sites must be examined as well. When examined. The relation between the landmark and the position of underling organ changes. and in patients with chronic hectic diseases as well. III Breast Normally the breast is not obvious in childhood and man. Flat chest: The thorax framework is flat. The clavicula is a little prominent and there is a little depression of both the supraclavicular and infraclavicular areas. In elder and childhood. present a ratio of 1:1. the vertical span is smaller. chondrocostal junctions usually bulge like rosary. assumes hemispherical. the greater pectoral muscle at the right side is usually more developed than that of the left side. the former usually has tenderness on the bulged cartilage.Shoulders are at nearly horizontal level. In severe cases of spine deformation. in addition to bone fremitus of the broken ends of ribs. Besides breast.

Mild asymmetry can also be seen as the result of difference in development of two breasts. During pregnancy the nipples become larger and more mobile. leading to shortening of the ligamentous fibers between the superficial layer and the deep layer in the involved area. greenish or sanguineous. The former is commonly associated with local swelling. skin retraction often indicates the presence of a malignant tumor.inspection. this provides a differentiation. Obvious enlargement of one breast may denote congenital deformation. or breast cancer involving the superficial lymphatic tube and causing carcinous lymphadenitis. then palpation. usually associated with skin redness. Inflammatory edema is caused by inflammatory irritation. Nipple retraction since childhood indicates mal-development. hotness. termed lymphoedema. When breast tumor is present. but also by the presence of breast carcinoma. cyst formation. 4) Skin retraction: Breast skin retraction may be due to trauma or inflammation which cause local fat necrosis and fibroblastic proliferation. the breast will enlarge obviously. usually indicates chronic cystic mastitis. ulceration. Edema of the breast makes the hair follicles and follicular openings easily seen. so that theinvolved skin looks like “ orange peel” or “ pig skin”. because of the hypertrophy of the breast tissue in preparation for lactation. The edema associated with carcinoma is caused by mechanical blockage of cancer cells in the lymphatic channels beneath the skin. It should be mentioned that if there isn't any definite evidence of acute breast inflammation. it may implies malignancy. yellowish. the superficial vessels are usually visible. skin fixation or ulceration does not appear. location. 2) Superficial appearance: Skin erythema of the breast may indicate local inflammation. which increases the capillary permeability. green. Moreover. or yellow. or tumor. Especially when advanced appearance of carcinoma such as tumor mass. if it appears recently. the mild degree of skin retraction may be the physical sign of early stage of breast carcinoma. purple. inflammation. with larger areola and more pigmental. In some instances the breast tissue extends to the apex of the axillae. Shrinkage of one breast usually indicates maldevelopment. 1.Inspection 1) Symmetry: two breasts are generally symmetrical in healthy female in erect sitting position. which may be obvious in breast carcinoma and inflammation. the hair follicles and follicular opening depress obviously. symmetry of two sides and whether or not inversion of the nipple must be noted. results in the extravation of plasma into the intercellular space. Secretion appearing at the nipple indicates abnormality along ductal system. Notations should be given as to the exact location and range of the edema on the breast skin. there may be obvious pigmentation on areola. and pain. In this situation. Clear nipple secretion becomes purple. 3) Nipple: The size. . pigmentation and scars on the breast skin should be mentioned. The secretion may be serous. In condition with hypoadrenocorticism. protrude and prollapse. During pregnancy and lactation period. superficial vein in breast skin can also be seen. whereas the latter presents scarlet skin without pain. The axillae becomes full. Bleeding is most often caused by the presence of benign infraductal papilloma.

with her arms at side first. whereas in older woman it will be more stringy and nodular. and the outer margin ends at anterioaxillary line. Take the nipple as the central point. then the ill one. This makes it convenient to locate the lesion. as well as induration. Detailed observation of the axillary and supraclavicular regions must be conducted to find if there are any bulging. The normal breast is felt like vague granular and pliable. with a rotary or to-and-fro motion. In addition. the inner margin at the sternal ridge. In supine position. or exerting pressure on both hips with her hands. 2. each quadrant is palpated superficially and then deeply. The same procedure is adopted for palpation of the right breast with anti-clockwise direction. Palpation: The upper margin of the breast is at the second or the third rib. which should not be misconstrued as tumor mass when palpated. During menses the breast becomes tight with congestion and the loose with decongestion thereafter. mis-elasticity and secretion. redness. fistula or scars. press gently with the palmar aspect of fingertips. During pregnancy the breast becomes larger and more pliable. a horizontal line and a vertical line through the central point departs the breast into four quadrants. the consistency and elasticity of the nipple must be noted. Upon palpation of the breast the following physical qualities should be noted: 1) Consistency and elasticity: Increase in firmness and lost of elasticity suggests infiltration of the subcutaneous tissue by the presence of an inflammation or neoplasm. tenderness and lump while palpation being performed. such as raising arms over head. its lower margin at the sixth or seventh rib. hotness. The palpation should begin from the healthy breast.In order to find skin or nipple retraction. The amount of subcutaneous fatty tissue will affect the “feel” of the breast. then overhead or pressed on both hips. The breast is made up of lobules of glandular tissue. The left breast should be palpated from the upper lateral quadrant. the shoulders can be elevated by a small pillow putted under them to allow the breasts rest more symmetrically on the chest wall for more detailed and convenient examination. Attention must be paid to any redness. mass. whereas during lactation period it is more nodular. ulceration. The examiner should place his palm and fingers flatly on the breast. with a procedure of clockwise direction for thorough examination. When the breast is palpated. The breast is prone to be . When subareolar carcinoma exist. the patient should be instructed to do such upper limb movements that cause the contraction of anterior chest muscles to stretch the breast ligament. swell. the patient may take sitting position. the elasticity of the skin of involved region is usually lost 2) Tenderness: The presence of tenderness in a position of the breast usually indicates an underling inflammatory process. pressing palms together. 5) Axilla fossa and supraclavicular fossa: Thorough inspection of the breasts includes observation of the most important lymphatic drainage areas. and the nipple is palpated finally. The breast of younger woman is softer and more homogeneous.

General method is to take the nipple as the central point. However. however. Furthermore. because these areas are usually involved in inflammatory lesion or invaded by inalignancy. clear of margin. ③ Contour: pay attention to whether the mass is regular or irregular. regular contour. the axilla. with firmed margin. ④ Consistency: The hardness must be described clearly. Most benign lesions have a large mobility. fever. swollen. he must determine wether the mass is fixed to the skin. the local skin appear as orange peel. whereas most malignant masses are convavoconvex. it should be characterized as the following features: ① Location: The exact location of the mass must be designated. it becomes fixed because other structures are invaded. After palpation of the breast. inflammatory lesion is considerably fixed. sometimes also in young women and men. moderately firm or extremely hard. hot and painful. tenderness is seldom in present with malignant lesions. and.sensitive during menstruation. as the process developes. 3. or fixed. Most benign tumors have a smooth. If it is movable in certain directions. associated with general toxic symptoms such as shiver. describe the mass according to the clock numbers and axis. usually associated with axillary lymphatic metastasis. a hard region may also be caused by inflammation. A benign tumor is usually felt soft. most are solidate and adherent to subcutaneous tissue. and a malignant lesion in early stage is movable. for the comparison in the future to determine if it progresses or regresses. ⑥ Mobility: The examiner should determine whether the lesion is freely movable. An inflammatory process is usually moderately or markedly tender. to what degree. inflammation is usually restricted in one quadrant of one breast. to the deep structures. 3) Mass: If a mass exist. Induration or mass is palpable. the margin is dull or acute. ⑤ Tenderness: It should be ascertained whether or not the lesion is tender. Benign lesions are soft. to detect any enlargement of lympho nodes or other abnormalities. It may be described generally as soft. Common breast lesions: 1) Acute mastitis: The breast is red. supraclavicular region and neck should be palpated carefully. whereas most malignant lesions are not obviously tender. It is most seen in female of middleaged or older. or to the surrounding breast tissue. if so. and whether it adheres to surronding tissue or not. the distance of the mass from the nipple must be recorded for the sake of accurate location of the mass. and somehow . This disease occurs commonly in lactation women. cystic. however. 2) Breast tumors: One must differentiate benign from malignancy. it must be mentioned that inflammatory lesions may also have an irregular contour. ② Size: The mass must be described in length. However. and sweat. the nipple is usually retracted. while a firm consistency mass with irregular contour usually denotes a malignant lesion. cystic. Breast carcinoma is lack of inflammatory appearance. width and thickness.

movable. etc. because shivering of the muscle caused by cold may lead to unsatisfactory inspection. Expiration is a passive movement depending on the elastical recoil of the lung and chest. hyperadrenocorticism. the blood PH drops. and the changes of intrathoracic pressure. and liver cirrhosis. thus breath becomes superficial and quick. The lateral walls can be examined with the same light. usually seen as cystic mastoplastia. such as estrogen intak. etc. the anterior parts of the ribs move outward and upward. or make auscultation misunderstood. intracanalicular fibroma. The respiratory movement is accomplished through the contraction and relaxation of the diaphragm and intercostal muscles. the anterior parts of ribs move inward and downward. the respiration is mainly dependent on intercostal muscles. pulmonary stretch reflex can also change the rhythm of respiration. C. When the patient is supine for the examination of the anterior thorax. Lung and pleura When chest is examined. The average tidal volume in adult with quiet breath at rest is about 500 ml. percussion. this is thoracic respiration. Pulmonary or pleural diseases such as pneumonia. if the examiner rotates the patient from front to back. accompanied by the decretion of negative intrapleural pressure. In condition of metabolic acidosis. whereas during expiration. while the relaxation of the diaphragm leading to retraction of the abdomen. the breath rhythm can also be controlled by consciousness. the lower part of thorax and the upper abdomen move up and down substantially. During inspiration. and respiration become deeper and slower to remove CO2 out of the lungcompensately. above and behind when the posterior thorax being examined. Hypoxemia can stimulate the carotid sinus and the aortic body chemo-receptor. leading to the expansion of the thorax. then the air in the lung is exhaled accordingly. may directly inhibit the breath center and make the breath shallow. both forms of respiration exist simultaneously with different degrees. Some diseases can change respiratory patterns. The room should be comfortably warm. resulting in the air flowing into the lung from the upper respiratory tract. thus quicken the respiration. In addition. Good lightening is quite important. I Inspection 1. seen in conditions like pneumonia or pulmonary congestion caused by heart failure. The examination of lung and pleura routinely includes inspection. increasing the intrathoracic negative pressure and expansion of the lung. Furthermore. and form abdominal respiration. Some serum factors. inspiration is an active movement. the air flow into and out of the lungs. Actually. Gynecomastia in male usually occurs with endocrine disorders. In normal condition. Whereas in female. The thorax expands and relaxex with the respiratory movement to bring about the expansion and collapse of the lung. inspiration and expiration are closely related to the negative intrapleural pressure. palpation. Respiration in healthy males and children tends to be predominantly diaphragmatic. This is controlled by the breath center and regulated by the nerve reflex. the light should be above and directly in front of the anterior thorax. severe . Breath movement: The breath movement in healthy subject at rest is steady and regular. and auscultation. such as hypercapnia. the patient is generally in sitting or supine position with upper garment stripped off for adequate exposure of the chest. while the contraction of diaphragm leading to bulging of the abdomen. Therefore.

