6. Palpation-sinuses
Examination of the nasal mucosa for colored
discharge .
Directly palpate and percuss the skin overlying the
frontal and maxillary sinuses. Pain suggests
underlying inflammation.
Using otoscope.
Using a tongue depessor, tap on the teeth which sit
in the floor of the maxillary sinus. This may cause
discomfort if the sinus is inflamed.
9. Anterior Cervical:
Drains the internal structures of the throat, posterior
pharynx, tonsils and thyroid gland.
Posterior Cervical:
drains the skin of the back of head. (rnlarged during
respiratory infections.)
Tonsillar:
Drains the tonsillar and thr pharyngeal
region.
10. Sub-Mandibular:
Drains the stuctures in the floor of the mouth.
Sub-Mental:
Drains the teeth and intra-oral cavity.
Supra-Clavicular:
Drains the part of thoracic cavity
and abdomen.
11. Palpation-neck(contd)
Thyroid gland
First locate thyroid cartilage.
Note its position relative to the midline.
If there is any deviation to one side or the other, it is
usually associated with intra thoracic pathology (eg.
pneumothorax).
12. Palpation-neck(contd)
Thyroid gland lies approximately 2-3cm below the
thyroid cartilage, on either side of the tracheal rings,
which may or may not be apparent on visual
inspection.
How to palpate thyroid gland?
Therapist position- standing behind the subject.
Patient position- sitting comfortably on chair or stool.
14. Palpation-neck(contd)
Trachea
Therapist position- in front of the patient.
Patient position- sitting upright with the neck flexed
slightly to allow relaxation of SCM and chin positioned in
midline.
Technique- keeping the middle finger on the sternal notch,
put index on one side and the ring on the other side.
If deviated, focus ensuing chest exam to the upper lobe
problem.
15.
16. Causes of Tracheal Displacement:
Towards the side of the lung lesion:
• Upper lobe collapse.
• Upper lobe fibrosis.
• Pneumonectomy
Away from the side of the lung lesion:
• Massive pleural effusion.
• Tension pneumothorax.
17. Palpation-chest
Clavicle, ribs.
Inter costal space
Lymphnodes
Chest expansion
Fremitus
Muscle activity of chest wall and diaphragm.
Apex Beat.
18. Palpation- chest
Palpating for the bony continuity, to rule out any
fracture.
Palpating for the subcutaneous air if present-it feels
like you are pushing bubble paper.
Palpating for tenderness and any painful area.
ICS for tenderness.
19. Palpation-chest: Axillary Lymphnodes
Feel all the “walls” of the axilla: superior, medial,
lateral and posterior.
Therapist use left hand to palpate the patient’s right
axilla and use right hand to palpate patient’s left
axilla.
It should be noted that lung disease rarely involves
the Axillary lymph nodes.
20. Palpation- chest: Chest Expansion
Assessed to determine the depth and quality of
movement on each side of chest.
Measured by hands and inch tape.
Symmetry is measured by hands and expansion is
measured by inch tape.
Normally, a 2-5” of chest expansion can be
observed.
21.
22.
23. Palpation- chest: Chest Expansion
Sites for measurement: by inch tape
Axillary level
Xiphoid level
Lower costal level
24. Unilateral decrease chest excursion, indicates
pathology on that side for eg pneumothorax, pleural
effusion, pneumonia and collapsed lung.
Bilateral decrease chest expansion is often seen in
asthma and COPD.
25. Palpation- chest: Fremitus
Fremitus is defined as the vibration that is produced
by the voice or by the presence of secretions in the
airways and is transmitted to the chest wall and
palpated by the hand.
26. Palpation- chest: Fremitus
Technique- Therapist places the ulnar aspect of the
both hands firmly against either side of the chest(ICS)
while the patient says the word “ninety-nine”.
27.
28. Lung consolidation: fremitus becomes more
pronounced as transmission of sound is more in
solid.
Pleural effusion: fremitus will be decreased.
29. Palpation-chest: Muscle activity
Is done to evaluate the amount of the accessory
muscle activity used during quiet breathing.
Done by palpating the accessory muscle, in
particular scalenes and the trapezii.
Extent of diaphragmatic contribution is assessed with
the patient in supine position.
30. Palpation-chest: Muscle activity
Palpation of the anterior chest wall with the thumbs
over the costal margin and thumb tips meeting at
the xiphoid gives the most accurate assessment of
the extent of the diaphragmatic activity.
With deep inspiration the hands should travel equally
apart.
31.
32. Palpation- chest: Apex Beat
The apex beat is the lateral most point of the cardiac
impulse palpable on the chest wall.
It is usually localized with reference to the rib level
at which it occurs- representing the x-axis, with the
mid clavicular line, representing the y-axis.
