AXILLARY AREA

INTRODUCTION
The axilla is a fat-filled pyramid-shaped space,
between the upper part of the arm and the side of the chest
Wall.
BOUNDARIES
The axilla resembles a truncated four-sided pyramid and
presents an apex, a base and four walls (anterior, posterior,
medial, and lateral)
• ANTERIOR WALL- Pectoralis major,Subclavius, Pectoralis minor
• POSTERIOR WALL- above by subcapsular muscle
below by latissimus dorsi and teres major
• MEDIAL WALL- Upper 4 or 5 ribs and corresponding intercoastal
spaces covered by the serratus anterior muscle
• LATERAL WALL- Tendon of biceps brachi,coracobrachialis and short
head of biceps brachii
CONTENTS OF AXILLA
• Axillary artery and it’s branches
• Axillary vein and it’s tributaries
• Cords of the brachial plexus
• Axillary lymph nodes
• Fibrofatty tissue
• Axillary tail of breast
• Long thoracic and intercostobrachial nerves
Palpation of the Axillary group of lymph
nodes
• 1. PECTORAL GROUP— This group is situated just behind the anterior
axillary fold. The patient's arm is elevated and using the right hand for the
left side the fingers are insinuated behind the pectoralis major. The arm is
now lowered and made rest on the clinician's forearm. This will relax the
pectoralis minor. With the pulps of the fingers try to palpate the lymph
nodes. The palm should look forward. The thumb of the same hand is used
to push the pectoralis major backwards from the front . This facilitates
palpation.
• 2. BRACHIAL GROUP— This group lies on the lateral wall of the axilla in
relation to the axillary vein. To palpate this group left hand is used for the
left side. The group is felt with the palm directed laterally against the upper
end of the humerus
• 3. SUBSCAPU-LAR GROUP— This lies on the posterior axillary fold and is
best examined from behind.Standing behind the patient the examiner
palpates the antero-internal surface of the posterior fold while withthe
other hand the patient's arm is semi-lifted. Now the nodes are palpated
lying on thissurface with the palm of the examining hand looking
backwards.
• 4. CENTRAL GROUP— This group of the left side is examined with the right
hand. At first the patient's arm is slightly abducted and pass the extended
fingers right upto the apex of the axilla directing the palm towards the
lateral thoracic wall. The patient's arm is now brought to the side of her
body and the forearm rests comfortably on the clinician's forearm. The
other hand of the clinician is now placed on the opposite shoulder to
steady the patient. Palpation is carried out by sliding the fingers against the
chest wall when the lymph nodes can be felt to slip out from the fingers
• 5. APICAL GROUP— Examination is carried out in the same manner as
the previous one, but the fingers are pushed further up. If the lymph
nodes are very much enlarged they may push themselves through the
clavipectoral fascia to be felt through the pectoralis major just below
the clavicle.
PERCUSSION OF AXILLARY AREA
• Axillary area – upto 6th rib
• Infra axillary – below 6th rib
METHOD
Percussion
Cardinal rules of percussion
1. Pleximeter (usually the middle finger of the examiner’s left hand) is firmly applied to the
chest wall so that no air pockets are interposed between the finger & the chest wall
2. Plexor (usually the middle finger of the examiner’s right hand) is kept flexed at a right
angle & must hit the middle phalanx of the pleximeter perpendicularly with the pad &
not the tip of finger.
• 3. Percussion note must be sudden, the plexor being withdrawn immediately
after the stroke& the movement of percussion should originate at the wrist
• 4. Percussion should procced from resonant to dull or from more resonant to less
resonant areas
• 5. Force of percussion stroke must be varied according to the purpose of
percussion, tissue/ organ being percussed. Area of the chest wall percussed etc
however the force of stroke must be kept absolutely constant while comparing
symmetrical areas of the chest.
• 6. During percussion of the chest pleximeter should be kept along the interspace
rather than obliquely across the ribs
• 7. When delineating the borders of an organ such as liver, heart the long axis of
pleximeter should be kept parallel to the expected position of that border.
• 8. Area percussed must be more or less equidistant from the two ears of the
examiner in order to prevent wrong interpretation
• Variants of percussion notes .
• Tympanic- pneumothorax, empty cavity
• Subtympanic- above the level of pleural effusion
• Hyper resonant- pneumothorax, emphysema, severe asthma
• Resonant- normal lungs, bronchial asthma, bronchitis, interstitial lung
diseases
• Impaired – localised fibrosis cavitation, bronchopneumonia
• Dull- collapse consolidation pleural thickening
• Stony dull- pleural effusion
AUSCULTATION
• Principles-
1. Ask the patient to breathe well
2. Put the diaphragm gently but firmly over the chest wall and listen
whether the air entry is good throughout the chest.
3. Now concentrate on the type of the breath sounds and adventitious
sounds heard.
4. First auscultate on normal side and then compare it with other side.
5. The areas to be auscultated are same as those of percussion.
References
• Vishram singh (2nd edition)
• S.das(9th edition)
• Arup kumar kundu(2nd edition )
• An insiders guide to clinical medicine by archith boloor (2nd edition)

