EXAMINATION

Have patient sit, disrobed to waist.

Thoracic landmarks. A, Anterior thorax. B, Right lateral thorax. C, Posterior thorax.

TECHNIQUE	FINDINGS
CHEST AND LUNGS
Inspect front and back of chest
See thoracic landmarks.
Size/shape/symmetry
Landmarks	EXPECTED:Supernumerary nipples possible (can be clue to other congenital abnormalities, particularly in whites).
Compare anteroposterior diameter with transverse diameter	EXPECTED:Ribs prominent, clavicles prominent superiorly, sternum usually flat and free of abundance of overlying tissue. Chest somewhat asymmetric. Anteroposterior diameter often half of transverse diameter.
Compare anteroposterior diameter with transverse diameter	UNEXPECTED:Barrel chest, posterior or lateral deviation, pigeon chest, or funnel chest.
Assess nails, lips, nares	UNEXPECTED:Clubbed fingernails (usually symmetric and painless; may indicate disease, may be hereditary), pursed lips, flared alae nasi.
Color Assess skin, lips, and nails.	UNEXPECTED:Superficial venous patterns. Cyanosis or pallor of lips or nails.
Breath	UNEXPECTED:Malodorous.
Evaluate respirations
Rhythm or pattern and rate See patterns of respiration in figure below.	EXPECTED:Breathing easy, regular, without distress. Pattern even. Rate 12 to 20 respirations per minute. Ratio of respirations to heartbeats about 1 : 4. UNEXPECTED:Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, platypnea, tachypnea, hypopnea. Use of accessory muscles, retractions.
Patterns of respiration. The horizontal axis indicates the relative rates of these patterns. The vertical swings of the lines indicate the relative depth of respiration.
Inspiration/expiration ratio	UNEXPECTED:Air trapping, prolonged expiration.
Inspect chest movement with breathing
Symmetry	EXPECTED:Chest expansion bilaterally symmetric.
Symmetry	UNEXPECTED:Asymmetry. Unilateral or bilateral bulging. Bulging on expiration.
Listen to respiration sounds audible without stethoscope
	EXPECTED:Generally bronchovesicular.
	UNEXPECTED:Crepitus, stridor, wheezes.
Palpate thoracic muscles and skeleton
Symmetry/condition	EXPECTED:Bilateral symmetry. Some elasticity of rib cage, but sternum and xiphoid relatively inflexible and thoracic spine rigid.
Symmetry/condition	UNEXPECTED:Pulsations, tenderness, bulges, depressions, unusual movement, unusual positions.
Thoracic expansion Stand behind patient. Place palms in light contact with posterolateral surfaces and thumbs along spinal processes at tenth rib, as shown in figure at right. Watch thumb divergence during quiet and deep breathing. Face patient; place thumbs along costal margin and xiphoid process with palms touching anterolateral chest. Watch thumb divergence during quiet and deep breathing.	EXPECTED:Symmetric expansion. UNEXPECTED:Asymmetric expansion.
Palpating thoracic expansion. The thumbs are at the level of the tenth rib.
Sensations	EXPECTED:Nontender sensations.
Sensations	UNEXPECTED:Crepitus or grating vibration.
Tactile fremitus Ask patient to recite numbers or words while systematically palpating chest with palmar surfaces of fingers or ulnar aspect of clenched fist, using firm, light touch. Assess each area, front to back, side to side, lung apices. Compare sides.	EXPECTED:Great variability; generally, fremitus is more intense with males (lower-pitched voice). UNEXPECTED:Decreased or absent fremitus; increased fremitus (coarser, rougher); or gentle, more tremulous fremitus. Variation between similar positions on right and left thorax.
Note position of trachea
Using index finger or thumbs, palpate gently from suprasternal notch along upper edges of each clavicle and in spaces above, to inner borders of sternocleidomastoid muscles.	EXPECTED:Spaces equal side to side. Trachea midline directly above suprasternal notch. Possible slight deviation to right.
	UNEXPECTED:Significant deviation or tug. Pulsations.
Perform percussion on chest
Percuss as shown in figure below. Compare all areas bilaterally, following a sequence such as shown in figures on p. 103
See table on p. 103 for common tones, intensity, pitch, duration, quality.
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