massive peritonal effusion. the respiratory rate is 16 to 18 per minute. hence called inspiratory dyspnea. 2) bradypnea: Indicates the decreased respiratory rate that less than 12 per minute. Usually the respiratory rate increases approximately four additional cycles per minute for each 1°above the normal temperature. ascites and fatness. seen in over dose of anesthetics or sedatives and elevated intracranial pressure. pain. This kind of deep and slow breath is also named as Kussmaul . Hyperpnea (fig. extreme enlargement of the liver or spleen. could be found during strenuous exercises. can all weaken the thoracic respiration and strengthen the abdominal respiration. exhalation with exertion may lead to bulging of the interspaces. On the contrary. Respiratory rate: In the normal adult at rest. or chest wall diseases such as intercostal neuralgia. Deep and slow breath could appear during serious metabolic acidosis. And also could be seen in pneumonia. 1) tachypnea: Indicates the increased respiratory rate that over 24 per minute. The respiration becomes superficial. and decreases gradually upon growing up. The ratio of respiratory rate to pulse rate is 1:4. hyperthyroidism and heart failure. superclavical fossa and interspaces. anemia. and PH is lower. whereas during expiration. rib fracture. which has the same clinic significance as the lower margin of lung. etc. During inspiration. for increased body oxygen supply needs more air exchange through the lung. Tetany and apuea may happen in severe cases. a phenomenon of diaphragm movementdemonstrated by the oblique projection of light. The respiratory rate in newborn is about 44 per minute. It can also appear when one is excited or nervous. it usually occurs in asthma and obstructive emphysema. In patients with partial obstruction of the upper breathing tract. air flow into the lung is impedent. called expiratory dyspnea. pleurisy. 3) Change of the breath depths: Hypopnea (fig. This is associated with prolonged expiration. a narrow shadow begins from the anterioaxillary line in the seventh interspace and shifts to the tenth interspace. pleural effusion and pneumothorax. Litten Phenomenon: Also named as wavy diaphragmatic shadow. Decreased PaCO2 ensues and could induce respiratory alkalosis. the examiner is in front of or at the side of the light with his vision line at the upper abdomen level. by foreign body. thus the inspiratory muscle contraction may lead to extremely high negative intrathoracic pressure and cause the depression of supersternal fossa. It usually occurs when trachea is obstructed. 1. in patients with lower respiratory tract is obstructed. because of over ventilation. usually seen in fever. for example.3-5-8). When the phenomenon is detected. for compensation.could be seen in respiratory palsy. the light should be placed at head or foot side. This phenomenon is due to the diaphragmatic movement corresponding to respiration. termed “ three depression sign”. tremendous intraperitonal tumor and advanced pregnancy. because the airflow out of the lung is impedent. Peritonitis. This is because the HCO 3 in the extracellular fluid is not enough. The normal shift range of the diaphragm is 6cm. the shadow regresses upward to the original position. can all limit the downward movement of the diaphragm . resulting in weakened abdominal respiration and compensatory strengthened thoracic respiration.tuberculosis and pleurisy. CO 2 is eliminated by the lung to maintain the acid-base balance. Patients often feel numbness around the mouth and at the tips of the limbs.3-5-8). On such occasions inspiration is prolonged.

2. pneumothorax. drug induced respiratory depression and brain damage(typically on both sides of the cerebral hemispheres or diencephalon).Inhibitory breath The inspiration is suspended while a severe pain in the chest happened. describe. uremia. Identify. Fremitus is typically more prominent in the interscapular area than in the lower lung . the respiratory movement restrained suddenly and momently. costal fracture and severe trauma of the thorax. The mechanism of the upper two rhythm is that the respiratory central excitability is depressed. Easy to obtain when examine the antero-inferior part of the thorax. Causes include heart failure. and your hands along the lateral rib cage. often happening before demise. In either case you are using the vibratory sensitivity of the bones in your hand to detect fremitus. (2) Vocal fremitus Also called tactile fremitus. Occasional sighs are normal. Ataxic breathing is characterized by unpredictable irregularity. pleural thickening and atelectasis etc(fig. seen in diabetic ketoacidosis and uremic acidosis. the whole process could be realized. Vocal fremitus refers to the palpable vibrations transmitted through the bronchopulmonary system to the chest wall when the patient speaks.breath. 4. The respiratory center can only be excited when anoxia is severe. The periods of the tidal breath can last from 30s to 2min. Palpate and compare symmetrical areas of the lungs using either the ball of your hand (the bony part of the palm at the base of the fingers) or the ulnar surface of your hand. Tidal breathing Also called as cheyne-stokes respiration. the feedback system of the breath can’t work normally. Breaths may be shallow or deep. the breath weakened and suspended. So only through carefully and long enough observation. Causes include acute pleurisy. this is a sign of cerebrovascular sclerosis. If fremitus is faint. Ataxic breathing Also called Biot’s breahting. and localize any area of increased or decreased fremitus. The rhythm of the breath usually changes in diseases. When the patient inhales deeply. PALPATION (1) Thoracic expansion It is the movement range of the thorax during respiration. and feel the range and symmetry of respiratory movement. 1. 3-5-0). watch the divergence of your thumbs as the thorax expands. Causes of unilateral diminution of or delay in chest expansion include huge pleural effusion. ask the patient to speak more loudly or in a lower voice. the prognosis is worse. The periods of apnea can persist 5-30s. The expression of the patient is suffering. tumor. sighing respiration Breathing punctuated by frequent sighs should alert you to the possibility of hyperventilation syndrome – a common cause of dyspnea and dizziness. where the respiratory movement is much obvious. and CO2 concentration in the blood reaches a certain degree. the center lost the effective excitability again. Ask the patient to repeat the words “yi—“. Ataxic breathing is more severe than the tidal breathing. 2. and stop for short periods (fig. 3-5-10). Respiration waxes and wanes cyclically so that periods of deep breathing alternate with periods of apnea(no breathing). when the CO2 is exhaled. Place your thumbs along each costal margin. breath become shallow and frequent. Aging people normally may show tidal breathing in sleep. 3. (3) Rhythm of the breath Normal adult respiration is basically regular and smooth in testing status.

A thick chest wall requires heavier percussion than a thin one. Put your right forearm quite close to the surface with the hand cocked upward. When the air passing through the narrow trachea and bronchus or through thick exudate in the airway. Aim at your distal interphalangeal joint. shift their scapulae lateralwards as obviously as possible. the fibrin deposit between the two layers of the pleura. It is most obvious at the lower part of the thorax for the movement range here is the greatest. percuss from apices to the lung bases. percuss from the axilla down to the costal margin. then percuss each intercostal space from up to sown. separation of the pleural surfaces by fluid (pleural effusion). after the width of apics be decided.3-1-2). the lateral chest wall. First. Causes include an obstructed bronchus. Thump about twice in one location and then move on. Your striking finger should be almost at right angles to the pleximeter. until the movement range of the diaphragm be identified. Fremitus is increased when transmission of sound is increased. and poised to strike. because this would damp the vibrations. ask the patient raise the arms and put them on the head. chronic obstructive pulmonary disease. strike the pleximeter finger with the right middle finger (the plexor). 2) Immediate percussion Percuss the thorax by the tip of your plexor finger or the united finger pad directly to show the changes of different places. percuss each intercostal space one by one from supraclavicular fossa. Press its distal interphalangeal joint firmly o the surface to be percussed. And last percuss the posterior chest. (2) Influencing factors Dullness replaces resonance when fluid or solid tissue replaces air-containing . keep your technique constant. It can be palpated both in inspiration and expiration. air (pneumothorax) or an infiltrating tumor. relaxed. When percussed the patient should be in a sitting or dorsal position. not the finger pad. Use the lightest percussion that will produce a clear note. fibrosis ( pleural thickening). however. so it is called pleural friction fremitus. sharp. Fremitus is decreased or absent when the voice is soft or when the transmission of vibrations from the larynx to the surface of the chest is impeded. the visceral pleura and the parietal pleura rub with each other. The right middle finger should be partically flexed. usually the former could disappear after coughing while the latter will not. (2) pleural friction fremitus During acute pleurisy. Withdraw your striking finger quickly to avoid damping the vibrations that you have created. as through the consolidated lung of lobar pneumonia. Differentiated. With a quick.Avoid contact by any other part of the hand. and breathing homogeneously. It disappears below the diaphragm. Ask the patient lower the head slightly. a kind of fremitus could also be produced. relaxed. examine the anterior chest.fields. In comparing two areas. You will perceive the sounds better by comparing one area with another than by repetitive thumping in one place(fig. and also a very thick chest wall. Second. 3 PERCUSSION (1) The method of percussion 1) Mediate percussion Hyperextend the middle finger of your left hand(the pleximeter finger). this can be felt by the examiner’s hand. The upper body leans slightly anteriolly. keep both arms crossed in front of the chest. and is often more prominent on right side than on the left. Use the tip of your plexor finger. but relaxed wrist motion.

the thickness of the chest wall. when the sound turns from resonance to dullness gradually. bery similar to the sound of knocking a water-filled container. (4) Normal percussion notes 1) Normal percussion notes of the lung: resonance is the normal notes of the lung. percuss from the same middle part to inner-side. duller in the upper part of the right thorax than of the left side. Duration is short. when the resonance turn to dullness again. It is also considered as the extreme dullness. The method is: percuss from the middle trapezius muscle outwards to lateral side little by little. It is influenced by the size of heart. Examples include: lobar pneumonia. fibrous tissue. The width of this resonant boundary is the width of apics. blood (hemothorax). and the left one is at the parasternal line from 4th to 6th interspace. Generalized hyperresonance may be heard over the hyperinflated lungs of emphysema or asthma. but it is not a reliable sign. aortic aneurysm. (2) The anterior pulmonary boundary The heart normally produces an area of dullness to the left of sternum. posterior part of the cervical muscle is its inner side and shoulder girdle is at its lateral side. the sound is duller in the upper part of the anterior thorax than the lower part. not very loud but could be heard easily . the inner termination of the border comes out. (3) Classification of the percussion notes 1) Resonance It is the normal sound of the lung. 5-8cm regularly. senses of vibration beneath the pleximeter finger is not so obvious.g. The boundary is narrowed or sounds dull when tuberculosis infiltrates the apics and fibrosis or atrophy is formed. very loud and very easy to be heard. The width of right side is narrower than left. It is high and soft in quality. but sense of resistance is increased. in which the alveoli are filled with fluid and blood cells. or tumor. And then. 3) Tympany The pitch is higher than resonance. and the organs around. Unilateral hyperresonance suggests a large pneumothorax or possibly a large air-filled bulla in the lung. e. duration is not so long. the lateral termination of the upper border is identified. And the sound of right infra-axilla is duller for the liver is near. the percussion soud is tympany for the gastic air bubble over there. It is influenced by the air containing. percussion on a stomach filled with gas produces such a sound. it is also named as Kronig isthmus. located at the 6th intercostal space at the . and pleural accumulation of serous fluid (pleural effusion). 2. The upper boundary widened or changed to hyperresonance when there is emphysema. pus (empyema). The right anterior pulmonary boundary is at the sternal line.lung or occupies the pleural space beneath your percussing fingers. duller in the posterior chest than the anterior chest. 2) Hyperresonance Lower and longer than the resonance. shown as a low pitched sound. and have a long duration. though in the left side at the comparable part. pericardial effusion. Influenced by muscle and skeleton. the duration is moderate. (3) The inferior pulmonary boundary It is about the same of two sides. for right apics is located lower and the muscle of right shoulder girdle is stronger. that is the width of the apics. enlarged lymph nodes of the pulmonary portal and also by the emphysema. this part is also called Tranbe tympany region. 4) Dullness Opposite to resonance. 5) Flatness It refers to the lacking of resonance. pitch and intensity are both of medium degree. Percussion of the pulmonary boundary (1) Upper pulmonary boundary. intensity is moderately loud.

