Mid-axillary line, anterior axillary line, posterior axillary line
Posterior landmarks:
Scapula region: acromion, spine, spina prominens; vertebral line
Posterior chest relationships:
Crest of ilium as a distant landmark
Diaphragmatic considerations:
Levels of hemidiaphragms project during respiration and can be assessed with percussion and chest expansion tests
Locations and Fields of the Lungs
Chest examination regions include:
Supraclavicular, infraclavicular, interscapular, infrascapular regions
Lung bases and upper/middle/lower lung fields
Tracheal bifurcation details noted above
Techniques of Exam (General Approach)
Patient position and exposure:
Posterior lungs and thorax: patient seated, back exposed
Anterior lungs and thorax: patient can be supine or seated
Sequence of technique:
Inspect, palpate, percuss, auscultate
Draping and privacy:
Proper draping to maintain modesty
Initial Inspection of the Thorax and Respiratory Effort
Observe:
Skin color and overall appearance
Rate, rhythm of breathing
Depth and pattern of respiration; use of accessory muscles
Signs of respiratory difficulty: cyanosis, audible wheeze or stridor, retractions
Chest wall shape and symmetry
Normal Breathing and Respiratory Rate
Normal breathing uses diaphragm and accessory muscles (scalenes, parasternal intercostals)
Breathing should be quiet and easy
Normal adult respiratory rate: 14−20/extmin
Posterior Thorax Examination: Inspection and Movement
Assess:
Shape of chest for deformities
Movement of chest for symmetry of expansion
Retractions, especially in lower interspaces
Unilateral impairment or delay in movement
Patient positioning for posterior assessment: seated with back exposed
Chest Wall and Posture Findings on Inspection
Barrel chest: increased AP diameter, as seen in emphysema
Kyphosis: forward curvature of the thoracic spine
Scoliosis: lateral curvature of the spine
Pectus deformities: carinatum (pigeon chest) and excavatum (funnel chest)
Ambulation and posture cues:
Ability to walk with/without effort
Position at rest (sitting, leaning forward, pursed lips)
Color cues: lips, skin coloration; cyanosis may indicate hypoxemia
Reference images/exercises cited in lecture materials
Palpation of the Thorax
Palpate for tenderness and surface abnormalities:
Tenderness, masses, bruising
Technique note:
Use finger pads (not fingertips) to palpate posterior chest wall
Palpate spinous processes with a closed fist or ulnar edge
Instructional phrases (verbalization):
“Tell me if you notice any discomfort…”
Percussion of the Chest
Purpose: to determine whether underlying tissue is fluid-filled, air-filled, or solid
Percussion depth: penetrates about 5extcm into the chest
Technique overview:
Hyperextend the pleximeter finger (middle) and press DIP firmly on surface
Use the opposite plexor finger to strike DIP quickly with a quick, sharp wrist motion
Strike with the tip of the plexor finger; avoid contact of other hand on the surface
Withdraw striking finger quickly
When percussing the lower posterior chest, stand a bit to the side
Compare symmetric regions using the same technique; strike twice in each location
The five percussion notes and their characteristics:
Flat: soft, high pitch, short duration; examples: thigh; pathologic example: large pleural effusion
Dull: medium intensity, medium pitch, medium duration; example location: liver; pathologic example: lobar pneumonia
Resonant: loud, low pitch, long duration; typical of a healthy lung or simple chronic bronchitis
Hyperresonant: very loud, lower pitch, longer duration; examples: emphysema, pneumothorax
Tympanic: loud, high pitch, longer duration; example: gastric air bubble or puffed-out cheek; typical for large pneumothorax
References to practice notes and visual guides included in lecture resources
Percussion Locations and Techniques (Practical Guidance)
Perform posteriorly and laterally; do not forget lateral fields
Locations are referenced in standard charts; ensure coverage of apices and bases
Auscultation of Breath Sounds
Equipment and technique:
Use the diaphragm of the stethoscope
Ask patient to take moderate to deep breaths through an open mouth
Use the ladder technique (gradual, systematic progression across chest)
The stethoscope must contact the skin directly; avoid clothing/gown
Standard exam regions:
Posterior thorax: at least 4 levels per side
Lateral thorax: at least 2 levels in the mid-axillary line
Normal breath sounds:
Vesicular: low-pitched, soft; inspiration longer than expiration; heard over most of both lungs
Bronchovesicular: intermediate intensity and pitch; inspiratory sounds equal to expiratory sounds; often anteriorly in 1st and 2nd interspaces
Bronchial: louder expiratory sounds with longer expiratory phase; usually over the manubrium
Tracheal: very loud and harsh; over the trachea
Adventitious (abnormal) sounds to listen for:
Crackles (rales, crepitations): can be fine or coarse; discontinuous, scratchy sounds; indicate fluid in alveoli or pulmonary edema