By
MAHESH KUMAR K
065
 TRIPOD POSITION

In this position patient is sitting in leaning forward

posture with his hands outstreched on his knees.

This is indicative of increased airway resistence or

stiffness of lungs or chest wall which leads to increased
work of breathing(supraclavicular retractions: use of
accessory muscles of respiration).
Causes:
 COPD(chronic obstructive pulmonary disease)
 Asthma in exacerbation
 Pulmonary edema
 Moderate to severe respiratoy distress

Mechanisms
1. This position fixes and lifts shoulder girdle and improves
functtion of pectoralis major and minor.
2. It is hypothesised that forward leaning posture probably
helpes by optimising requirment of accessory muscles
or conversly by promoting relaxation of accessory
muscles consequent upon fixation of arms and hence
reducing use of upper chest muscles
3. Alternatively cephaled displacement of a short flattened
diaphragm could lead to streaching and greater tension
generation and hence improve the diaphragmic function.

LIKHITH GOWDA
Roll no: 60(18M6062)
Source: Harrison 21st edition
Research article published by AIIMS, Delhi
Percussion of anterior chest

Name : Majida p
Roll no : 66
Position of the patient
Sits up straight with hands by his sides.

Direction of percussion
Always percuss from resonant to non-resonant area.

Pleximeter: Usually middle phalanx of the left or non dominant hanf and is
firmly placed on the surface while rest of fingers are slightly lifted off.
Plexor/ plessor(percussing finger): It is the middle finger of the right or dominant
hand.
Movement of the plexor hand should be sudden and originating from the wrist.
• Pleximeter should be kept parallel to the border to be percussed.
• Percuss around 2-3 times over each area
• Percussion has to be heard as well as felt.
• Always percuss the identical areas of chest for comparison.
• The movement should be at your wrist rather than at your elbow.
• The percussing finger is bent so that its terminal phalanx is at right
angles and it strikes the other finger perpendicularly.
• As soon as the blow has been given, the striking finger
is raised: the action is a tapping movement.
In healthy people, anterior chest percussion is symmetrical except for the area
immediately lateral to the lower left sternal edge, where the right ventricle causes
dullness ; this ‘ cardiac dullness’ is lost in hyperinflated patients in whom the lingula
overlies the heart.

Anterior sites of percussion

Types of percussion

• Heavy percussion : posterior part of chest

• Light percussion : anterior part of chest and abdomen.
• Direct percussion : directly over the bony structures like clavicle.
• Indirect percussion : by percussing over the pleximeter finger with the
plexor/plessor
• Auscultatory percussion : used to delineate the size of organs by placing the
stethoscope directly above the structure to be outlined, followed by percussion
from periphery towards the organ of interest.
Direct percussion
• Stretch the skin over the clavicle using the left hand.
• Percuss the middle third of the clavicle with plexor finger.
• Normally middle third of the clavicle is resonant whereas the medial
and lateral thirds are dull( because of muscles attached ).
Impaired note – heard in apical fibrosis
Dull note – in mass lesion like pancoast tumor.
Widening of zone of resonance – heard in pneumothorax or
emphysema.
Lung resonance
Normal
Vesicular resonance
Front of chest more resonant.
Lesion > 5cm from chest wall or < 2-3 cm in size will not alter the percussion note.

