Expiration

Tracheal (bronchial) breath sounds

Characteristics Character is aspirate or guttural

Expiration in longer

Expiration is louder

Expiration has high pitch

I:E = 1:1

There is a pause between inspiration and expiration (due to absence of

alveolar phase)

Distribution Larynx

Trachea

Mode of production Due to in and out movement of air through narrow aperture of glottis

Graphical representation Tubular phase of

inspiration

ABSENT

Expiration

Type of bronchial breathing

Tubular Amphoric Cavernous

High pitched sounds at the bronchioles are

conducted to the chest wall without modification,

e.g.

Consolidation

Above the level of pleural effusion

Massive pericardial effusion (Ewart’s sign)

Low pitched bronchial breathing with high

pitched overtones producing a metallic quality,

e.g.

Open pneumothorax due to bronchopleural

fistula

Large communicating cavity

Low pitched sound with a

peculiar hollow quality, e.g.

cavity

Bronchovesicular breath sounds (also known as vesicular breath sounds with prolonged expiration)

Characteristics Intermediate in character between vesicular and bronchial breath sounds

Expiratory phase is louder, longer, higher pitched than inspiratory, or hollow character

Distribution Upper part of sternum

Up to 3rd/4th dorsal spines between scapula

At times over the lung apices particularly on right side

Mode of

production

Usually seen when air containing lung tissue is interposed between a large bronchus and the chest wall—thus

combining the characteristics of both vesicular and bronchial breath sounds

Graphical

representation

A. Tubular phase of inspiration

B. Alveolar phase of inspiration

C. Expiration

It is the hallmark auscultatory finding of obstructive lung disease like chronic obstructive pulmonary disease and asthma

Diminished intensity of breath sounds

Defect in production Defect in transmission

Bronchial obstruction

Emphysema

Respiratory muscle paralysis

Pleural effusion

Pneumothorax

Thickened pleura

Thick chest wall

Fibrosis

Adventitious Sounds

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Continuous adventitious sounds:

Lasts for more than 250 ms

Musical in quality

Mechanism of production of sound: Important prerequisite 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 and rhonchi.

Wheeze Rhonchi

High pitched sounds Low pitched sounds

400 Hz 200 Hz

Hissing quality (sibilant) Snoring quality (sonorous)

Predominantly arise from small

airways obstruction

Usually produced when air moves through tracheo-bronchial passages in the presence of mucus or respiratory secretions

Classification of wheezes/rhonchi:

Monophonic or polyphonic

Inspiratory or expiratory

Monophonic Polyphonic

Single tones Diffuse, multiple tones, both phases

Due to local pathology producing bronchial obstruction

Tumor

Foreign body aspiration

Bronchostenosis

Mucous plug

Lymph node compression

Due to dynamic compression

COPD

Bronchial asthma

Tropical pulmonary eosinophilia

Hypersensitivity pneumonitis

Eosinophilic pneumonia

Churg-Strauss syndrome

Discontinuous Adventitious Sounds (Rales/Crepitations/Crackles)

These are discontinuous, explosive, nonmusical and harsh in quality

Mainly inspiratory (can be in expiratory or both).

Mechanism of crepitation:

Bubbling sounds produced by passage of air through accumulated secretions.

Sudden snapping opening of successive small airways when airflow is through it.

Fine crepitations Coarse crepitations

Due to snapping opening of successive small

airways

Due to bubbling sounds produced by passage of air through accumulated

secretions

High pitched (soft) Low pitched (loud)

Smaller airways Larger airways

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Heard during inspiration Heard during inspiration and expiration

Not modified by coughing Modified by coughing

Not palpable Palpable

For example

Indux crepitations (initial stages of

pneumonia)

Pulmonary edema (early phase)

Interstitial lung disease

Asbestosis

Hypersensitivity pneumonitis

Sarcoidosis

For example

Redux crepitations (resolution phase of pneumonia)

Pulmonary edema (late phase)

Bronchiectasis

Lung abscess

Bronchitis

Inspiratory crepitations Expiratory crepitations

Early Acute bronchitis

Chronic bronchitis

Redux crepitations (Resolution phase of pneumonia)

Pulmonary edema (late phase)

Bronchiectasis

Lung abscess

Bronchitis

Mid Bronchiectasis Resolving phase of pneumonia

Late Interstitial lung disease

Asbestosis

Early pneumonia

Pulmonary edema

Few named crepitations

Coarse

leathery

Bronchiectasis

Velcro

crepts

Interstitial lung disease

Posture

induced

crackles

Appearance of fine crackles while changing of posture (sitting to supine or supine with passive leg elevation).

