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X-ray study of the lungs has become so widespread that it is now included routinely in every careful study
of a patient, because the x-ray will reveal abnormalities in some instances that cannot be detected by physical
examination. It is well recognized that some serious conditions can be detected by physical diagnosis only in their
advanced stages, whereas the chest roentgenogram will reveal their presence much earlier, at a stage when the
outlook for recovery is best. The superiority of chest roentgenography over physical examination in certain aspects
has led all too often to the erroneous conclusion that x-ray films can detect everything that can be found a s well as
much that cannot be found by physical examination. A friction rub, rales, and wheezing cannot be seen on x-ray
films and can be detected only by our senses. In fact, the findings on the x-ray film in many instances can be
intelligently only when coupled with the history and physical findings. Careful examination should enhance our
ability to interpret the x-ray films, and the chest film should serve as a check on the physical examination.
Experience would indicate that the following order of procedure has much to recommend it: (1) inspection, (2)
palpation, (3) percussion, (4) auscultation.

Inspection allows one to observe the rate, rhythm, and effort of breathing. Also, from a midline position
behind the patient, one s able to note the shape of the chest and the way in which it moves, including some
deformities of the thorax (anteroposterior diameter in proportion to its lateral diameter, slope of the ribs, abnormal
retraction of the interspaces during inspiration, abnormal bulging of the interspaces during expiration, local lag or
impairment in respiratory movement). Palpation of the chest enables one to identify areas of tenderness, assess
observed abnormalities, assess further respiratory excursion and elicit vocal or tactile fremitus. Percussion of the
chest sets the chest wall and underlying tissues into motion, producing audible sounds and palpable vibrations.
Percussion helps to determine whether the underlying tissues are air-filled, fluid-filled or solid. Auscultation of the
lungs is useful in estimating air flow through the tracheobronchial tree, detecting obstruction, and assessing the
condition of the surrounding lungs and pleural spaces.

To demonstrate the different methods and proper techniques of chest examination useful in the assessment
of respiratory function.

There are 4 general steps in chest and lung examination:
1. INSPECTION-allows one to observe rate, rhythm, and effort of breathing as well as the shape
of the chest, the way in which it moves and deformities of the thorax
2. PALPATION-allows one to identify areas of tenderness, assess observed abnormalities, assess
further the respiratory excursion and elicit vocal or tactile fremitus
3. PERCUSSION-sets the chest wall and underlying tissues into motion, producing audible
sounds and palpable vibrations. It helps to determine whether underlying tissues are air-filled,
fluid-filled or solid.
4. AUSCULTATION-estimates air flow through the tracheobronchial tree, detecting obstruction,
and assessing the condition of the surrounding lungs and pleural space

1. Give the different percussion sounds and the palpable vibrations arising from the respiratory tree
There are five percussion notes which are easily distinguished by differences in their basic
qualities of sound (intensity, pitch, quality and duration):

1. Resonance, the sound heard normally over the lungs, although not loud, is usually heard with
ease, is well sustained, and is moderately low in pitch. In addition, it has a characteristic
quality. The composite normal resonant note can only be learned from personal experience,
accomplished by percussion of many normal chests.

2. Hyperresonance, is of lower pitch than normal resonance. It is a well-sustained sound that has
deep “booming” character. It is relatively intense and consequently is usually heard with ease.

A relatively hyperresonant note is normally found in children. The hyperresonant note in the
adult is commonly the result of emphysema and occasionally pneumothorax.

3. Tympany, is a relatively musical sound in which the fundamental pitch can often be
distinguished (somewhat similar to the sound of a drum). The sound, a s a rule, tends to be
higher than that of the normal resonance, is only moderate or loud in intensity. It results from
air in an enclosed chamber (the stomach and bowel), and in general the greater the tension
within the viscus, the higher the pitch. Tympany is the sound heard anteriorly and laterally
over the abdomen except in the area of the liver. It never occurs in the normal chest, except
below the dome of the left hemidiaphragm, where the underlying stomach and bowel will
produce tympany.

4. Dullness, is essentially the opposite of resonance and hyperresonance in that a dull note is
short, high pitched, and is not loud. The quality is difficult to describe but is most nearly
compared to a dull “thud”. Further, it should be noted that the pleximeter finger perceives
relatively little vibratory sensation. Instead there often is a sense of increased resistance. This
is in distinct contrast to the note of hyperresonance, such as encountered in the
emphysematous chest, where there is considerable feeling of vibration. It should be
emphasized that a dull percussion note is dull only as it compares with other percussion notes,
not in terms of measurable scales of frequency and amplitude.