On the right side, there is loss of resonance inferiorly as the liver is encountered.

On the left side, the lower border overlaps the stomach, so there is a transition
from lung resonance to tympanitic stomach resonance.
Abnormal types of percussion notes

Qualitative Quantitative

• Tympanic note • Crack pot

• Subtympanic note • Amphoric
• Hyperresonant note • Bell tympany
• Impaired note
• Dull/ woody dull note
• Stony dull note
Tympanic note
It is a drum like note
Normally seen over the stomach,intestine- traube’s space
In chest – superficial cavity, subcutaneous emphysema
Subtympanic note( skodaic)
Seen just above Pleural effusion
Hyper resonant note
Intermediate between normal and tympanic note
Bilateral- emphysema
Unilateral - pnuemothorax,compensatory emphysema
Large bullae
Impaired note : Airless areas ( fibrosis, collapse)
Dull note : Consolidation , thick pleura
Stony dullness:
Pain over the pleximeter finger with resistance felt by plexor.
Large pleural effusion
Large solid tumor
Cracked pot resonance
Normally seen in chest of infants or child during the act of crying.
Pathological lung cavity with communication with bronchus due to sudden expulsion of
air from the
Cavity to bronchus
Amphoric
Low pitched hollow note
Normally seen in trachea and cheek distended with air
Pathologically seen in pneumothorax and large cavity
Bell tympany
High pitched tympanic or metallic note
Seen in massive pneumothorax
Place coin on affected side of chest and percuss with another coin while simultaneously
auscultating the back.
Sources :

• Hutchinson’s clinical methods ( an integrated approach to clinical practice ) 24 th edition

• An insider’s guide to CLINICAL MEDICINE by Archith Boloor and Anudeep
Padakanti – 2 nd edition.
• Macleod’s clinical examination – 14 th edition.
PERCUSSION OF POSTERIOR
ASPECT OF CHEST
Name : M ganga
gudihal
Roll number : 064
• RULES OF PERCUSSION
1. Direction of percussion :Always percuss from resonant to non
resonant area.
2. Pleximeter : Middle phalanx of middle finger of nondominant
hand and is firmly placed, rest of the fingers slightly lifted off.
3. Plexor/pressor (percussing finger) : Middle finger of the
dominant hand.
4. Movement of plexor hand should be sudden and originating
from the wrist .
5. Pleximeter should be parallel to the border to be percussed .
6. Percuss around 2-3 times over each area.
7. Percussion has to heard as well as felt.
8. Always percuss identical areas of chest for comparision.
9. Distance between pleximeter finger and ear should preferably
be maintained.
TYPES OF PERCUSSION
• Direct percussion : Directly over bony structures like clavicle
• Indirect percussion : By percussing over pleximeter finger with
plexor /pressor
AREAS TO BE PERCUSSED OVER POSTERIOR
ASPECT OF CHEST
• Suprascapular
• Interscapular
• Infrascapular
ABNORMAL TYPES PERCUSSION NOTES
• Tympanic note : In chest, superficial cavity, subcutaneous
emphysema.
• Subtympanic note : just above pleural effusion.
• Hyperresonant note : Bilateral emphysema, unilateral
pneumothorax, compensatory emphysema, Large bullae.
• Impaired note : Fibrosis, collapse.
• Dull note : consolidation, thick pleura.
• Flat dull : pleural effusion.
• Stony dullness : Large pleural effusion, solid tumour.
SOURCE
• Hutchinson clinical methods - 24th edition.
• Archit boloor clinical medicine -2 nd edition.
 Tidal Percussion
• It is a measure of Diaphragmatic Excursion.
• It is used to differentiate whether the causes of
dullness are above the diaphragm (subpulmonic
effusion) or below (subphrenic collections).
• Explain the procedure to the patient, then
percuss the right side of chest from above
downwards till you get the liver dullness.
Normally, is in 5th intercostal space.
• Then ask the patient to take a deep inspiration
and hold his breath.
• Now again percuss the same area.
• Normally, dullness moves down by 1-2
intercostal spaces.
• Tidal percussion is negative in right sided
subpulmonic effusion, Diaphragmatic paralysis.
• In emphysema, since the lung is already fully
expanded tidal percussion will be negative.