Using locations similar to those recommended for percussion and moving from one side to the other. It is different in different body type. the boundary could be elevated about one intercostal space and in thin person descended about one interspace. compare symmetrical areas of the lungs. If the effusion is moderate. The note will be dullness or flatness when air contain decreased. liquefacient pulmonary abscess and cysts. this dull region then disappeared. Change the position. the spine stretched.midclavicular line. Listen to at least on full breath in each location.Percussion of thorax in a lateral decubitus. Abnormal percussion sound of the thorax The percussion sound can be changed at least the focus is larger than 3cm and the distance between the surface less than 5cm. such as cavernous lung tuberculosis. 8th interspace at the midaxillary line. Pathologically. pulnomary edema. there will have a Damoiseau curve formed by the effusion. the note will be tympany. 3. there are Garland and Grocco triangle region of dulltympany formed by the effusion. For its metalloid reecho. An abnormally high level suggests pleural effusion or a high diaphragm. pleural effusion. The size of this region is influenced by the quantity of effusion. the note is also called Amphorophony. celiac organ declined. without pleural thickening or adhesion. the local percussion note can be a mixed sound which has the character of both dullness and tympany. pulmonary infarction. 4. Influenced by the bed. celiac hypertension. It elevates with a atelectasis. atelectasis. and pulmonary lower boundary. spine. the boundary descends with emphysema. congestion and dissolution stage of pneumonia. as from atelectasis or diaphragmatic paralysis. examine again to prove the influence of the posture(fig 3-5-13) 5. when pillow is removed. 10th interspace at the scapular line. If the breath sounds seem faint. You . normally around 6-8cm. If the diameter of the cavity lesion is larger than 3-4cm. we can percuss out a comparative dullness region at the tip of the subscapular angle on the upper side. tumor. Such as emphysema. Also show as the same figure. or patient with hypertonic pneumothorax. patient in a sitting position. With the pleximeter finger held parallel to the expected border of dullness. The diaphragm elevated caused by the celiac pressure. 4. AUSCULATION Listen to the breath sounds with the diaphragm of a stethoscope as the patient breathes somewhat more deeply than normal through an open mouth. pleura thickening etc. Percuss in progressive step downward until dullness clearly replaces resonance. Method is: identify the level of diaphragmatic dullness during quiet respiration. If cavity is very large and located shallow. such as atelectasis. pulmonary edema. Diaphragmatic excursion may be estimated by nothing the distance between the levels of dullness on full expiration and on full inspiration. we name it as dulltympany Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. The note will be hyperresonance when the pulmonary tension decreased and air contain increased. Show as figure 3-5-14. ask the patient to breathe more deeply. Examples include: pleural effusion. When pulmonary air contain decreased. the percussion note will be tympany locally. An the nearbed-side intercostal space. we can percuss out a comparative dull zone alone the near –bed-side thorax.movement range of the lower pulmonary boundary That is equal to diaphragmatic movement. such as pneumonia. and close to the chest wall. In fat person.

huge tumor in the abdomen etc. Bronchovescicular breath sound: is a mixed sound composed of bronchial breath sound and vescicular breath sound. continue without pause into expiration.3-5-15). and sith less tubular characteristc and shorter expiratory phase. eg. then there is diminished alveolar breath sound on the involved side. 2). acidosis. and . it is usually abnormal. abnormal vesicular breath sound 1) Decreased or absent vesicular breath sound: This is associated with decreased or slower air flowing ito the vesicls and also with impaired conduction of breath sound. trachea or major bronchi. diaphrmatic paralysis and diaphramatic muscular spasm etc. If such a sound is heard at other location than those mentioned above. the nearer to the trachea one listca to. (2) Abnormal breath sounds 1. bronchial stricture etc. c) bronchial obstruction. makes respiration accentuated.3-5-15). higher pitched and louder. and out flow is slow. on such occasion. like chronic bronchitis. a disorder should be suspected of. 3. age. and around the lung apex. and around the 1 st and 2nd thoracic vertebra. unilateral accentuated alveolar breath sound could been seen in patients with unilateral thoracic pulmonary diseases. respiratory deepth. such as pleural effusion. while expiration is of passive movement. inspiration is shorter than expiration because inspiration is of active movement. and then fade away about one third of the way through expiraton(fig. Besides. eg.may then hear them easily.3-5-15). such as myasthenia. with lower loudness and pitch. This sign on the lung could appear localized. b) anoxia stimulattes respiratory center. anemia c) blood acidity increases. inflow is rapid. similar to the sound of “ha” when one lift tongue to make the expiration through mouth. the causes may be the followings: a). ossification of rib cartilages and resection of ribs etc. 2) Increased alveolar breath sound: Alveolar breath sound accentuated on both sides is associated with exaggerated respiratory movement and vetilation. unilateral or bilateral. like massive ascitis. there is more and faster air flow into the lunge. bronchial breath sound could be heard over the laryngus suprasternal. or pneumothorax etc. The strength of the sound is associated with sex. Its pitch is high. pulmonary elasticity. notch the areas near the 6th and 7th cervical vertibra. Exercise. The louder and the lower pitched is the sound. eg. Bronchial breath sound: is the sound of turmoil flow produced by the inspirated air through glottis. d) oppressive under-expansion of the lungs. e) abdominal disorders. the glottis gets narrower. b) respiratory muscle diseases. (1) Normal breath sounds 1) vesicular breath sound It is soft and low pitched. grakis. and the thickness of the chest wall.restricted movement of the thorax due to chest pain. In normal persons. there is a very short gap between inspiratory and expiratory phase. Stimulates respiratory enter. fever and high metabolism rate etc. The causes are as follows: a) body oxygen demand increases and makes respiration deep. there is a very slow silent pause between inspiration and expiration(Fig. the expiration is more exaggerated and higher pitched. durations of two phases are almost the same(Fig. around the intrascapular region at the 3rd and 4th thoracic vertebrae. the glottis widens. While its expiratory component is similar to bronchial breath sound. Bronchovescicular breath sound could be heard in the 1 st and 2nd intercostal space near the sternum. long and faster. They are heard through inspiration.

3) Pressed atelactesia: pleural effusion may press on the lung. . 3) Elongated expiratory breath sound. sputum. siginificant in inspiration or in the terminal phase of inspiration. often series of jeveral sounds appear. 5) Hoarse breath sound: heard in the early stages of bronchial or lung inflammations. happening in COPD etc. bronchial breath sound heard at the locations where vesicular breath sound should be heard is abnormal. and conducts well through the consolidated tissur. it may diminish or disappear after cough. resulting in decreased expiratory power. bronchial asthma etc. and differentiation is easy. 4) Interrupted breath sound: Segmental pulmonary inflammation or bronchial structure makes the air enter alveoli unharmoniously and thus results in interrupted breath sound. such as exudate. happening in bronchitis. (3) Rales. 1) The characteristics of rales: adventious sounds besides breath sound. 2. often seen in pulmonary abxcess or cavity-formed pulmonary TB. This condition is often seen in lung abscess and cavitous pulmonary TB. make underlying lung tissue more dense and cause atelactesia. painful or nervous. often seen in bronchopneumonia. 3. its location. discrete and short in time. blood. but they are not related to respiration. not present in normal situation. the adventitious sound. mucus. bronchial breath sound is often louder and high pitched near the listening ear. 2) Big cavity in the lung. 1. present sometimes in the early phase of expiration. Abnormal bronchial breath sound. the larger and the shallower the lesion. often seen in pulmonary TB and pneumonia. and is also called tubular breath sound. medium and fine rale could be present simultaneously. the location is rather fixed. moist rale: produced due to passage of air through thin secretions in the respiratory tract. Several kinds of rales could be discerned according to their characteristics.compensatory accentuated breath sound on the normal side. Leading go elevated expiratory impedence. Abnormal bronchoalveolar breath sound: heard over the area where only normal alveolar breath sound is heard. bronchial breath sound could be heard clearly. bronchial breath sound could be heard clearly. and the vice versa. due to smoothlessness or stricture produced by mild bronchial membranous edema or inflammation. Occurs because of partial obstruction. It must be noticed that interrupted adventory sounds due to muscular contractions may be produced when one feels chilly. quality not variable. At consolidation stage of lobar pneumonia. the louder the sound. Because of better conduction through the consolidated past of the lung. pulmonary TB early stage of lobar pneumonia or over the underexpanded lung area above pleural effusion. It is produced because consolidated part is smaller and mixed with normally air contained pulmonary tissues or the consolidated part is deep and covered by normal lung tissue. It is also called cogwheel breath sound because of short irregular pauses. or pus etc. spasm or stricture of the lower respiratory tract. The sound could also be regasded as crackles produced by reopening of the bronchials at inspiration when bronchiolar wall adheres and closes because of tenacious secretion at expiration. the reasons are as follows: 1) Consolidation of lung tissue: This makes bronchial breath sound conducted easily through the dense consolidated lung tissue to body surface. not due to the change of breath sound. communicating with the bronchus. area and loudness is related the location size and depth of the lesion. when there is a cavity in the lung surrounded by consolidated lung tissue. The breath sound harmonicates in the cavity. or because of lowering elasticity of pulmonary tissue.