Ausculate in the posterior axillary line in the 8th, 9th and 10th intercostal spaces after 3 minute of supine position.

It indicates ischemic heart disease with heart failure

Posttussive

crepitations

Crepitations which are not present normally but appear after a bout of cough. Seen in early pneumonia, early

tuberculosis and lung abscess

Stridor

High pitched whistling or grating sound which is produced by upper airway obstruction.

It is louder over the neck than the chest wall.

Indicates extrathoracic upper airway obstruction (like vocal cord paralysis, supraglottic growths, etc.)

It usually seen during inspiration, however, can be seen in expiration in intrathoracic tracheobronchial

obstruction.

Pleural rub

It is harsh discontinuous, localized, nonmusical, superficial grating sound due to rubbing of the

inflamed pleural surfaces against each other.

It is heard in both phases of respiration and disappears on holding the breath.

Causes

Dry pleurisy

Consolidation

Infarction

Differences between pleural rub and crepitations:

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Pleural rub Crepitations

Both inspiratory and expiratory phases Inspiratory/expiratory or both

Localized to small area Wide spread

No change after coughing May clear after coughing

Pressure on stethoscope increases the sound No effect

Associated with pleuritic chest pain and local tenderness No pain or tenderness

Vocal resonance:

Make the patient sit

Place the stethoscope firmly on the chest wall

Ask the patient to speak “one-one-one” or “ninety nine” repeatedly

Compare corresponding areas anteriorly, in axilla and posteriorly.

Increased vocal resonance

Vocal resonance

Increased Decreased

Consolidation

Large cavity

Bronchopleural fistula

Pleural effusion

Pneumothorax

Fibrosis

Collapse

Asthma

Emphysema

Thick pleura

Note: in upper lobe fibrosis, VR is increased due to the pulled trachea.

Variations of vocal resonance

Bronchophony Increase in loudness as well as clarity of the sound

Seen in:

Consolidation

Just above level of pleural effusion

On spine up to T4

Aegophony Selected amplification of high frequency sounds. “E” is heard as “A”

Seen in:

Consolidation (it is the auscultatory sign of consolidation)

Whispering

pectoriloquy

When the whispered sound in the chest wall is heard clearly and distinguishably as if uttered directly into

the external ear

Seen in:

Consolidation

Cavity with communication with bronchus

Other Auscultatory Features

Post-tussive suction:

It is a sign of superficial collapsible cavity seen in active tuberculosis. When you auscultate a cavernous

bronchial breathing (which indicates a cavity), ask the patient to cough. A suction sound will be heard if

the cavity collapses.

Prerequisites for post-tussive suction:

Superficial cavity

Thin-walled cavity

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Has to be communicating with bronchus

Surrounding lung should be normal.

Succussion splash (Hippocrates succussion):

It is seen in hydropneumothorax

First percuss and get the air fluid level in hydropneumothorax

Keep the diaphragm at the air-fluid level

Hold the opposite shoulder of the patient and shake vigorously as shown in Figure 3D.40.

Tinkling or splashing sound will be heard.

Other conditions like large cavity with fluid, diaphragmatic hernia can also produce succussion splash.

Fig. 3D.40: Demonstration of succussion splash.

Coin test:

High pitched metallic or tympanic note

Place one coin flat on affected side of chest (posteriorly/anteriorly) and percuss with another coin

perpendicularly on it, while simultaneously auscultating from the opposite direction of the same

affected side as shown in Figure 3D.41.

Seen in massive pneumothorax/hydropneumothorax.

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Fig. 3D.41: Demonstration of coin test.