Source:- Archit Boloor(2nd edition) & Hutchison(24th edition)

 Ronchi
Mohamed Suhail
Roll No. 70
Reg No. 18M6072
Reference- Archit Boloor Manual of Clinical Medicine
2 Types of Adventitious sounds-

1. Continuous
- High pitched ( wheeze)
- Low pitched ( ronchi)
2. Discontinuous
- Crepitations
- Pleural Rub
Continuous adventitious sounds
-Lasts for more than 250ms
-Musical in quality
-Mechanism of production of sound:

Important pre-requisite for the production of wheeze is airflow

limitation. Narrowing of airways along with increased intrathoracic
pressure results in airflow limitation producing sinusoidal oscillations

- For example:- Wheeze & rhonchi

Wheeze
• High pitched sounds
• 400Hz
• Hissing quality (sibilant)
• Predominantly arise from small airways obstruction
Ronchi
• Low pitched sounds
• 200 Hz
• Snoring quality (sonorous)
• Usually produced when air moves through tracheo-bronchial
passages in the presence of mucus of respiratory sections.
Classification of wheezes/ ronchi:
• 1) Monophone or polyphonic
• 2) Inspiratory or expiratory
Monophonic
• Single tones
• Due to local pathology producing bronchial obstruction
• 1) Tumor
• 2) Foreign body aspiration
• 3) Bronchostenosis
• 4) Menous plug
• 5) Lymph node compression
Polyphonic
• Diffuse, multiple Tones , both phases
• Due to dynamic Compression
• 1) COPD
• 2) Bronchial asthama
• 3) Tropical Pulmonry eosinophilia
• 4) Hypersensitiunty Pneumonitis
• 5) Eosinophilic pneumonia
• 6) Churg-Strauss syndrome.
CREPITATION / CRACKLES / RALES

Reference : HARRISON MOHAMMED SHAHID

& ARCHIT BALOOR
071
CLINICAL MEDICINE.
 CREPITATIONS
.

- Discontinuous sound
- Harsh in Quality, Non musical
- TYPES : Fine & Coarse Crepitation

FINE CREPITATION. COARSE CREPITATION.

> sudden snapping opening > Passage of air through accumulated

of successive small airway secretions, which makes bubbling
, when air flow through it. sound.

> High pitched. > Low pitched.

> Involves small airways. > Involves large airways.

> Heard during inspiration. > Heard during Inspiration&Expiration.

> Not Palpable. > Palpable.

> Not modified by coughing. > Modified by

> Ex: INDEX CREPITATION > Ex: REDUX CREPITATION

(initial phase). (reduction phase).
PULMONARY OEDEMA PULMONARY OEDEMA
(early stage). (late stage).
ILD. BRONCHEICTASIS.
BRONCHITIS.
LUNG ABSCESS.
INSPIRATORY CREPITATION :

EARLY MID LATE

ACUTE & CHRONIC BRONCHIECTASIS. PULMONARY EDEMA.

BRONCHITIS.
RESOLUTION - EARLY PNEUMONIA.
PNEUMONIA.

EXPIRATORY CREPITATION : BRONCHIECTASIS, BRONCHITIS

RESOLUTION-PNEUMONIA
PULMONARY OEDEMA
LUNG ABSCESS

NAMED CREPITATION :

1] COARSE LEATHERY = BRONCHIECTASIS.

2] VELCRO CREPT’S. = ILD.

3] POSTURE INDUCED CRACKLE’S = IHD WITH HEART FAILURE.