which occur in the large air passages above main bronchi. basic frequency may be over 500 Hz. heard over the areas of trachea major bronchi and cavitation. haking them adhere one another. often occussing at the terminal phase of inspirationlike the sound when one hold a lock of hair near your ear and sub it. Sibilant rhonchi are often produced in smaller bronchi or bronchioles(Fig3-5-16). it disappears after several deep breaths or coughing.loud or unloud rale according to its louderness (1) loud rale: rales sonorous. Rhochi are rather high-pitched with the basic frequency of about 300-500 Hz.(2) Medium rales: or medium bubble sound. when the patient inhales. the pathologic basis for which is inflammatory membranous congestion and edema oversecretion. They often occur in trachea or . quality and location. met in bronchiolitis. Localized lung rales only indicate localized lesions of the same plase. these bronchiole and alveoli open again and result in high. at the late phase of inspiration(Fig3-5-17). are too weak to excrete secretion in the respiratory tract. Rhonchi are easily variable in intensity. it is then called death rattle on this occasion.pitched fine crackling rales with high frequency. If the cavity wall is smooth. with no clinical significance. pulmonary TB or lung abscess cavitation. relatively long. They are often met in inflammation of brochioles and alveoli or pulmonary congestion. Rales could be divided into coarse. 3) classification: (1)sibilant rhonchi: high pitched. in general more prominent during expiration. sonorous rale may mix with somewhat metalic pitch. often happening in the early phage of inspiration(Fig 3-5-17). audible easily even without stethoscope. early phase of pneumonia and alveolitis etc. and often accentuated by forced expiration.(2) sonorous rhonchi: are low pitched.2. even without usage of stethoscope. medium and fine ones and even crepitations according to the size of respiratory tract lumen the amount of secretion(Fig.2) Classification of rales: 1. Comatose and death impending patients. bronchopneumonia pulmonary congestion and pulmonary infarction etc. (4)Crepitus: a very fine and harmonious rale. lung edema. Some rhonchi. air through these passways becomes turbulent. Audible both during inspiration and expiration. short like “zhi-zhi” sound.3-5-16). 2. lung abscess or cavitous pulmonary TB. obstruction due to tumor and foreign bodies in the bronchial lumen. Coarse rale could be heard over the trachea. like pneumonia. heark in pneumonia. Rhonchi: produced because there present stricture or partial obstruction of the trachea. sound becomes gradually lower during conduction. or bronchiectasis etc. Rales over the whole two lung fields are often met in acute lung edema and severe bronchopneumonia. such as bronchiectasis. 1) Characteristics of bronchi: they are continuous. they are the result of presence of secretion in the bronchioles and alveoli. bronchopneumonia etc. at the middle phase of inspiration(Fig 3-5-17). heard in bronchitis. pulmonary TB. and musical adventious breath sound. bronchial muscular spasm. Rales over two lung bases are often met in pulmonary congestion due to heart failure and bronchopneumonia etc. and stricture due to oppressian of extraluminal enlarged lymph nodes or mediastinal tumors. bronchi or bronchioles. like moaning or snore in character. sometimes they change obviously instantly. (1) coarse rales: also named as large bubble sound. However in normal old people or patients with prolonged bed rest. produced in bronchioles. or musical in character. produced in the medium bronchi. produced due to surrounding tissue with better conduction. the basic frequency is about 100-200 Hz. the sound is low and for to ear because there is still much normal lung tissur around the lesion. (3) fine rale also named small bubble sound. crepitus alsocould heard over two lung bases. may be very loud. (2) unloud rale. Consolidation or harmony in the cavity lead to loud rale.

chest wall edema.It is often heard over the upper portion of a moderately pleural effusion or where there is a small amount of fluid in association with pneumonic consolidation. Ask the patient to say”yi-yi-yi”. It is seldom heard over the apex because its respiratory excussion is less than the laver portion of the thorax. The characteristics of a friction rub can be imitated by pressing the palm of one hand over the ear and then rubbing the back of the hand with the fingers of the other hand. If mediastinal pleura becomes inflammed. Its presence always indicates large area of consolidation. Vocal resonance changes when there present pathologic conditions. Accentuated and higherpitched pectoriloguy could be clearly heard when there is pneumonic consolidation. relatively superficial. more clearly at the end of inspiration or at the beginning of expiration.1. Normally. Vocal resonance is decreased in bronchial obstruction. and the syllables are not distinguishable. It is elicited by having the patient repeatedly say “yi” with ordinary voice loudness. Rhonchi heard on both sides of lungs. pleusal thickening. Friction rub may disappear or reappear with the changes of body position. (5) Pleural friction rub: Normally the visceral and parietal surfaces of the pleura glide quietly during respiration because of the presence of a little amount of fluid in the pleural cavity. pleural effusion. when these surfaces become inflammed and there is exudated fibrin. obesity and emphysema etc. Pleural friction rub often occus in fibrioous pleusisy. “whispered” pectoriloguy. An increase in intensity of the friction sub may be noted with pressure of the stethoscope over the chest wall. the word spoken are not as loud and clear as when heard directly. Localized rhonchi are often heard in bronchial membranous TB or tumor because of localized bronchial structure. The syllables may be understood when the patient whispers. However. sound vibration at laryngus will conduct through trachea. dullness to percussion and abnormal bronchial breathing. (4) Vocal resonance : is produced in the same fashion as vocal fremitus. . the sounds must actually whispered as :yi yi yi”. it is usually associated with increased vocal fremitus. Bronchophony: This indicates vocal resonance that is increased both in intesity and clarity. are often met in bronchial asthma. It also disappear when there presents moderate amount of pleural effusion. Occasionally. but reappears when effusion is absorbed and two layers contact again. and two layers of pleura separate. broncho alveoli and chest wall to the stethoscope. it is classified as follows according to auscultation differences. pectriloging may be obvious before bronchial breath sounds develop. they will sound as “a-a-a”. chronic bronchitis and cardiogenic asthma etc. eqophony: not only there is an increase in intensity of the spoken voice but its character is also altered so that there is a nasal or bleating quality. pectorilogny: a kind of bronchophony that is more intense and clear and near to ear. the area of greatest thoracic mobility. and indicates the presence of pulmonary consolidation. pulmonary infarction.3. Friction rub disappears when breath is held.major bronchi(fig3-5-16). if egophony is present.In the normal subject the whispered voice is heard only faintly in the areas where bronchovesicular breath sounds are normally heard. pleural friction rub could be heard both with respiration and heart beat. It is often heard during both phases of respiration.2. The most common site for a friction rub to be heard is the lower anterolateral chest wall. thus this sign is of value for the diagnosis of pulmonary consolidation. pleural tumor and uremia etc. the subbing of the roughened surfaces during respiration produces such pleural friction rub.4. It is heard loudest near the trachea and major bronchi and is less intense at the lung bases.

the main pathogen is streptococcus pneumoniae. and bronchial breath sounds. pleural friction rub could be heard if pleura is involved. which worsens during exercise. muscular pain. etc. The amount and location of the rales are often variable. they usually complain of headache. During resolution stage. with flushed cheeks. deficiency of local defense mechanism and immune function and unbalance of autonomic nervous system. decreased or disappeared after cough. including increased vocal acute exacerbations one could hear sparse dry or moist rales. as significantly increased . rusty brown sputum. tachypnea. [symptoms] Chronic cough is the main symptom in winter. vocal fremitus and resonance. (7) D The major symptoms and signs of common respiratory diseases (1) Lobar pneumonia Lobar pneumonia refers to lobar distribution of pulmonary inflammation. dyspnea. and perioral herpes is also common. bronchial membranous atrophy. oversecretion of the glands. signs of congestive stage may be present. wine drinking. they are congestion. allergic tendency. as sustained fever.(6) Coin sign: press a coin on the patients’ one side of middle of front chest. then tap it with another coin. rapid pulse. with chill and then high fever. often located at the lung bases. [Signs] No obvious signs are found in the early stage. the sputum becomes purulent when the patient has infection. cyanosis. and accompanied by massive sweating. all the above signs gradually disappear. consolidation and dissolution. signs of consolidation appear. . More rhonchi associated with elongation of expiratory phase could be heard for the asthmatic pattern of chronic bronchitis. When pneumonia involving a whole lobe progresses. long time contact with toxic gas and dust. cough. On the comparable part of the back of the ipsilateral thorax. and often lasting longer than 3 months. The patient often feels dyspnea and chest dicomfort. which could be met in pneumothorax. Clinical manifestations are different with different stages. alae nasi fans. and dyspnea gradually progresses. resulting in bronchial spasm. most propably associated with prolonged smoking. Crackles are localized to the involved region. [symptom] the patients usually are adolescent with the occurrence after tiredness. rupture and damage of bronchial smooth muscle. edema. and finally bronchiolar and alveolar dilatation. there are bronchial membranous congestion. repeated respiratory tract infections. In the lesion. Pathologically. chest pain on the affected side. however there are no clear demarcation among three stages. The disease often starts abruptly. Its etiology is variable. air pollution. [signs] The patient appears acute faces. the temperature could be up to 39-40°C . worsens to become chronic obstructive emphysema in the late stage. (2) chronic bronchitis complicated with emphysema Chronic bronchitis is a non-specific inflammation involving membrane of the brachea and bronchials and the surrounding tissues. It occurs insidiously and progresses slowly. the cough is often more severe in the morning and is associated with a lot of white mucoid or serous frothy sputum. the temperature may drop drastically several days later. three stages could be discovered. one could hear a tympany with a kind of metal tone. dullness or flatness to percussion. the patient then may feel much better. this is the positive coin sign. hyperplasia of peribronchial fibrous tissue. and even leads to pulmonary hypertension and cor pulmonale. exposing in the coldness. bad weather conditions.

and will show related symptoms and signs. Airways are highly sensitive to various stimuli. wide intercostal space. with the recruitment of respiratory ancillary muscles. and have symptoms of HF. pneumonia and tumor etc. Besides. dry rales and wheezing sound could be heard on both lungs. full thorax. and this can lead to diffuse reversible airway obstruction for the vulnerable ones. narrow intercostal space. Contact with allergens are often present before the attack. however. moist rales could be heard on two lung bases. showing orthopnea.). restricted movement of affected side. sneezing. massive diaphoresis. diminished vocal fremitus and hyperresonance on percussion. TB. resulting in increase of production or decrease of absorption of fluid in the pleural cavity. weakened vocal fremitus and resonance. ascites. nephropathy) or higher capillary wall permeability(eg. for example. hyperresonance over the lungs to percussion. there could be seen shallow respiration. snivel or dry cough. repeatedly occur with the change of seasons. (4)pleural effusion Pleural effusion is produced because the static pressure of the pleural capillaries are elevated (eg. In the patients with moderate or large amount of effusion. impaired drainage of pleural lymph and trauma also could lead to pleural effusion or hemothorax. they appear severely expiratory dyspnea. bronchial smooth muscle is spastic. When effusion increases. dyspnea. Patients with more than 500 ml effusion often complain of dyspnea and chest discomfort. decreased respiratory movement. besides the symptoms due to pleural effusion itself. mucous membrane is congestive and edematous. patients often have symptoms of the orginal diseases. heart failure). orthopnea or even cyanosis. lower osmotic pressure (hypoalbuminemia due to liver sclerosis. one could find barrel-shaped thorax. patients with small amount inflammatory fibrous exudation often complain of irritative unproductive cough. pain may become milder or even disappeare. [Sign] Patients with small amount of effusion often have no obvious signs. or they may only show diminished chest wall movement on the affected side. parietal and visceral layers of the pleura separate. The grave patients may show cyanosis. Patients with prolonged duration and multiple recurrence may be complicated by obstructive emphsema. such as nose tickling. Huge effusion may press or even displace mediastinal organs to cause palpitation. while during the attacks. Pleural effusion could be classified into exudate and transudate due to different etiologies. Then chest discomfort and shortness of breath quickly appear.. [symptoms] Majority patients start in young or adulthood. and the gland oversecretion is common. [Symptoms] Symptoms are often not obvious if effusion is less than 300 ml. the lower liver margin is displaced downward.In patient with obstructive emphysema. (3) bronchial asthma Chronic bronchial inflammation is mainly caused by allergic reaction. Alveolar breath sound with elongation of expirtory phase is diffusely distributed. worsened on inspiration. displacement of apex . the asthma usually relieves gradually after more or less thin sputum was spit out. patients often have symptoms associated with respiratory infection or allergic manifestations. lowerness and the diminished movement of the lower lung margins. Patients would rather lie on the affected side to restrict respiratory movement of this side in order to alleviate pain. [signs] Patients usually have no obvious signs during resolution stage. Heart dullness area is smaller. they have fever and toxic symptoms because of exudate due to inflammation. edema etc if the effusion is of noninflammatory transudate. lasting hours or even days. diminished respiratory movement with the chest almost at the inspiratory position. and accompanied by chest pain on the affected side. At the attack.