33. The mid-clavicular line is drawn from a point midway
along the clavicle and descending vertically
downwards.
The apex is usually located in the fifth intercostal
space in the mid-clavicular line.
34. Patient position- patient lying at 45degree to the
horizontal.(if not identified rotate the patient to the
left side)
Technique- palpation with the palm of the hand and
fingers should start at a lateral position and move
more anteriorly in order to avoid missing a displaced
beat.
35. A normal apex beat is about 3-4cm in diameter, or a
little more than 1.5 fingertips.
36. Absent apex beat causes:
Obesity
Pericarditis
Emphysema, other copd
Sinus inversus
Death
41. The double apical impulse: is a distinct double
movement of the apex with sinus rhythm, that may
be found in hypertrophic cardiomyopathy, a left
ventricular aneurysm involving the anterior wall or
apex.
42. Parasternal Impulse:
May be felt when the heel of the hand is rested just
to the left of the sternum with the fingers lifted
slightly off the chest.
Normally no impulse or a slight inward impulse is
felt.
In cases of right ventricle enlargement, the heel of
the hand is pushed anteriorly, and lifted off the chest
wall with each systole.
43.
44. Thrills:
Turbulent blood flow, which causes cardiac murmurs
on auscultation, may sometimes be palpable, and
are called thrills.
Palpated with the flat of the hand, first over the apex
and left sternal edge, and then over the base of the
heart.
Best felt with the patient sitting up, leaning forward
and in full expiration( as base of the heart is moved
closer to the chest wall.
45. A thrill that coincides with the apex beat-systolic
thrill.
The one that does not coincide with apex beat-
diastolic thrill.
Presence of thrill usually indicates an organic lesion.
46. Palpation: Circulation
Patients with diabetes or PVD often have diminshed
pulses, particularly in hand and feet.
Individuals with right sided heart failure and bilateral
peripheral edema demonstrate diminished pulses in
the foot and ankle.
47. Radial – palmar side of wrist, between flexor carpi
radialis tendon and radius.
Brachial – cubital foassa, medial to the biceps tedon.
Carotid – just lateral to upper border of thyroid
cartilage.
48. Femoral – below inguinal ligament, midway between
ASIS and pubic symphysis.
Popliteal – in midline, on popliteal side of lower end
of femur.
49. Posterior Tibial artery – posterior, inferior to medial
malleolus.
Dorsalis pedis – lateral to extensor hallucis longus,
over tarsal bones.
55. Examination: Percussion
The purpose of percussion is to detect whether the
underlying lung tissue are air filled, fluid filled, or
solid.
56. Technique:
1. Hyperextend the middle finger of the left hand.
2. Place it flat on the chest, running in the ICS.
3. Separate the fingers as wide as possible and make sure
they are not touching the chest.
4. The right middle finger is used to strike the finger placed
on chest.
5. The striking motion is a quick, sharp one, with movement
happening at the level of the wrist.
6. Chest should be percussed in 5 areas on each side, again
comparing the right and left side at each step.
7. It is usual to strike finger 2-3 times in quick succession
before pausing to move on the next area.
57.
58. The lungs are normal resonant to percussion.
Abnormal lung may be: hyper-resonant, dull or stony
dull.
Dullness is expected over the liver and over the
heart.
Obese people may show reduced resonance, but this
is equal on both sides.
62. Auscultation: Lungs
The purpose is to assess airflow through the lungs.
Helps to assess the condition of the surrounding
lungs and pleural space.
Compare each side with the other.
Ask patient to “breath in and out, through mouth”.
65. Normal Breath Sounds:
Normal sounds are produced from the turbulence of
the airflow in the airways.
Bronchial Breath Sounds:
Heard behind the upper part of sternum.
Are tubular sounds.
Are loud, high pitched sounds.
Approx equal inspiratory and expiratory duration.
A pause occurs between the two components.
66. Normal Breath Sounds:
Bronchovesicular Breath Sounds:
Heard over the junction of the mainstem bronchi with
the segmental bronchi.(1st and 2nd ICS anteriorly and
Interscapular region posteriorly)
Are softer version of the bronchial breath sounds.
Are continuous between inspiration and expiration.
Equal inspiratory and expiratory duration.
67. Normal Breath Sounds:
Vesicular Breath sounds:
Sounds produced by the lung parenchyma except
sternum.
Are soft, low pitched sounds.
Normal inspiration followed by early phase of
expiration can be heard.
69. The American Thoracic Society and The American
College of Chest Physicians Ad HOC Subcommittee
on Pulmonary nomenclature(ATS-ACCP) further
classified the continuous sounds as wheeze(
previously defined as rhonchi) and the discontinuous
sounds as crackles( previously called rales).