(appearance of fine crackles on changing posture, auscultation done
at Posterior axillary line @ 8,9,10th i.c.s after 3 mins of supine)

4] POST TUSSIVE CREPITATION = EARLY PNEUMONIA, EARLY T.B.

(Crepitation which is not usually present, but occurs after a bout of
cough)

NOTE : To differentiate between lung pathology due to

1) Fluid in alveoli 2) Fibrosis of interstitium

Do EGOPHONY & WHISPERING PECTROLIQUY.

VOCAL RESONANCE
Mounisha
18M6074
Department of medicine
• Vocal resonance is the ascultatory counterpart of vocal
fremitus
• Vocal resonance is the resonance within the chest of
sounds made by voice
• Vocal resonance is the detection of vibration
transmitted to the chest from vocal cords as the repeats
a phrase ninety nine
Increased vocal resonance
when the sounds appear to nearer to the ear
than chest piece and louder than normal,the vocal resonance is
said to be increase
• Three types of increased vocal resonance.
• Bronchophony
• Aegophony
• Whispering pectoriloquy
• Bronchophony
If the vocal resonance is increased and appears to
arise from the ear piece of the stethoscope.
It is seen in consolidation of the lungs as in lobar
pneumonia
• Aegophony
. When the vocal res resonance is high pitched giving a
nasal intonation
Massive pleural effusion
• Whispering pectoriloquy
If the vocal resonance is increased to such an extent
that the sounds become very clear and seems to be spoken right in
to listeners ear

Dimnished vocal resonance

• Pleural effusion
• Pneumothorax
• Collapse
• Thickened pleura
• Emphysema
Reference:
• Hutchison’s clinical methods
• G K pal practical physiology
THANK YOU
 Lokeshwar. A
062
SKODAIC RESONANCE

Boxy note just above the effusion.

Here, That the lungs, partly deprived of air, should yield a tympanic sound—and a
nontympanic sound when the quantity of air in them is increased—seems contrary to the laws
of physics.
when the lower portion of the lung is entirely compressed by any pleuritic effusion, and its
upper portion reduced in volume, the percussion sound at the upper part of the thorax is
distinctly tympanitic .
The mechanism for skodaic resonance is unknown.
Significance::Now, if the dullness over an area of pleural effusion were incorrectly attributed to
the diaphragm, then the skodaic hyperresonance above it might be misinterpreted as normal
and the resonant, but duller, contralateral side might incorrectly be thought to be the site of
pathology.
Skodaic resonance :tympanic note
elicited over relaxed lung above the
level of pleural effusion
The area of skodaic resonance (actually hyperresonance) is above the area of dullness
due to pleural effusion. S, skodaic resonance; D, dullness.
Other features of pleural effusion
Auscultatory percussion for pleural effusion

The bell of the stethoscope is placed in the lower axilla, when the patient is seated,
and the spinous process of the vertebrae tapped gently from above downward with
the percussion fi nger.
If an effusion is present, a change to a note of higher and shorter pitch is detected
at a spinous process which, in the case of the affected side, is above that of the
normal side.
In many instances, this change of tone accords with the apex of the Grocco triangle,
and it does not in general coincide with the upper edge of the fl uid content.
The method should be practiced on normal persons, with the eyes closed, and it will
be determined that the change of note is at the same spinous process on each side,
about at the twelfth dorsal.
Shifting dullness to confirm pleural effusion
This is done to demonstrate the shift of fluid in pleural effusion and hydropneumothorax. In
hydropneumothorax shifting occurs immediately, whereas it is very slow in case of pleural effusion. The
immediate shift of fluid can be demonstrated by the dull area percussed in the axilla in the sitting posture,
becoming resonant on lying down on the healthy side

In sitting position, there is dull note in mammary area, which becomes resonant when patient assumes
supine position as the air shifts anteriorly and fl uid settles posteriorly
Ref : golwala 25 ed
Algappan manual 4 th ed.
Manual of clinical and practical medicine 1st ed
Sapira art and science of bedside diagnosis 4 th ed