Examination of Thorax and Lungs

Brief survey of the patient's thorax and respiration

- Examination of the Posterior thorax and Anterior thorax using Inspection, Palpation
Percussion and Auscultation.
- Examiner will assess a healthy patient. Keep in mind that other patients may have the
same normal findings or may display normal variations or abnormal findings.

Begin your examination with:

- A brief survey of the patient's chest and respiration
- Observe the rate rhythm depth and effort of breathing
- Listen to the sound of his breathing normally a resting adult breathes easily quietly and
regularly about 14 to 20 times a minute

INSPECTION

- Inspect the patient's neck for supraclavicular retractions and for contractions of the
sternomastoid muscles (normally they are not present)
- Check the position of the trachea (it should be in the midline)
- Check the color of the patient's lips and fingernails for abnormal color, both are normally
pink
- Note the lateral diameter of the patient's chest. (Does the anteroposterior diameter seem
large in relation to it?)
- Have the patient place his arms on the opposite shoulders and breathe normally

POSTERIOR THORAX

Examine the posterior thorax beginning with inspection:

- Observe the chest for shape symmetry and deformities
- Inspect the overlying skin
- Palpate the chest to:
- locate any areas of pain or tenderness
- assess any lesions or abnormalities you may have found during inspection

To assess respiratory expansion:

- Place your thumbs close to the patient's spine at the level of the 10th ribs and spread
your hands lightly over the thorax
- Ask the patient to inhale deeply and exhale fully while you watch the divergence of your
thumbs and feel for the range and symmetry of movement
Next using this pattern, systematically palpate for tactile fremitus

1. Using the base of your palm, palpate and compare symmetrical areas for tactile fremitus
as the patient repeats 99.
- identify areas of increased, decreased or absent fremitus

Continue the examination by percussing the chest in a systematic manner going from side to
side as you move down to the thorax.

1. Percuss down the chest wall from the apices to the bases of the lungs
- listen to the intensity, pitch and duration of your percussion notes, and decide what kind
of notes you are hearing
- Normal lungs are resonant
- locate any areas where you hear abnormal notes

2. Next, use percussion to identify the level of diaphragmatic dullness and measure
diaphragmatic excursion.
- Ask for permission to mark the area
- Then instruct the patient to breathe all the way out and hold it in
- Percuss downward from above the expected level of diaphragmatic dullness
- Until dullness is definitely heard, mark the level of full expiration.
- Next, instruct the patient to inhale deeply and hold it in. (instruct the patient to breathe
all the way in and hold)
- Percuss downward to the level of dullness at full inspiration and mark it.

3. Repeat the process on the other side.

 4. Then measure the distance between the expiratory and inspiratory levels of dullness.
(The distance is normally 5-6 cm)

NORMAL BREATH SOUNDS

Normal breath sounds are classified by their intensity, pitch and duration during inspiration
and expiration.

Vesicular sounds
- Soft and low pitched
- Normally heard during inspiration and the first third of expiration
- Can be heard throughout most of the lung fields

Bronchial breath sounds

- Louder and higher in pitch than vesicular sounds
- The expiratory sound lasts longer than the inspiratory sound and a silent gap separates
these two sounds.
- Normally bronchial breath sounds are sometimes heard over the manubrium

Bronchovesicular sounds
- Have an intermediate pitch and intensity
- Inspiratory and expiratory sounds are about equal in duration, a silent gap may or may
not separate them
 - These sounds may be heard in the:
- Anteriorly: first and second interspaces
- Posteriorly: between the scapulae

ADVENTITIOUS SOUNDS
(Added breath sound)

Two basic types of adventitious sounds

A. Discontinuous Sounds (Crackles)
B. Continuous Sounds (Wheezes and Rhonchi)

Fine Crackles
- Intermittent, non-musical and brief, like dots in time
- Soft, high pitched and very brief

Coarse crackles
- Louder, lower pitched and longer
Wheezes and Rronchi
- Last much longer and sound more musical

A. Wheezes
- Relatively high pitched and have a hissing or shrill quality

B. Rhonchi
- Lower pitched, snoring quality

To auscultate the posterior thorax begin at the apices and proceed downward moving
systematically from side to side and comparing the sounds in symmetrical areas.

(1,1 - 2,2…..

Using the diaphragm of the stethoscope

- Listen to at least one entire breathing cycle at each location
- Listen to the Duration, Pitch and Intensity (Inspiratory and Expiratory sounds)
- Decide what type of breath sounds you're hearing
- Note any added sounds

During Auscultation have the patient breathe deeply through his mouth
- If the patient becomes uncomfortable allow a rest period
If you hear bronchial or bronchovesicular breath sounds where they should not be, listen for
transmitted voice sounds

While auscultating the chest:

● Ask the patient to say “99”
- Voice sounds that are louder and clearer than normal are called bronchophony
● Then have the patient say “E”
- When E sounds like A, and has nasal quality egophony is present
● Finally, ask the patient to whisper “one, two, three”
- When these sounds are louder and clearer than normal - whispered
pectoriloquy is present
All these changes in voice sounds suggest the air filled lung has become airless

ANTERIOR THORAX

To examine the anterior thorax:

1. Have the patient lie supine and breathe normally
2. Observe the condition of the skin
3. Inspect the chest for deformities, symmetry and respiratory movement.
4. Palpate the chest to:
- Locate any areas of tenderness
- Assess any lesions and abnormalities
5. Assess respiratory expansion
- Place your thumbs along each coastal margin with your hands along the lateral
rib cage
- Raise loose skin folds between your thumbs
- Ask the patient to take a deep breath
- Observe the placement of your thumbs and feel for the symmetry of movement
as the patient exhales fully
6. Next, following this pattern palpate tactile fremitus

- As the patient repeats 99, use the ball of your hands to compare symmetrical
areas (because fremitus is difficult to feel breast tissue of women you may need
to gently displace the breast)
7. Percuss the anterior thorax in symmetrical areas proceeding from the supraclavicular
area down to the sixth rib or below (compare both sides)
 8. Identify your percussion notes and their locations
- You should hear resonance over the anterior lung fields
9. If you want to check the level of the right diaphragm anteriorly
- Percuss from resonant lung downward to liver dullness

To auscultate the anterior chest

1. Take the same systematic approach used for percussing the anterior thorax

2. If necessary gently displace the patient’s breasts to auscultate all important areas
3. Listen to the Duration, Pitch and Intensity (Inspiratory and Expiratory sounds)
- Decide what type of breath sounds you're hearing
- Note any added sounds
- if you hear heart sounds near the heart try to ignore them while you concentrate
concentrate on the breath sounds
4. Instruct the patient to say “99”
- If you hear Bronchial or Bronchovesicular breath sounds where they should not
be, listen for transmitted voice sounds

To summarize, examination of the thorax and lungs includes a brief survey of the thorax and
respiration, inspection, palpation, percussion and auscultation of the posterior and anterior
thorax.