Garland triangle on the upper and back area of the effusion. holding breath. sometimes. holding heavy things. In patients with huge effusion or effusion with thickening and adhering of the pleura. diminished respiratory movement. due to bleb beneath the surface of the normal lung. with or without sputum. then on the affected side appear fullness of the chest. over the effusion areas. cyanosis and even respiratory failure besides dyspnea. restlessness. Scoda hyper-resonant area above and in front of area on the normal side. liver dullness edge displaces downward when pneumothorax is on the right side. breath sound and vocal resonance are diminished or absent. and diminished or no vocal fremitus or resonance. wide intercostal spaces. chronic respiratory emphysema. rapid pulse. diaphoresis. such pneumothorax is called artificial pneumothorax. [symptoms] Inducing factors are often as follows. syncope. Besides. Pleural friction rub is often heard in fibrinous pleuritis. Trachea and heart displace toward the healthy side. flatness on percussion is common. (5) pneumothorax Pneumothorax means that the air enters the pleural cavity. they can’t lie supine and so have to lie on the normal side. Sometimes doctors inject filtered air into the pleural cavity artificially to treat some diseases. may show nervousness. Patients feel ipsilateral chest pain suddenly and progressive dyspnea. 3-5-19). Patients could have cough. let the affected side upward in order to alleviate pressing symptoms. In patients with moderate amount of effusion without thickening and adhering of the pleura. The signs of common pulmonary and pleural diseases are listed in table 3-5-1 Table 3-5-1 inspection palpation Percussio Auscultation n Chest Respirato Trachea Vocal Note Breath rale Vocal appearance ry location fremitus sound resonance movemen t Symmetrica Diminish Central Increased Dullness Bronch Moist Strengthened l ed on the on the or ial rale affected affected flatness breath side side sound BarrelDiminish Central Diminish Hyperres Dimini Always Diminished shaped ed on ed on onance shed without both sides both sides . When air trapped in the pleural cavity is voluminous. [Signs] Patients with mild pneumothotax often have no obvious signs. Severe tension pneumothorax patient. and patients may calm down several hours later. In mild closed pneumothorax only mild dyspnea is present. or pulmonary TB.(Fig. or absent apex beat. Breath sound is diminished or disappeared on the affected side. tympanic sound on percussion. one could percuss out Damoiseau line of the upper margin of effusion. it is called spontaneous pneumothorax. those caused by thoracic injury or acupuncture are called traumatic pneumothorax. strenuous exercises or cough. Coin sign is positive.Cons olidat ion Emph ysem a beat and trachea toward the opposite side. If the pneumothorax is caused by rupture of visceral layer of the pleura. bronchial breath sound sometimes could also be heard.

Bedside clinical examination should be performed and practiced in the same way following similar sequences. Adequate (preferably fluorescent or natural) light is essential. and free from distracting noise and sources of interruption. The examining table may be placed with its head against the wall. the patient should feel when it is all over. If the physician is considerate and gentle.Atele ctasis Denting of the affected side Fullness of the affected side Diminish ed on the affected side Diminish ed or disappear anced on the affected side Diminish ed on the affected side Diminish ed or disappear anced on the affected side Pleur al dffusi on Deviate toward the affected side Deviate toward the normal side Deviate toward the affected side Deviate toward the normal side Diminish ed or disappear ed Diminish ed or disappear ed Dullness Flatness Disapp Withou Disappeared or eared t diminished or diminis hed Dimini Withou Diminished or shed or t disappeared disappe ared Thick ened pleura pneu moth orax Denting of the affected side Fullness of the affected side Diminish ed Dullness Dimini shed Withou t Diminished Diminish or disappear ed Tympany Dimini shed or dissape ared Withou t Diminished or disappeared E . Preparing the patient The heart examination should be made as easy as possible for the patient. And the results should be recorded carefully. there is a growing conception among practicing physicians in cardiovascular medicine that bedside physical examination is unnecessary and does not provide useful information. that most of his or her fears on that score were unfounded. Observe precordium . that for proper application and interpretation of various new and old tests that are available for cardiovascular evaluation in a given patient. but both sides (particularly the right) and the foot should be accessible to the examiner. The Heart In the present era of technological advances. The ideal examining room is private. who usually expects it to be a relatively distasteful experience. It should be emphasized. particularly in the various imaging modalities. warm enough to avoid chilling. however. Inspection 1.

usually the pulsation can be found inferior the xiphoid process. but also discovers diagnostic signs. such as congenital heart disease and rheumatic heart disease. either at or medial to the mvl and about 2-2. Asymmetry of the thoracic cage due to a convex bulging of the precordim suggests the presence of heart disease since childhood. The examiner should always observe the shape and contour of patint’s chest. In the adult. the examiner should aim to determine the location and size . Abnormal pulsations in the other areas. d) Pulmonary hypertension with dilatation the pulsation in systole may be detected in left second intercostal space to the edge of sternum. The subject should be supine with the legs horizontal and the head and trunk elevated to approximately 15-30 degrees. b) Thoracic disease: pneumothorax and pleural effusion will displace the apical impulse to the normal side. with skeletal molding to accommodate cardiac enlargement. dilatation or both. Pleuraladhesion and ateleotasis will result in a displacement of impulse toward the diseased side. 2. one may detect abnormal pulsations in aortic area. the apical impulse is displaced laterally and inferiorly and sustained. massive ascites. scoliosis often alter the shape and position of the apical impulse. c) In asending or arch aortic aneurysm. fever. Apical impulse 2 The apical impulse is occurring early in systole. b) Pulmonary emphysema with RVH. In adults the apical impulse normally is located in the left fifth intercostal space. It can be found at the right fifth intercostal space in dixtrocardiac and can not be found in massive pericardial effusion. Through careful palpation. it serves the examiner as a marker for the onset of cardiac contraction. a) Right vertricular hypertophy (RBH).Inspection of the precordium should begin at the foot of the bed. hyperthyroidism and anxiety. Palpation not only confirms the results in inspection. precordial bulge may be produced from the massive pericardial effusion. The impulse is clearly seen in left third fourth intercostal space. d) The apical impulse may have increased amplitued and duration in those persons with a thin chest.5 cm diameter. with bulging or pulsation in systole. Displacement of the apical impulse: a) Heart disease: Some heart diseases cause the left ventricular hypertropy dilatation or both. and it may be shifted to the left and upward in right ventricular hypertrophy. Depressions of the sternum. c) Abdominal disease: The apical impulse also can be displaced by large mass. Kyphosis of dorsal spine. anemia. palpation Usually inspection and palpation are discussed together because there is an intimate relationship between these two processes in the heart examination.

sustained throughout systole and has a great amplitude. Any thrill should be described as to its location. with the physician at his right side. its time in cardiac cycle. to upper border of the third right costal cartilage. patient should lie supine on an examining table or sit on the chair. In left ventricular hypertrophy (LVH) the impulses are very forceful. at a point 2 cm lateral to its sternal junction. The palm of the hand. The intensity of the thrill varies according to the velocity of the blood. 1) The heart borders (1) The base of the heart. In the presence of pericardial effusion the rub will usually disappear because of the separation of visceral and parietal layers by the accumulated fluid. 1) Usage of the palpation confirms the precordial pulsation’s location. and fingers should all be used for palpation because each is useful for optimal appreciation of certain movements. 4th. Percussion The chest is percussed to confirm the cardiac borders. it may occur in systole. It is outlined by percussing in the 5th. ventral surface of the proximal metacarpals. 3rd and 2nd interspace on the left sequentially. diastole. size contour and position in the thorax. 3) Pericardial friction rub is a to-and-fro grating sensation. rapid vibrations result in fine thrills whereas slower vibrations produce coarser thrill. (3) The left border of heart. The apical impulse may have decreased amplitude and duration in those patients with myocarditis. to the sixth right chondrosternal articulation. to the left of its articulation . duration and intensity. measurement should be made along a straight line paralleled to the transverse diameter in the thorax. and identify any abnormal precordial pulsations. starting near the axilla and moving medially until cardiac dullness is encountered. Usually we employ indirect percussion for percussing heart borders. characterize its contour. The rub is caused by a fibrinous pericarditis. and its mode of extension or transmission. most commonly produced by blood from one chamber of the heart to another through a restricted or narrowed orifice. extending from the upper border of the third right costal cartilage 2 cm lateral to its junction with the sternum. to the lowerborder of the second left costal cartilage 1-2 cm. at a point just to the left of its juction with the sternum. extending from the 5th left interspace 1. 2) Thrills are actually palpable fine vibrations. The beginner should mark with a skin pencil where the note changes.of the cardiac apex impulse. Amplitude. In massive pericardial effusion the impulse cannot be palpable. (2) The right border of the heart: It confirms with a curved line with its convexity toward the right. from the lower border of the second left costal cartilage.5 cm medial to the Mvl. The distance from left midsternal line to the left border should be measured and recorded. which is usually present during both phases of cardiac cycle. often rubs are more readily palpated with the patient sitting erect and leaning forward during the end period of deep inspiration. corresponds to a line crossing the sternum obliquely. the degree of narrowing of the orifice and which it is produced and difference in pressure between the two chambers of the heart. It is formed by the left ventricle and the atrium and is represented by a curved line with its convexity directed upward and toward the left. formed by both atria. presystole and at times may be continuous. Quality of a thrill depends on the frequency of vibration producing it.

