Visual inspection of the chest

Shape must be described (normosthenic, asthenic, hypersthenic; pathological: emphysematous, paralytic, rachitic, funnel, foveated, scoliotic, kyphotic, kyphoscoliotic.

Pattern of breathing: type of respiration (thoracic, abdominal, mixed), participation of the chest wall in breathing act, respiration rate, depth and rhythm, participation of the accessory muscles in breathing.

Palpation of the chest

Identification of the tender areas – palpate under the ribs along both sides of the vertebral column, along middle axillary lines, along both sides of sternum where the intercostals nerves closer to surface.

Assess elasticity of the chest by pressing the chest from both lateral sides and front-back direction.

Assess of the vocal fremitus by putting both hands on the symmetrical parts of the patient’s chest and asking patient to say “тридцать три”.

Assess the Potenzher’s symptom by palpating the trapezium muscles and noting sensation of muscle’s tone, tenderness and mass.

Percussion of the lungs

1. Comparative percussion of the lungs: character of the percussion sound over different parts of the lungs.

Percuss from side to side and from top to bottom. Omit the areas of the heart, covered by the scapulae.

Compare one side with the other to define for asymmetry.

Note the location and quality of percussion sounds you hear.

Interpretation of the percussion sounds

Clear lung sound	Normal
Dull sound	Syndromes of lobar consolidation, complete atelectasis, pleural effusion
Small dull sound	Syndromes of focal consolidation, incomplete atelectasis, sclerosis of pleural sheets, pneumosclerosis
Tympanic	Pneumotorax, cavernas or abscess of lung
Box sound	Emphysema

2. Topographic percussion of the lungs:

- determination of the upper borders of the lungs (posterior and anterior positions of the apex): apex height and Krenig’s areas width

- determination of the lower borders of the lungs (along topographic lines: right from parasternal till paraspinal, left from axillary anterior till paraspinal),

Normal lung borders

Topographic lines	Right lung	Left lung
Parasternal line	V interspace	-
Midclavicular line	VI rib	-
Anterior axillary line	VII rib	VII rib
Midaxillary line	VIII rib	VIII rib
Posterior axillary line	IX rib	IX rib
Scapular line	X rib	X rib
Paravertebral line	Spinous process of XI chest vertebra	Spinous process of XI chest vertebra

- determination of the excursion of the lower borders of the lungs (scapular and midaxillary lines).

• Find the level of the lower border of the lung.

• Ask the patient to inspire deeply and again find the level of the lower border of the lung.

• Ask the patient to expire deeply and again find the level of the lower border of the lung.

• The normal movement of low lung border on midaxillary line – 6-8 cm and on scapular line – 4-6 cm symmetrically.

Auscultation of the lungs:

Listen from side to side and from top to bottom. Omit the areas of the heart, covered by the scapulae.

Compare one side with the other to define for asymmetry.

Note the location and quality of percussion sounds you hear.

1. Listen the sounds generated by breathing – breath sound (vesicular or bronchial). Vesicular breath sounds are low pitched and normally heard over almost all lung fields. Bronchial breath sounds are heard over the larynx, trachea and big bronchus (near seven cervical vertebra, 1^st and 2^nd interspaces, between scapula).

2. Listen the adventitious sounds: rales (wheezes, dry, moist), crepitation, pleural friction rubs.

Assessment of the respiratory system examination

1. Highlight pathological signs obtained by examination.

2. Indicate connection between different obtained signs.

3. Suggestion about possible syndrome of the respiratory disease.

Examination of the cardiovascular system