70. Wheeze :
Varying duration.
Most frequently heard on exhalation.
Associated with airway obstruction.
Inspiratory or expiratory.
Wheeze on expiration are most common and are
often associated with airway constriction as found in
bronchospasm or when secretions are narrowing the
airway.
71. Wheeze:
Wheeze on inspiration is not very common and
indicates a more severe obstruction of the airway.
The pitch(frequency) of wheeze varies.
High-pitched wheezes are produced in the smaller
bronchi and have a whistling quality.
Low-pitched wheezes arise from the larger bronchi.
May diminish or change in pitch as a result of
bronchodilator treatment.
72. Wheeze:
The monophonic, continuous adventitious sounds
heard over the upper airways of a patient with upper
airway obstruction is called stridor and differ from
the wheeze in intensity and pitch.
Srtidor is always inspiratory.
73. Wheeze:
In severe airway obstruction, Wheeze can be absent
because ventilation is so reduced that the velocity of
the air jet is reduced below a critical level necessary
to produce the sound.
A fixed bronchial obstruction, usually due to a
carcinoma of the lung, tends to cause a localised
wheeze, which has a single musical note and does
not clear with coughing.
75. Crackles:
Are probably the result of loss of stability of
peripheral airways that collapse on expiration.
With high inspiratory pressures, there is rapid air
entry into the distal airways, causing the abrupt
opening of alveoli and of small or medium sized
bronchi containing sectretions.
76. Crackles:
Sounds like brief bursts of popping bubbles.
Most commonly heard during inspiration and may be
associated with restrictive or obstructive respiratory
disorders.
May result from sudden opening of closed airways or
as the result of the movement of secretions during
inspiration and expiration.
77. Crackles are divided into two types depending on
their acoustic properties:
Fine Crackles Coarse Crackles
Noise made when salt is heated on a
frying pan.
Sound of water being poured from a
bottle.
High pithched, less intense and of
shorter duration.
Lower pitched, less intense and of
longer duration.
Mechanism Mechanism
Appreciated only during inspiration. Detected during both inspiration and
expiration.
78. The timing of onset of crackles aids in the differential
diagnosis of parenchymal and airway-disease.
Crackles auscultated during early inspiration are
thought to be more indicative of airways disease,
such as chronic bronchitis, emphysema and asthma.
Crackles auscultated during late inspiration are more
suggestive of parenchymal disorders, such as
pulmonary fibrosis, interstitial pneumonitis and
pneumonia.
79. Early inspiratory crackles Mid to Late inspiratory
crackles
Dependent atelectasis Bronciectasis
Bronchitis Restrictive lung disease
•Asbestosis
•Idiopathic pulmonary fibrosis
•Sarcoidosis
•Scleroderma lung disease
Asthma Pulmonary edema
Emphysema
80. Pleural Rub:
The visceral and parietal pleurae normally move
silently against each other during respiration.
When the pleurae are inflamed, the two thickened
surfaces produce vibrations as they move irregularly
over each other.
Is the sound produced by the motion of inflamed
pleurae.
81. Pleural Rub:
Is loud, grating sound.
Heard during inspiration and expiration.
Also described as leathery sound.
82. Transmitted voice sounds:
Egophony, bronchophony and pectoriloquy, refers to
auscultatory signs that can be heard over areas of
pulmonary consolidation.
The pathogenesis of these signs relates to the
increased sound transmission through the
consolidated lung.
83. Egophony:
Elicited by having the patient say the letter “E”.
If present the “E” sounds like “A”.
Bronchophony:
Elicited by having the patient say a phrase as you
auscultate; “ninety-nine” is the conventional phrase.
Is indistinct and muffled over normal lung.
84. If present, the “ninety-nine” will be heard distinctly
over the consolidated lung, without loss of clarity.
Whispering Pectoriloquy:
Similar to bronchophony, except it is usually elicited
by having patient say the phrase, “ one, two, three”.
Phrase will be muffled and indistinct when
auscultated on normal lung.
Is clearly audible when auscultated over an area of
consolidation.
85. A pathological condition in the lungs can change the
transmission.
This is the reason one may hear bronchial breath sounds in
areas other than mainstem bronchi when a pathological
condition that causes consolidation exists.
A decrease in lung tissue density as in emphysematous lung,
would cause decreased sound transmission.
Decreased transmission also occurs if only shallow breaths are
taken.
Also decreased if distance between the airways and
stethescope is increased( as in obesity, pleural effusion or
barrel chest)
86. Auscultation: Heart
Area where sounds are best heard are:
1. Aortic area: 2nd ICS to the right of the sternum.
2. Pulmonary area: 2nd ICS to the left of the sternum.
3. On the 3rd ICS murmurs of the both aortic and
pulmonary origin are best heard.