5. Flatness, is the term used to describe the percussion note when resonance is absent. The
sound and feeling are very similar to striking a barrel or other container filled with water.
Therefore, flatness is a more extreme manifestation of dullness. ( Prior, 1981)

Sound Relative Intensity Relative Pitch Relative Duration Example Location

FLATNESS Soft High Short Thigh
DULLNESS Medium Medium Medium Liver
RESONANCE Loud Low Long Normal Lung
HYPERRESONANCE Very Loud Lower Longer
Gastric air bubble or
TYMPANY Loud * *
puffed-out cheek
Table 1. Percussion notes and their characteristics (Bates, 1983)
*distinguished mainly by its musical timbre

The term fremitus means vibration. In physical diagnosis the may be perceived by the hands
as a vibratory sensation of the thoracic wall is vocal, pleural friction, tussive, and rhoncal fremitus:

1. Vocal fremitus, is a palpable vibration of the thoracic wall produced by phonation. The sounds
that arise in the larynx are transmitted down along the air column of the
tracheobronchoalveolar system into the bronchi of each lung, on through the smaller bronchi
into the alveoli, setting in motion the thoracic wall that acts as a large resonator. Thus,
vibrations are produced in the chest wall that can be felt by the hand of the examiner.
Consequently, vocal fremitus is often called tactile fremitus. In eliciting the vocal fremitus,
the patient is directed to count “one, two, three”- “one, two, three”, to repeat the words
“ninety-nine”-“ninety-nine”, or to say “e-e-e, e-e-e, e-e-e-“. The patient should speak with a
voice of uniform intensity throughout the examination so that the examiner can better
compare the transmission of the fremitus in different areas of the chest. If the fremitus is
slight, it can be increased by having the patient speak in a louder, deeper voice. The vocal
fremitus is perceived by placing the palmar aspect of the fingers against the chest wall.
Usually, both hands are used, placing them in corresponding areas so that simultaneous
comparison of the two sides can be made. Some examiners prefer to use the ulnar aspect of
the hand with the fingers extended or sometimes with the fingers closed in the palm. If only
one hand is used, it should be moved from one place to the corresponding area of the other
side to compare the transmission of sound

2. Pleural fremitus, is a palpable friction rub, produced by the inflamed pleural surfaces rubbing
against one another as in acute pleurisy. This pleural friction fremitus gives a sensation of
“grating” that is synchronous with the respiratory excursion. When present, it is palpable
usually in both phases of respiration, but occasionally it can be palpated only during one
phase, most commonly inspiration. Friction rubs most commonly are felt as well as heard in
the inferior anterolateral portion of the chest, the area of greatest thoracic excursion.

3. Tussive fremitus, is a vibration of the thoracic wall that is produced by coughing

4. Rhoncal fremitus, is produced by the passage of air through thick exudates or an area of
stenosis in the trachea or major bronchi. (Prior, 1981)

2. Give the 2 normal breath sounds. Where are these sounds heard best?
As the result of the movement of air in the tracheobronchoalveolar system,
relatively soft sounds are produced that are termed the breath sounds:
1. Vesicular breath sound is believed to be the result of movement of air in the bronchioles and
alveoli. Variously described a sighing or a gentle rustling, vesicular breathing is a soft, relatively
low-pitched sound. The normal vesicular respiration is longer than in the expiratory phase by a
ratio of approximately 5:2, in contrast to the ratio of the respiratory thoracic motion, which is 5:6.
It should be emphasized that expiration as heard in vesicular breathing is not actually shorter than
inspiration-only that n\much of expiration is not audible. Inspiration is higher in pitch and louder
than expiration. In fact, expiration occasionally may be inaudible. Vesicular breath sounds are
heard normally over most of the lungs.

2. Bronchiovesicular breath sound is a mixture of both tracheobronchial and vesicular elements in

certain areas where the trachea and major bronchi are in close proximity to the chest wall. This
type of breath sound is heard normally on each side of the sternum in the first and second
interspaces, between the scapulae, and over the apices anteriorly and posteriorly, but is more
prominent on the right than on the left. When heard in other locations, bronchiovesicular breathing
is abnormal and is indicative of some disease processes. In bronchiovesicular breathing the
inspiratory phase resembles that of normal vesicular breathing, except that it is slightly louder and
higher pitched. The expiratory phase is longer, and increased in pitch and intensity, with a slightly
tubular quality, as compared with the vesicular sound, but is still somewhat shorter, softer, lower in
pitch, and less tubular than in the true bronchial breathing. A very brief pause may be noted
between inspiration and expiration. In essence, the expiratory and inspiratory phases are very
similar as to duration, pitch, intensity, and quality. (Prior, 1981)

Bates, Barbara. 1983. A Guide to Physical examination, 3rd ed.NY: JB Lippincott Company. pp
Campos, Paulo, et. al. 1979. A Textbook on Physical Diagnosis, 2nd ed. Quezon City,
Philippines: JMC Press, Inc. pp 117-127
Prior, John, et. al. 1981. Physical Diagnosis: The History and Examination of the Patient, 6th ed.
London: CV Mosby Company. pp 189-217