The right ventricular is severely enlarged the right border of the hert will extended to the right. At this area. myocarditis. the cardiac dullness will be extended to the left and downward.5-4. It is called “auscultatory valve area”. all those diseases may cause the base border of heart enlargement. the pulmonary artery will be exaggerated to leftward. so that the base border of the heart will be widened. 2) Normal relative dullness of the heart Right Intercostal space Left (cm) 2-3 II 2-3 2-3 III 3. the murmur will be hear easier. it is frequentlyseen in mitral valve stenosis. 3) Changing cardiac dullness Heart disease Left ventricular enlargement. V. percussion at times may be helpful in outlinging the changing cardiac silhouette resulting from a change in the patient’s position. the murmur at the apex will be hear more clearly. myocardiopathy and pericardial effusion may cause the heart silhouette extending both to right and left. I. In auscultation. Especially in presence of pericardial effusion. . the cardiac dullness will extended to left and upward. The auscultatory valve area does not correspond with the anatomic location of the valve themselves. sometimes let the patient holding the breath at the end of expiration. but it is difficult. Aortic dilation. aneurysm of aorta. Congestive heart failure. Right ventrucular enlargement. It plays a very important role in the diagnosis of heart disease. It is a very interesting thing to master the auscultation.5 3-4 IV 5-6 (cm) V 7-9 In normal person the distance from the 5th to the midsternal line is about 7-9 cm. Left atrium and pulmonary dilatation Both the left artrium and pulmonary artery enlarged.with the sternum. and change the position of patient in order to detect some abnormal sounds and murmurs. is represented by a line drawn from the 5th chondrosternal articulation to the site of the cardiac impulse in the left 5th intercostal space 1-2 cm to the M. one can hear the sound clearest in auscultation. while the patient roll onto his left side. It is frequently seen in aortic regurgitation and called aortic heart. The cardiac silhoutte is like a pear and called mitral heart. lying. and left lateral recumbent position. AUSCULTATION OF THE HEART The purpose of auscultation of the heart is to find the normal and abnormal sounds of the heart. auscultation must be done with the patient in a sitting. pericardial effusion. the heat silhouette is like a shoe. I. Exercise is valuable for increasing the intensity of faint murmurs. Auscultatory Valve Areas Sounds produced by each valves of the heart may propagate to different area at the pericardial area following the blood stream. For a thorough examination. (4) The inferior border: It is formed by the RV and a lesser extent by the L V.

Sinus bradycardia : <=60 beats/min in adults. rhythm. The clinical auscultatory characters are “three inconsistence”. axilla. heart sound. Pulmonary valve area: in the second intercostal space just lateral to the sternum. and back may be examined. We call it the second auscultatory area of AV.Heart rhythm: It is regular in Normal adults. It is caused by a very high frequency impulse coming from the atrial ectopic point or caused by the circus movement of the ectopic impulse. Tricuspid valve area: at the lower part of the sternal near the xiphoid. 2. then move to the PV area . Beside. Atrial fibrillation: It is the common arrhythmia in clinical. according the clinical feature. (3) The peripheral arterial pulse is absent. The Content of Auscultation It includes rate. Mitral valve area: it is at the apex. sex.and followed by a longer compensatory pause. The first and second sounds can be heard with ease in normal subjects. . but young adult and children may sinus arrhythmia. Heart sound A. just lateral to the sternum. The physician should adopt a systematic way of listening: start at the apex. (1) The ventricular rhythm has absolutely no regularity. . the other part of pericardium. one is located in the second right intercostal space. in the fifth left intercostal space. The characteristic auscultation of extrasystole is: (l) The intensity of S1 is increased. The other is at the third or fouth intercostal space. murmur and pericardial friction sound. second AV area. (2) The intensity of S1 is inconsistence. neck. (2) The intensity of S2 is decreased or even disappeared. medial to the midclavicular line.l. Heart rate: It means how many beats per minute. left to the sternum border. Ⅱ. Premature beat is a sudden extrasystole of the heart in the basis of normal heart rhythm . 2. However. Normal heart sounds In most of normal individuals there are four heart sounds. (3) The rate of heart and pulse are unconcerned. 1. TV area. The fourth sound is frequently inaudiable. In normal adults: 60-80/min Sinus tachycardia : >1OObeats/min in adults. The most common arrhythmias in clinical practice are: premature beat (extrasystole) and atrial fibrillation. 3. Aortic valve area: there are two auscultatory area of AV. It normally varies with age. 4. physical activity and emotional status. the third sound only can be heard in young person and children. The producing mechanism of heart sound . AV area. 3.

The S2 is produced after the apical impulse. It is maximal in intensity at the apex. The S 2 is high in frequency and shorter in lasting duration than the S1 It has a snapping-like tone. The S2 has a higher pitch. Abnormal Heart Sounds Change in loudness .1 second. The S1 indicates the beginning of the ventricular contraction. It is also low in frequency and intensity and rarely heard under normal conditions. The exist of S2 is an indicator of the beginning of ventricular diastole. It can be heard at any part of pericardium and loudest at the basic. Usually it is heard clearly at the apex or superinternal of the apex. the moving of blood flow within the great vessels.l second . loudest at apex. The differentiate between S1 and S2: 1) The S1 has a lower pitch. 4) S4: The fourth heart sound occurs late in diastole or just prior to the S 1 about 0. S1 can be heard at any part of pericardium. B. and is mimic coincident to the aortic artery pulse. last about 0. which have been related to the various events occuring at the onset of systole: (a) Development of tension in the ventricular musculature.12-0. only the components due to the closure of the AV valves and the opening of the similar valves are heard. the blood moves into ventricle rapidly from atrium.Normally. produced in the ventricle during the ventricular filling associated with an effective atrial contraction. (c) Opening of the semilunar valves and the onset of ventricular ejection. lower in pitch than those of the S2. It is maximal in intensity at the basic. It occurs in early diastole approximately 0. produces the vibrating of ventricle wall. It is a composite sound result from closure of both the aortic and pulmonary valves. are taken part in the formation of S 2. Phonocardiographic analysis shows four components in the S1. 2) The duration between the S1 to S2 is shorter (has a shorter pause) than the duration between the S2 to the S1 of next cardiac cycle (has a longer pause). a shorter lasting time. It occurs during the phase of early diastolic filling.18 second after the S1. Often some residual vibrations of auricular origin occur at the very beginning of the S1. longer than those of the S2. a longer lasting time.1) S1: Although several cardiac events play a part in the production of the S 1 . b.with 55-58 Hz in frequency. Being lower in both frequency and intensity. 3) S3: The third heart sound is heard in most children and some adults. but the either components may be heard under abnormal circumstance. the opening of MV and TV. (d) Acceleration of the blood in the arteries during maximum ejection. 2) S2: The second heart sound is mainly produced by the vibration of the closure of the semilunar valves during the beginning of the ventricular diastole. (b) Closure of the Atrioventricular valves. The vibration of the relax of ventricular muscle in diastole. the vibration of the closure of the atrioventricular valves is the most important and accounts for most of the sounds that are heard. 3) The S1 is synchronized with the apical pulse.

(2) S2 increased at pulmonary valve area: It is due to pulmonary hypertension. 3) Change of the S2:It mainly depends on the pressure within the aorta and pulmonary artery and the situation of semilunar valves. In pathological situation.1) Both the S1 and S2 are affected simultaneously: Both increased. In arrhythmia. (4) Fixed splitting of S2: in the usual case of ASD. the PV closure does not occur until the ventricle has emptied itself. It may occur in normal children and young person. If accompany with tachycardia. both decreased. hyperthyroidism and ventricular hypertrophy. Splitting of S1 :It is due to the closure of MV and TV asynchronously. this is referred to as paradoxical splitting of S2. it is called embryocardia. S1 increased: (1) In the situation of high fever. This is referred to as fixed splitting. with little or no change in . the S1 at apex may be louder or weaker. the S2 over the PV area is widely split. (1) In normal person. (1) S2 Increased at aortic valve area :It is due to the pressure increased within the aorta. The RV require a slightly longer period to empty it itself. the emptying time of left ventricle is delayed. the filling degree of ventricle. The order of valve closure may be reversed. the heart sound like a pendular. inspiration will produce the S2 splitting more. the two components then more closer together or may be single. If the abnormal is within the left side of the heart. c. b. Splitting of heart sounds.the degree of splitting during either phase of respiration. the pressure within the thorax is decreased and the venous return to right heart is increased. 2) Change of S1:It depends on the myocardial contraction. like the heart sound of embryo. Splitting of S2:It can be heard in following conditions. (2) In mitral insufficiency. so make the S2 splitting slightly in normal condition. (2) In pathological situation: conditions that cause an over volume to empty or delay of emptying time of one side of the heart will produce splitting of the S2. (3) In aortic insufficiency. and usually occur in right bundle branch block. the elastic and position of the valve. (4) S2 decreased at pulmonary valve area: It is due to the pressure diminished within the pulmonary artery. (3) S2 decreased at aortic valve area: It is due to aortic pressure diminished. such as AS. (3) The influence of respiration: in inspiration. extra sounds: The extra sounds in systolic period . it is called pendular rhythm. loudest over the apex. (2) In MS (3) In complete AV block S1 decreased: (1) It occurs in myocardial infarction. Change of the quality of the heart sound If the myocardial muscle is damaged severely. d. if the splitting of S2 is due to the abnormal of right side of the heart.

This is reffered to as the pericardial knock. it can be heard. It is lowpitched. Sometime it may produce MI. (2) Presystolic gallop: The extra sound in prespstolic gallop is pathological S4. In systolic period the pathological tandea chordea suddenly be tight. It reflexes that the LV function is decreased. the diastole of ventricle are eliminated at the ventricular rapid filling phrase in early diastole. It is due to the increasing contraction of atrium. and its presence is. It may be heard all over the precordium and loudest at the apex and left side at lower part of the sternal. Quadruple rhythm In some pathological situation. produce vibration. (2) Aortic early systolic ejection sounds: It appear after the S1.It occurs precede the the S1. occuring shortly after the second heart sound.It is termed as S 4 gallop or atrium gallop. The pitch is lower that in early systolic click. 2) Opening snap of MV: It occurs after the S2 in MS. best heard at the apex or 3-4 intercostal space. left to the sternal border. a quadruple rhythm results. or in the hypertension of aorta or pulmonary artery.1) Early systolic ejection sound: In the presence of dilatation of the aorta or pulmonary artery. 2) Mid and late systolic click:It occurs in MVP. In the early diastole. (1) Pulmonary early systolic ejection sound : It can be heard after S1 with a high pitch sharp. have the equal quality of pulmonary artery early systolic click. in the 2-3 intercostal space. The redudent and floppy of the tandae chordea can not control the mitral valve at annul level and prolapse into the LA at late systolic period. It is due to the vibration of the opening AV valve suddenly stopped during the blood from LA into LV in early diastole of the ventricle. when the presystolic gallop and protodiastolic gallop both sounds are present. the tension is poor. an evidence that the valve is probably suitable for mitral commisurotomy operation. the ventricular diastole has to stop suddenly produces the vibrate of ventricular wall. best heard at apex. the blood through into the ventricle from the atrium in failing myocardium. The extra sounds in diastolic period: 1) Gallop (l) Protodiastolic gallop rhythm: It is termed S3 gallop orS3 gallop. at time an extra sound is heard in diastole.The click usually occurs after the S1 close to the S2.It is a brief low-pitched sound It occurs at middle diastole at the end of rapid filling phase of diastole. The heart rate usually . It is the pathologic counterpart of the S3 and occurs at the time of rapid diastolic ventricular filling. This sound is brief in duration and high in pitch than other gallop sounds. These sound are not transmit to the apex. so the click occurs. They are heard over the base of heart as well as at the apex.. The opening snap of the MV usually indicates a flexible valve.It occurs in late diastole and is temporally related to atrial contraction . It can be heard in obvious pulmonary dilation and pure PS. produced by the overlapping of early diastolic gallop and presystolic gallop while the heart rate is quite faster. They are best heard at the left side of the sternal border. so there is SM after the click. (3) Summation gallop: It is termed the middle diastolic gallop. 3) Pericardial knock: In the presence of constrictive pericarditis. It is due to the constriction of the pericardial after inflammation. produce the vibration of the ventricular wall.