Scratch sign:

Used for diagnosis of pneumothorax

Patient sitting, place the diaphragm of the stethoscope in the midpoint of sternum or spine

Scratch the chest wall from mid axillary line towards the sternum on either side.

Sound will be louder on the side of pneumothorax.

Hamman’s mediastinal crunch:

Loud cracking or clicking sound heard in the 3rd to 5th intercostal spaces near the left sternal border

synchronous with the heartbeat.

It is the sign of mediastinal emphysema (pneumomediastinum) or can also be seen in left-sided

pneumothorax.

Forced expiratory time (FET):

It is a simple inexpensive and sensitive bedside test to detect airflow obstruction.

Instruct the patient to inhale up to the total lung capacity and then blow it as fast and complete as

possible.

Place the bell of stethoscope in suprasternal notch and time the audible expiration.

A value less than 5 seconds indicates FEV1/FVC more than 60%, whereas FET more than 6 sec

indicates FEV1/FVC less than 50%.

Summary of findings in pleural effusion based on the severity

Finding Mild effusion (<300 mL)

Moderate effusion (300–1,500 mL)

Massive effusion (>1,500 mL)

Tachypnea No Present Significant

Chest expansion Normal Decreased on the effected side Significantly decreased on the effected

side

Tactile fremitus Normal Decreased Absent

Breath sounds Vesicular Decreased Absent or bronchial

C/L tracheal or mediastinal

shift

Absent Absent Present

Bulging intercostal spaces No Sometimes Present

Egophony No Yes Yes

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E. RESPIRATORY SYSTEM: SUMMARY OF FINDINGS IN COMMON RESPIRATORY DISEASES

Findings Fibrosis Collapse Pleural

effusion

Pneumothorax Hydropneumothorax Conso

Inspection

Trachea/Mediastinum Pulled to

same side

Pulled to

same side

Pushed to

opposite side

Pushed to

opposite side

Pushed to opposite

side

Central

Retraction/bulge Retraction

on the

affected

side

Retraction

on the

affected

side

Bulging/fullness

on the affected

side

Bulging/fullness

on the affected

side

Bulging/fullness on

the affected side

—

Palpation

Chest expansion Reduced

on the

effected

side

Reduced

on the

effected

side

Reduced on

the effected

side

Reduced on

the effected

side

Reduced on the

effected side

Reduce

the effe

side

Hemithorax

dimension

Reduced

on the

effected

side

Reduced

on the

effected

side

Increased on

the effected

side

Increased on

the effected

side

Increased on the

effected side

Normal

dimens

Vocal fremitus Reduced Reduced Reduced Reduced Reduced Increas

Percussion

Percussion note Impaired

note over

fibrosed

lung

Dull note

over the

collapsed

lung

Stony dull note

over the pleural

effusion and

skodiac

resonance at

the level of

pleural effusion

Hyper-resonant

note over the

pneumothorax

Hyper-resonant note

above the air fluid

level and dull note

below the air fluid

level.

Woody

note ov

consolid

Special findings William’s

tracheal

resonance

Ellis curve

pattern of

upper level of

effusion

Grocco’s

triangle

Obliteration

of Traube’s

space

Garland’s

triangle

Bell tympany

can be

appreciated

(Coin test

positive)

Shifting dullness,

Straight line dullness,

Succussion splash,

Bell tympany can be

appreciated (Coin test

positive)

Auscultation

Breath sounds Diminished

breath

sounds

Absent

breath

sounds

Absent breath

sounds

Absent breath

sounds

Absent breath sounds Tubular

sounds

Adventitious

sounds/special

findings

Fine

crepitations

— — Bell tympany

can be

appreciated

(Coin test

positive)

Bell tympany can be

appreciated (Coin test

positive)

Crepita

heard

Vocal resonance Reduced Reduced Reduced Reduced Reduced Increas

(Bronch

egopho

whisper

pectoril

NOTES

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A. CASE SHEET FORMAT

HISTORY TAKING

Name:

Age:

Sex:

Residence:

Occupation:

Chief complaints (describe in chronological order):

________ × days

________ × days

________ × days

Dyspnea:

Duration

Onset

Grade

Progression

Aggravating factors

Relieving factors

Orthopnea

Trepopnea

Platypnea

Bendopnea

Paroxysmal nocturnal dyspnea

Associated symptoms

Wheeze

Cough with expectoration

Chest pain:

Duration

Onset

Site

Type of pain

Radiation

Diurnal variation (nocturnal angina)

Aggravating factors

Relieving factors

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Associated symptoms

Nausea, vomiting, sweating

Dyspepsia

Local tenderness

Angina equivalents.