Wheezes: continuous, high-pitched, whistling; most evident on expiration; e.g., asthma
Rhonchi: continuous, low-pitched, snoring; caused by obstruction in large/medium airways; may clear with coughing (bronchitis)
Stridor (inspiratory wheeze): usually indicates upper airway obstruction; requires urgent attention; potential causes include foreign body or anaphylaxis
Pleural rub (pleural friction rub): creaking sounds during both phases of respiration; localized to areas of pleural inflammation
Examples and prompts provided in lecture visuals (video resources cited)
Special Exam: Techniques Beyond the Basics
Do not listen through clothing; ensure skin contact during auscultation
Auscultation should cover symmetrical areas and full respiratory cycles with patient breaths
Documentation phrases:
“Breath sounds are vesicular and symmetric”
“No adventitious breath sounds are heard”
“No rales, wheezes, or rhonchi appreciated”
Specialized Tests (Indications and Methods)
Tactile fremitus:
Palpable vibrations using the ball or side of the hand while patient says a number/word (e.g., “99” or “1-2-3”)
Egophony: patient says “eee”; if it sounds like “ay,” egophony is present, often with lobar consolidation
Whispered Pectoriloquy: patient whispers “99” (or “1-2-3”); whispered voice is typically faint or inaudible; louder/clearer sounds indicate pathology
Diaphragmatic excursion:
Measure difference between diaphragmatic level at full inspiration vs. expiration
Normal excursion: 3−5.5extcm
Technique: ask patient to exhale and hold, mark dullness; ask to inhale and hold, mark again; compute excursion
Chest expansion:
Place thumbs at the level of the 10th rib; slide hands medially to raise a small skin fold; ask patient to inhale deeply
Observe distance between thumbs as they move apart on inspiration
Unilateral decrease in expansion suggests pleural effusion or consolidation
Effusion vs. Consolidation: Key Differentiators
Pleural Effusion:
Fremitus: decreased to absent
Percussion: dullness
Auscultation: decreased or absent breath sounds
Transmitted voice sounds: bronchophony, egophony, and whispered pectoriloquy decreased or absent
Pulmonary Consolidation (e.g., pneumonia):
Fremitus: increased
Percussion: dull
Auscultation: bronchial breath sounds
Transmitted voice sounds: bronchophony, egophony, and whispered pectoriloquy increased (louder/clearer) in affected regions
Pneumothorax: Expected Findings
Fremitus: decreased to absent
Percussion: hyperresonant
Auscultation: decreased to absent breath sounds
Documentation Formats (Examples)
Short form example:
Normal thorax exam: “Respirations regular and unlabored. Lungs clear to auscultation (CTA) to bases bilaterally with no wheezes, rales or rhonchi.”
Long form example (typical structure):
General appearance, vital signs, and detailed findings across inspection, palpation, percussion, and auscultation; all negative for pathology where applicable; references to complete respiratory exam video in lecture materials
Practical and Ethical Considerations
Respect patient modesty: ensure proper draping; do not listen through clothing
Communicate throughout: use simple verbalizations to describe each step, seek consent for each part of exam
Documentation should be precise, reproducible, and reflect the patient’s condition accurately
Practical relevance: physical examination findings guide differential diagnosis and guide further testing or imaging
Connections to Foundational Principles
Anatomy informs location and technique (landmarks, lung lobes, pleural spaces)
Physiology underpins breath sounds and percussion (air-filled vs fluid-filled vs solid tissue)
Clinical reasoning: correlate history (ROS, cough, dyspnea) with physical findings (inspection, palpation, percussion, auscultation) to narrow differential
Evidence-based references used in teaching materials (e.g., Bates’ Guide; Stanford resources; UCSD and UMich surface anatomy guides)
Key Numerical and Quantitative References (LaTeX-format)
Normal respiratory rate: 14−20extbreaths/min
Normal diaphragmatic excursion: 3−5.5extcm
Cough duration thresholds:
Acute: <3 ext{ weeks}
Subacute: 3−8extweeks
Chronic: >8 ext{ weeks}
Pleural and lung science references discuss imaging and pathology examples (as cited in lecture slides and texts)
Quick Reference: Common Breath Sounds and Their Implications
UCSD Clinical Med – Lung Anatomy and Surface Anatomy references
University of Michigan – Surface Thorax/Back anatomy guides
YouTube/Video resources cited for auscultation and percussion techniques (as in lecture materials)
Endnotes
The content above consolidates the lecture transcript into comprehensive study notes suitable for exam preparation. It emphasizes anatomy, technique, normal findings, and the key differentiators for common thoracic pathologies, while highlighting practical considerations and documentation practices.