sigh-like and rumbling. We usually describe the SM as blowing. Abnormal connection.Radiation: some murmurs are transmitted with the direction of the bloodstream by which they are produced. the abnormal heart sound are produced by the crush of metal stent or metal annuls of the valve. diastolic and continuous. (2) the velocity of blood flow. grade 2 is usually readily heard and slightly louder . Forward flow though narrowed or deformed valves. it may be describe as blowing. It usually caused by one of the following mechanisms: l). Increased velocity of blood flow though normal valves. 3. such as the click sounds. harsh or musical. 5). 5. The most widely used system (Levine and Harvey)for grading the intensity of heart murmur is six-point scale: grade 1 murmur is barely audible and is often missed on the first cardiac examination. 3. Backward or regurgitant flow through incompetent valve. Heart Murmurs 1. other murmurs are propagated from their point of origin in many directions. Quality: the quality of murmur depends on the frequency and intensity of the sound wave. 3) It has a very important clinical value.Characterized of murmurs: 1. 4. There are three basic types of murmurs: systolic. In the therapy of pacemaker. In the patients suffering from valvular disease. The CM are described as machine-like and hum. 2) It should be differentiate from the heart sounds. after the operation of valvular replacement. Location: murmurs of valvular origin are usually best heard over their respective auscultatory valve area. General considerations l) Heart murmurs are an abnormal sound. and related close to the pathology and hemodynamic changes of the heart. (3) the pressure gradient of crossing valve. The pacemaker sound is produced by the contraction of the local intercostal muscle due to the leakage of the electric current stimulate the intercostal nerves. Increase with diameter of a major vessels. 6). About the DM. 2). 2. Mechanism of production: Mechanism of production: Heart murmurs are abnormal sounds produced by vibrations within the heart itself or in the walls of the large arteries. Timing: murmurs are timed according to the phase of the cardiac cycle during which they occur.increased . murmur and extra sounds. Vibration of loose structure within the heart. this is the summation gallop. 2.Intensity: the intensity of murmurs are related to several factors: (1) the severity of abnormal. 3). the presystolic gallop and protodiastolic gallop usually summate together. there are some abnormal heart sounds. 4). the prosthetic valve as in mechanical valve.

Ⅳ. (1) Systolic murmur 1) MV area: the murmur at apex is produced by mitral insufficiency. . It is best heard in left supine position.Respiration: respiration may change the output volume of left and right ventricle. Heart murmur usually is a feature of the disease of cardiac or vessels.The murmur of hypertrophic obstructive cardiomyopathy is decreased in squatting and increased in standing position. the blood volume of pulmonary circulation increases.the tricuspid valve closes to the chest wall more.The clinical value of murmur in each valve area of auscultation. louder than 3/6 degree in decresento type and frequently radiate toward the left axilla.overlap the S1. grade 6 may be heard with the stethoscope just removed from the chest wall. If it decreases in intensity. Organic MI most are due to rheumatic heart disease.Change the body position: it may produces some heart sound or murmur increase or decrease. It is a pansystolic M. grade 3 and 4 are quite loud and grade 5 is even more pronounced.Exercise: exercise increases heart rate. therefore the output volume of right side heart is large than those of left side heart and the heart has a clock wise rotation along long axis . increase the murmur of MI and AI . Its origin and cause may be organic. held respiration in the end of deep expiration.TS. blood volume of circulation and blood velosity. the pressure with in the thorax decreased. it is referred to as “decrescends”. so the murmur due valvular stenosis will increase. The functional M usually reveals in systolic period in part of healthy child or young person or in the situation due to increasd flow across a normal valve. blowing in charter.PI increase in intensity. The murmur of mitral stenosis is more evident in left recumbent position. relative. increased in expiration. and function murmur. and produce a relative stenosis or insufficiency of the orifice of the valve. Some of the most helpful maneuver are discussed below: 1. It consist the dilation of the valve annulus. In sitting position. 2. Prompt squatting from standing position or raising two legs at supine position may increase venous return. more harsh. 3.we call it organic. produce the murmur of TI.than grade 1. the enlargement of cardiac chamber or great vessels. MVP and dysfunction of papilly muscule. leaning forward. . The term “relative M” indicates the valves itself is not involved but the supporting tissues of the valves are abnormal. A murmur that increases in intensity after its onset termed “crescends”. relative. and functional. the venous return increases. During deep inspiration. It is in the opposite way during expiration. relative or functional. If the first portion of a murmur is increases in character and the latter portion is decreased it is then referred to as a “diamond-sharped” murmur. then inflence the tensity of the murmur. therefor increase the strock volume and cardiac out put. 6. It is diminished in inspiration.Physiological maneuver : The examiner may intervene in several ways to modify sounds and murmurs for the purpose of better recognition and differentiation. is useful to the ausculation of aortic insufficiency murmur.high-pitched. The abnormal which produce the murmur may be organic. It may appear in rare normal individuals. the damage of chordae tendineae.

most are produced by relative Pi. such as dilation of aorta due aortic arteriosclerosis. most of them are functional. usually are accompanying with systolic thrill. thus the murmur of Mi is heard throughout systole and for a brief period following the S2. radiate toward the neck following the great vessels. The S2 decreased in this area. It is generally confirmed to a rather small area.It is also heard in relative lesion of AV. left to the sternal border. 2) AV area: The murmur begins immediately after the AV closure sound. most are relative TI due to dilate of right ventricle. cresendo-sharped. increased in inspiration. more local in area. d. enemia in middle degree. 2) AV area: it is heard in organic mid-late rumbling diastolic murmur can be heard at the apex. in soft charter. (2) Diastolic murmur: 1) MV area: Most of them are produced by organic lesion of the valve. hyperthyroidism. The murmur are sigh-like. The DM of relative MS may occurs in AI.It is termed Austin Flint murmur.The organic murmur in this area are produced in congenital PS.such as .It is usually heard in rheumatic AI. usually are accumpanying with louded S1. When the aortic and pulmonary valves close. The M will disappear when the cause producing faster velosity of the blood flow disappeared. usually is less than 2/6 degree. It is heard in high fever. usually accompanying with systolic thrill. in low-pitch. It is heard in hypertensive heart disease.produce relative stenosis of MS. best hears in left recumbent position at the end of expiration. may radiate to the left side of the lower part of sternal. It is best heard at the aortic second area. dilated cardiomyopathy and severe enemia.MS. It is soft and weakness in charter. It is louder in intensity. When valvular insufficiency exists. does not radiateto other part. hypertensive heart disease. 5) Other position: In VSD. harsh in quality. the ventricular pressure is still well above the atrial pressure.The M is in soft charter and less in radiation. 3) PV area: The diastolic murmur at this area.acute rheumatic fever. 4) TV area: The systolic murmur in this area indicates Ti. It is heard in part of the normal adult. ASD. decresedo. . cresendodecresendo type.The mechanism are the blood regurgitating from the aorta into LV stricking the MV area up. It is a blowing SM. This murmur may exist in relative stenosis of the orifice of pulmonary artery.Relative MI: It is due to the dilated LV. the ventricular pressure remains above atrial pressure throughout systole. 4) TV area: It is rare in clinical. due to pulmonary artery dilation in pulmonary hypertension.It can be heard in part of normal children and young person. . The Grahan Steell murmuris also a relative murmur. diamond-shaped. The organic SM are very rare here. Functional MI: the valve is normal but the blood flow is quite faster. 3) PV area: it is an ejection murmur. usually are accompanying with systolic thrill and S2 is diminished at AV area. In rheumatic MS. Do not accompanying with louding S1 or OS. OS of MV and diastolic thrill. a loud and harsh SM can be heard at third and fourth intercostal space. The murmur is harsh in charicter.

since blood enters the aorta much faster than it flows to the more distal arteries. It Is important bear In mind the following points: rate. . This results in an abrupt sharp rise in aortic pressure. rhythm. the function of circulation. intensity. It is best heard in the sitting position leaning forward and held breath. As the ventricle relaxes there is a transient reversal of flow from the central arteries to the ventricle and the aortic valve closes. uremia and SLE. but the systolic component predominates. During the systolic phase of left ventricular ejection a large portion of the blood is temporarily stored in the proximal aorta.The common cause of pericardial friction rub is pericarditis(TB. and compare the radial A. The rub is most commonly heard at the third to fourth intercostal space left to the sternal border. THE BLOOD VESSELS ⅠPulse The palpation of artery is an important step in the cardiovascular examination. Pericardial friction rub The pericardial friction rub is produced by the rubbing on each other of the parietal and visceral surfaces of the roughened pericardium during pericadiatis. and some cardiovascular abnormalities. a. The arterial pulse can be papated at any point where the arteeainst a firmer surface usually bone.non-spicific. 3.cresendo type. Compare the pulse of artery of both lower extremtries at the relevant position. the peak of diamond is at the top of S2. recher peak intensity at late systole. Intensity: The intensity depends on the arterial filling degree and the resistance of peripheral vessels. The sound is usually in both systolic and diastolic. rheumatic). The aortic pressure continues to decrease during diastole as blood flow continues to the peripheral vessels. harsh in quality. The pulse intensity may not be equal between the upper and lower extremitries. Wave form The arterial pulse starts at the instant the valve opens and left ventricular ejection begins. such as in Patent Ductus Arteriosus.(2) Continuous murmur: Murmurs which extend from systole into diastole are called continuous murmur. and blood continues its flow in the peripheral arteries. Continuous murmur can also be heard in arterio-vein fistula. l. F. consistency. persistent from systole to diastole. it seems closer to the ear than the heart sounds. It also can be seen in acute myocardial infarction. it is soft. middle pitch. in both sides if it is equal or not. the sound is harsh. with a to-and-fro character. At times. From here We can get data of the patient above the general condition. It is a continunous murmuur. left to the sternal border. The murmuer begins after S1. envelop the S2 and decreased at early-middle diastole. So it has an important value in the clinical diagnosis. Once the aortic pressure reaches a peak it begins to fall as ventricular ejection slows. produceing a large diamond sharp. wave form and condition of the arterial wall. it also depends on the cardiac output and pulse pressure. resemble massage the ear using the finger. d. e. rhythm c. mimic the sound of machine rotating. 2. rate b. First pay attention to the intensity and the beginning time of the radial A. In examining the pulse.It is best heard at second intercostalspace. In general. tention: The tention of pulse depends on the level of the arterial systolic pressure. and sometime the sound is heard only during systole.