Dyspnea

Diaphoresis

Discomfort in lower jaw

Dyspeptic symptoms

Fatigue

Palpitations:

Duration

Onset

Fast or slow

Regular or irregular

Precipitating factors

Associated symptoms

Stoke Adams

Post-palpitation diuresis

Syncope:

Duration

Onset

No of attacks

Awareness

Precipitating factors

Associated symptoms

Pedal edema:

Duration

Onset

Progression

Aggravating factors

Relieving factors

Is it preceded by facial puffiness or followed by facial puffiness?

Hemoptysis

Cyanosis

Decreased urine output

Gastrointestinal symptoms

Right hypochondrial pain

Fatigability

Fever

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Rheumatic fever history

Infective endocarditis

Cyanotic spells

Squatting after exertion

Past history:

Asthma

Chronic obstructive airway disease

Tuberculosis

History of contact with tuberculosis

Diabetes mellitus

Hypertension

Ischemic heart disease (IHD)

Seizure disorder

History of sudden cardiac death.

Family history:

Third generation pedigree chart to be drawn

Personal history:

Bowel habits

Bladder habits

Appetite

Loss of weight

Occupational exposure

Sleep

Dietary habits and taboo

Food allergies

Smoking Index or Pack years

Alcohol history (if yes mention in grams of alcohol)

Treatment history:

Drugs using

Frequency of drug (e.g. drug taken 5 times a week most likely to be digoxin)

Duration of usage

Any blood test to be monitored (e.g. INR for warfarin)

Any intramuscular injections (once in 3 weeks IM injection most likely to be benzathine penicillin for

rheumatic heart disease prophylaxis)

Menstrual and obstetric history

Gravida, parity, live births, abortions (GPLA)

Age of menarche __

Menopause at __

Duration

Summarize:

Differential diagnosis:

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GENERAL EXAMINATION

Patient

Conscious

Coherent

Cooperative

Obeying commands

Body Mass Index (BMI)

Weight (kg)/H2

(meters)

Grading according to WHO for Southeast Asian countries

Arm span

Upper segment: Lower segment ratio

Vitals Examination

Pulse

Rate

Rhythm

Volume

Character

Vessel wall thickening

Radio-radial delay and radio-femoral delay

Peripheral pulses

Blood pressure

Right arm

Left arm

Leg—right and left

Postural drop in BP

Respiratory rate

Regular/irregular

Abdominothoracic (male) or thoracoabdominal (female)

Usage of accessory muscles

Jugular venous pressure

__ cm of water (blood) above sternal angle (+ 5 cm from the right atria)

Jugular venous pulse

Waveform

Pulse oximetry

Physical Examination

Pallor:

Icterus:

Cyanosis:

Clubbing:

Lymphadenopathy:

Edema:

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Others

Signs of infective endocarditis

Signs of rheumatic fever

SYSTEMIC EXAMINATION

Inspection

Chest shape and symmetry

Breast abnormalities

Spine deformity

Precordial prominence

Cardiovascular pulsations

Apical pulse

Pulsation in aortic and pulmonary area

Sternoclavicular pulsations

Left parasternal pulsations

Epigastric pulsations

Ectopic pulsations

Distended veins

Palpation

Confirmation of shape and symmetry

Palpation of precordium

Palpation of cardiovascular pulsation for sounds, thrills and rubs

Tracheal tug

Percussion

Right heart border

Left heart border

2nd IC space

Sternal percussion

Auscultation

Apex (mitral area)

S1

S2

S3, S4

OS/clicks

Murmur

Timing

Grade

Quality

Pitch

Configuration

Radiation

Best heard with diaphragm or bell

Patient positon

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