Chest and Lungs


image Skin-marking pencil

image Ruler and tape measure

image Stethoscope with bell and diaphragm


Have patient sit, disrobed to waist.


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

Inspect front and back of chest
See thoracic landmarks.  
imageLandmarks EXPECTED:Supernumerary nipples possible (can be clue to other congenital abnormalities, particularly in whites).
imageCompare 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.
UNEXPECTED:Barrel chest, posterior or lateral deviation, pigeon chest, or funnel chest.
imageAssess nails, lips, nares UNEXPECTED:Clubbed fingernails (usually symmetric and painless; may indicate disease, may be hereditary), pursed lips, flared alae nasi.

image Color
Assess skin, lips, and nails.
UNEXPECTED:Superficial venous patterns. Cyanosis or pallor of lips or nails.
imageBreath UNEXPECTED:Malodorous.
Evaluate respirations

image 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.

imageInspiration/expiration ratio UNEXPECTED:Air trapping, prolonged expiration.
Inspect chest movement with breathing
imageSymmetry EXPECTED:Chest expansion bilaterally symmetric.
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
imageSymmetry/condition EXPECTED:Bilateral symmetry. Some elasticity of rib cage, but sternum and xiphoid relatively inflexible and thoracic spine rigid.
UNEXPECTED:Pulsations, tenderness, bulges, depressions, unusual movement, unusual positions.

image 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.

imageSensations EXPECTED:Nontender sensations.
UNEXPECTED:Crepitus or grating vibration.

image 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.  


Method for percussion.

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Mar 25, 2017 | Posted by in PHYSIOLOGY | Comments Off on Chest and Lungs

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