there is an alternating series of high and low pulse waves caused by an alternating contractile force of the left ventricle. Pathological sound: including systolic murmur and continuous murmur. a decrease in left ventricular output.Consequently it is a valuable indication of left ventricular failure . This is often referred to as a “pipe stem” artery may be beaded in consistency and tortuous in its couse. The cuff is evenly and firmly wrapped about the . In elderly persons the examiner may actually visualize these snakelike pulsating arteries under the skin of the arms and forearms. Since the weak beats are but slightly weaker than the strong beats. There is a small notch near the peak of the ascending limb and a similar notch on the descending limb. since it can be easily overlooked while palpating the radial artery. peak. and thus a decrease in arterial blood pressure. 2. l. and the vessel may be rolled easily between the examining digits. The patient should have been resting for some time. the patient may be either sitting or lying in the supine position. The trun consistency of this vessel can then be determined by means of palpation. Pistol-shot sound 3. Duroziez's sign. and descending limb. Water hammer pulse. In turn this results in a decrease in the return of blood to the left side of the heart. so the distal margin of the cuff is at least 3 cm proximal to the antecubital fossa. It must be distinguished from bigeminy. This phenmenon is caused mainly by pooling of blood in the pulmonary circuit during inspiration resulting from the expansion of the lungs and an increase in the negative intrathoracic pressure. Paradoxical pulse. in which every other beat is weaker than the preceding beat. 2. This is best accomplished by expressing the blood from a distal segment of the radial artery that has been ocluded by digital pressure. It is more likely to be detected when the patient is sitting or standing. 3. In arteriosclerosis the wall offers more resistance to compression by the palpating finger. 4. 4 Paradoxical pulse is charterized by a decrease in the amplitude or an actual imperceptibility of the pulse that occure during the inspiratory phase of respiration. The most accurate means of identifying a sphygmomanometer. Actually. The presence of a paradoxical pulse should suggest the possibility of massive pericardial effusion. Measurement of Arterial Blood Pressure For routine measurement. A strong bounding pulse with a tall rapid ascending limb and an equally rapid decending limb . Normally the wall of an artery under these circumstances is soft and pliable. 4. It usually occurs in the presence of high fever and may be palpated in both the carotid and peripheral arteries. In dicrotic pulse there are two impulses that are palpable during diastole. Dicrotic pulse. Bare the arm and affix on it the collapsed cuff smoothly. Pulsus alternans. constrictive pericarditis.It is called a water-hammer or collapsing pulse. this arrhythmia may be overlooked unless the examiner is skilled or alerted to its possibility.The pulse wave is composed of an ascending limb. When the systolic blood pressure falls more than 10 mm. Pulsus alternans is charterized by a regulary alternating pulse. f.Consistency of the arterial wall.Hg during inspiration the pulse is refferred to as paradoxical.

Palpation: diastolic thrill may be felt at apex. Press the bell of the sterhoscope hightly over the brachial A. As the cuff pressure approaches diastolic. acute myocardial infarction. The systolic pressure is depended on the myocardial contractility and the cardiac output. the sounds undergo changes in intensity and quality. During the course of M. Some serious causes of low blood pressure(hypotension) include Addison’s the pressure drops gradually(2 mm/second). In certain instances-for example. race. left ventricle filling is then decreased. Under normal circumstances there is little or no significant difference in the blood pressure in the two upper extremities. Among the causes of high blood pressure(hypertension) are essential hypertension.S. The radial pulse is palpeted and inflate the cuff to a pressure about 30 cm of mercury about the point where the palpable pulse disappears. and coarctation of the aorta. the flow of blood is damped from left atrium to left ventricle in diastole. The right ventricle is overloaded and then the compensatory hypertrophy and dilatation occur. this reading is taken as the systolic pressure. chronic glomerulonephritis. From this point. left atrium is overfilled. As the blood pressure cuff is further deflated. The apical pulse may extend to left side. Open the valve slightly . The cardiac output decreasing or the peripheral vesseular resistance decreasing may produces the blood pressure drop.arm with the center of the inflatable portion over the brachial artery. pheochromocytoma. Right ventricular failure may be present finally.S. at the antecubital fosse. hemoptysis and occasional paroxysmal nocturnal dyspnea. The point of complete cessation of sounds is the best index of the diastolic pressure. Then pulmonary artery pressure increased gradually due to the increased pulmonary circulatory resistance and pulmonary arterial sclerosis developed later on. MAJOR SYMPTOM AND SIGN OF COMMON DISEASE IN CIRULARORY SYSTEM Mitral stenosis Mitral stenosis(MS) results from recurrent rheumatic activity. renal artery stenosis. observation may be made by either auscultation or palpation. and note the pressure reading at which sounds first become audible. . hemorrhage. Blood pressure is somewhat variable and depends on sex. Major symptoms (due to left atrial dysfunction)are as follows.and climatic conditions. Percussion: The cardiac dull area extend to left in early stage and later on to right. making the heart to form a pea – shaped dullness. the sounds often quite suddenly become dull and muffled and then cease. and the left atrial pressure is increased. The diastolic pressure is depended on the resistance of peripheral vessels. G. Signs Inspection: The so-called “Mitral Facies” May be present. The high atrial pressure induces a dilatation and stasis of pulmonary vein and capillary. aortic aneurysm or obstruction of the innominate artery-there may be a significant discrepancy in the blood pressure in the upper extremities. Symptoms There is no symptom. cough. causing dilatation and hypertrophy of it. place the chestpiece of the stethoscope over the brachial A. Exertional dyspnea. A prominence of “cardiac waist” may be present. and shock. or only a slight in a case of mild or moderate M..

In aortic stenosis blood is forced under great pressure by the left ventricle through a narrowed aortic valve into the aorta. palpitation in the early stage. Palpation: The apical beat is heavy. the blood flow in coronary artery and periphelow artery is decreased. The pulmonary second heart sound was accentuated. so that the filling degree and pressure were augmented for the left atrium and them the compensatory dilatation of left atrium occurs. and MI may be produced by left ventricular dilatation due to any cause. Right ventricular enlargement may be seen in late stage. Calcific stenosis may occur when the underlying pathologic condition is either rheumatic or sclerotic. The opening snap may be present. X-ray shows dilated left ventricle and left atrium and pulmonary congetion. The wall thickening of LV gatting high and high due to the constraction of LV increased. Consequently.. fatigue. If without heart failure. or right in late stage. During left ventricular contraction the blood regurgitates into the left atrium. Signs: The apical impulse is increased. EKG: A broad p wave with a notch “Mitral P” and enlargement of right ventricle may be present.and displaced laterally. The main symptom are palpation. Mitral Insufficiency (MI) The main cause of MI is rheumatism. Auscultation: a grade Ⅲ or more pansystolic blowing murmur may be heard and transmitted to the left axilla and supscapular region. X . which can be clearer when the patient in lying in left lateral position. EKG shows left ventricular hypertrophy.angina. Anterior and posterior leaflets move in same direction. the left ventricle bears blood volume so heavily during the left ventricular contraction that the compensatory dilatation and hypertrophy of the left ventricle occur gradually. cardiac dullneus enlarged toleft.ray. Barium meal of esophagus may show an enlargement of the left atrium which compresses the esophagus backwardly. The mean pressure of aorta is decreased. The pulmonary second sound may be accentuated or splitting. The resistance of output the blood in left ventricle is increased. During the left ventricular diastole the left ventricle accepts more blood flow from left atrium and from left ventricle regurgitate. The lung markings are increased. Moist rales at the base of lung may be appeared. Symptoms: The patient has fatigue.A systolic thrill . percussion. The first heart sound was decreased and masked by the murmurs. even syncope. the patient feels no symptom for a long time. Echo: Double -spike of mitral anterior leaflet disappeared and flat curve may be seen. Enlargement of right ventricle may be present in late stage.Ausculation : A loud snappy first sound and a localized cresendo rumbling diastolic murmur in the mid-late stage may be hear at apex. Aortic Atenosis The valvular deformity in aortic stenosis may be the result of rheumatic fever but also occur on the basis of a congenital defect or atherosclerosis. Signs: Inspection: The apical beat is displaced to left and lower. The heart shadow showed a “ Mitralized contour”.

The murmur is heard over the right second interspace lateral to the sternum and radiated widely. the diastolic pressure is decreased causing an increase in pulse pressure and other signs of peripheral vessels due to A. Syphilis is a less common cause of A. In aortic insufficiency. the augmentation of stroke volume leads to compensatory. and arteriosclerosis and infective endocarditis.I. Palpation: The apical impulse is displaced laterally and inferiorly. The regurgitant jet from aorta hits the anterior mitral leaflet and causes it moving toward left atrium during diastole. The aortic component of the second sound is delayed in most cases and is absent in a few. and usually has a crescendo-decrescendo charter. there is no effect on heart and hemodynamics. Duroziez dicrotic murmur etc. Because the blood leaks to the left ventricle in diastole.In auscultatioin. systolic in time. Musset sign. For a slight effusion. the elevated pressure of pericardial cavity limit the dialate of the heart. harsh.I. or a reversed splitting of the second sound. there is either a single second heart sound.may palpable at the second intersapace lateralal to the sternal with a pulsus parvus. i. in our country now. A soft blowing systolic murmur at apex may be heard due to the relative mitral insufficiency. (2)Carotid pulsation. left ventricular dilatation and hypertrophy and relative M. it is called “Austin-Flint” murmur. Aortic Insufficiency Etiology: The cause of aortic insufficiency are rheumatic fever. nephrosis). the left ventricle receives both blood from left atrium and aortic regurgitation. the commonest.. The cardiac dullness shows a boot-shaped shadow. produceing a serious hymodynsmic changes. there is a murmur . the aortic component occurring after the pulmonary. The murmur is ejection in nature. (3)Capillary pulsation. A blowing diastolic murmur is audible in the aortic area or third intercostal space left to sternum and transmitted to apex. Pericardial Effusion The commonest causes of pericardial effusion are inflammatory( tubercurosis or purulent disorders)and noninflammetory ( Rheumatism. beginning shortly after the first heart sound and ending just before the aortic component of the second sound. Peripheral varcular signs due to increased pulse pressure are as follow: (l) Moving of head with each heart beat. Percussion: cardiac dullness is enlarged laterally and inferiorly. loud. frequently to the right side of the neck and especially to the apex. the ventricular filling and out put were reduced. result in relative mitral stenosis. water hammer pulse. lifting impulse may be felt. a rumbling murmur in early-mid diastole at apex may be heard. pistolshot sound.influnce the blood flow retun from systemic venus to the right ventricle.e. Auscultation: First heart sound is decreased at apical area and the aortic second heart sound decreased or disappeared.I. Symptom: The patient may be free symptom or only feels palpitation in the early signs: Signs: Inspection: Patient looks pale. If pericardial effusion increased rapidly or gradually but massive. Consequently. the apical impulse is diffuse and displaced laterally or inferiorly. If there is relative mitral stenosis. The “cardiac waist” is decreased. .

.patients may complainpericardial compression. Percussion: Cardiac dullness is enlarged and almost coincide with posture. broncbial breath. Auscultation: A faint heart sound and sometimes pericardial friction rub may be heard. Elevated venous pressure. with fast and small pulse. hiccup. there are inflammatory symptoms of fever. fatigue and pericardial pain. Palpation: Apical pulsation reduced or absent. If the effusion compresses the neighboring organs. Ewa's sign with dullness below the angel of left scapula as associated with the increased vocal fremitus . leaning forwarl posture. The cardiac impulse decreased or disappeared. In addition. cough. small pulse pressure and positive hepatojugular reflex may be present. dyspnea.Symptom: The severity of symptom depends on the pericardial effusion volume and the velosity of effusion producing. dysphagia may be present. paradoxlcal pulse may be present. sweating. Signs: Inspection: It is dyspnea in a sitting.