4. Tricuspid area: lower left sternal border, approximately
the 4th to 5th ICS.
5. The mitral area(apex of heart): in 5th ICS medial to
midclavicular line.
89. Auscultation: Heart
The first heart sound,S1:
The lub of the lub-dub.
Is associated with the onset of ventricular systole.
Is normally louder and longer.
Lower pitched when auscultated at the apex or even
in the tricuspid region.
90. Auscultation: Heart
The second heart sound,S2:
The dub of lub-dub.
Associated with the closure of the aortic and
pulmonary valves and corresponds with the start of
ventricular diastole.
Has greatest intensity when auscultated at the aortic
or pulmonary regions.
91. Auscultation: Heart
Transient splitting of the 1st or 2nd sound may be noted
during inspiration.
Splitting of S1 is best heard over the tricuspid region,
whereas S2 is best heard more readily over the
pulmonary region.
Both splitting sounds are considered to be normal and
are indicative of slight timing differences between closure
of the left heart values and right heart values.
94. Auscultation: Heart
Third heart sound:
Occurs early in diastole while the ventricle is rapidly
filling (immediately following S2 and sounding like lub-
dub.)
Is low pitched and must be auscultated with the bell
of stethescope.
Auscultation is best performed with the patient lying
on the left side so that the apex of the heart is closest
to the chest wall.
95. When S3 is heard in healthy children or young adult, it
is considered to be normal and is called a physiologic
third heart sound.
When S3 is heard in an older, physically inactive
person or in the presence of heart disease it typically
indicates a loss of ventricular compliance(failure),
often called as ventricular gallop.
Key diagnostic sign for CHF.
96. Auscultation: Heart
Fourth heart sound:
Occurs late in diastole (just before S1 and sounding
like lub-dub).
Is associated with atrial contraction.
Is a low pitched sound best heard with the bell of the
stethescope.
Otherwise known as atrial gallop sound.
97. Is not normal and is associated with an increased
resistance to ventricular filling.
Commonly heard in individuals with hypertensive
cardiac disease, CAD or pulmonary disease.
Also commonly found in individuals with a history of
myocardial infarction or CABG.
98. Auscultation: Heart
Murmurs:
Three broad classifications of murmurs:
1. Murmurs caused by high rates of flow either through
normal or abnormal valves.
2. Murmurs caused by forward flow through a constricted
(stenotic) or deformed valve or by flow into a dilated
vessel or chamber.
3. Murmurs caused by backward flow through a valve
(regurgitation).
99. Murmurs are classified according to their timing,
quality, intensity, pitch, location and radiation.
Murmurs are also classified by the position of the
patient in which the murmur is best heard and by
the part of respiratory cycle in which it is best heard.
Systolic murmurs and diastolic murmurs.
100. Systolic Murmurs:
Are most common.
May be caused by either ejection or regurgitation.
Are heard between S1 and S2.
Are best described as a swishing sound associated
with S1 (instead of hearing lub-dub, one usually hear
swish dub).
101. Most classic systolic murmur is associated with aortic
stenosis.
Murmur heard is high pitched.
Best heard at the right sternal border, 2nd ICS.
Frequently radiating to the neck and the carotid
arteries.
May be produced with other valvular dysfunction
including congenital defects of atria and ventricles.
102. Diastolic Murmurs:
Are rare.
Heard immediately following S2 and diminish in
intensity quickly.
Pathologic conditions associated with these murmurs
include aortic and pulmonary regurgitation and
mitral stenosis.
103. Grade Charecteristics
1/5 1/6 Very faint and detected
only afetr careful
auscultation.
2/5 2/6 Faint but readily
recognizes after several
seconds.
3/5 3/6 Low to moderate
intensity and heard over a
larger area.
4/6 Moderate to loud
intensity. No palpable
thrill.
4/5 5/5 Loud and accompanied
by a palpable thrill.
5/5 6/6 Extremely loud with a
palpable thrill and
auscultable with the
steth held of the chest
104. Auscultation: Heart
Pericardial Friction Rub:
An abnormal sound associated with each beat of the heart
is known as pericardial friction rub.
Has three components (atrial systole, venritcular systole
and ventricular diastole).
Is distinguished from a pleural rub by having the patient
hold his breath, pleural rub dissaperas but pericardial rub
persists.
Sign of pricardial inflammation (pericarditis).
108. References:
Diagnosis of the diseases of the chest by Fraser,
Pare.
Textbook of Respiratory Medicine by Murray &
Nadal.
Cardiopulmonary physical therapy by Ellen Hillegass.
Clinical Examination by Nicholas J Tally.
Bates Guide To Physical Examination
Internet.
