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276 CHAPTER 8: The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts
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Point of maximum
impulse at
fifth intercostal
space
Vibratory Acuity in Various Parts of the Hand. Place t he handle of a vibrating t uning fork sequentia lly
FIG. 8-12
on the fingertip and the palmar aspect of the metacarpophalangeal joint: the palmar base is more sensitive. This part of the
hand should be applied to the precordium to detect thrills.
Vibratory palpation. Vibratory palpation uses the examiner’s vibration sense
which is most acute over the examiner’s bone and joints. Applying the handle
of a vibrating tuning fork rst to a ngertip and then to the volar surface of
the metacarpophalangeal joint demonstrates the greater vibration sensitivity
of bone and joint than ngertip (Fig. 8-12).
Speech vibrates the tracheobronchial air column. The vibrations normally conduct through the lung septae and pleurae to the chest wall where
they are felt as vocal fremitus. Diminished vocal fremitus is caused by airway
obstruction, uid or air in the pleural cavity, and any disorder which increases
the thickness of the pleura. Conversely, increased transmission of vocal fremitus is caused by consolidated lung with patent airways. Each test word must
be spoken with equal pitch and loudness to allow valid comparisons between
regions. Vocal fremitus is normally most intense parasternally in the right
second interspace, where it is closest to the bronchial bifurcation. The interscapular region also being near the bronchi, registers increased fremitus. Use
the same technique to feel for pleural friction rubs (friction fremitus).
Procedure for vibratory palpation. If possible, have the patient sit or stand.
Place the palmar nger bases onto the interspaces (Fig. 8-13). Alternatively,
use the ulnar side of the hand and fth nger. Ask the patient to repeat the
test words “ninety-nine” or “one–two–three,” using the same pitch and intensity of voice each time. If vibrations are not felt, have the patient lower the
pitch of their voice. Compare symmetrical parts of the chest sequentially with
the same hand. It is better to compare two sensations sequentially with the
same hand than to compare simultaneous sensations from two hands. When
the lower thorax is reached, ascertain the point at which fremitus is lost. In the
absence of a pleural lesion, this indicates the lung bases. Compare this with
the position obtained by percussion and auscultation.
Chest percussion. Tissue density is evaluated by percussion. See Chapter 3,
pages 30-32 for a discussion of percussion techniques. For best results, press
the pleximeter nger into the intercostal spaces parallel to the ribs, then strike
a series of blows with the plexor. Percuss the back with the patient sitting and
Physical Exam of The Chest and Major Vessels 277
10th
Krönig
Anterior Posterior
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FIG. 8-13 Detection of Vocal Fremitus by Vibratory Palpation. Symmetrical points on the chest are palpated
sequentially with the same hand and the strength of vocal fremitus is compared in different regions. The palpating hand is
applied firmly to the chest wall with palm in contact with the wall, and vibrations are sensed with the bases of the fingers.
Cardiac
dullness
Hepatic
dullness
FIG. 8-14 Percussion Map of the Thorax. The entire lung surface is normally resonant. At the apices, a band of
resonance, the Krönig isthmus, runs over the shoulders like shoulder straps. Hepatic dullness ranges downward from the right
sixth rib merging into hepatic flatness. The Traube semilunar space of tympany extends downward from the left sixth rib; it is
variable in extent, depending upon the amount of gas in the stomach. Posteriorly, the dullness below the lung bases begins
at about the tenth rib.
isthmus
6th
Traube
semilunar (tympanitic)
Lung
base
the anterior chest with the patient sitting and supine. Both sonorous percussion and denitive percussion techniques are used to assess the density of
the lungs (sonorous technique) as well as the symmetry and border of chest
structures (denitive technique).
Denitive chest percussion. Denitive thoracic percussion outlines the borders between lung resonance and the dullness of the heart, spleen, upper liver
border, and lumbar muscles below the lung bases. Denitive chest percussion
is used to assess the position of the diaphragm, cardiac borders and to identify diaphragmatic asymmetry and pleural effusions (Fig. 8-14). When the patient is unable to sit, examine in the right and left lateral decubitus positions
acknowledging that this introduces problems in interpretating percussion
sounds (see pages 304-305 and Fig. 8-31). The boundary between resonant
lung and tympanitic gastric bubble outlines the Traube space. The Krönig isth-
278 CHAPTER 8: The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts
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mus over the lung apices is identied by percussing the area of resonance in
the supraclavicular fossae.
Cardiac dullness. See Precordial Percussion, page 280.
Hepatic dullness. The liver’s domed superior aspect normally produces a
transverse zone of dullness from the fourth to the sixth interspaces in the
right midclavicular line. If a wedge of lung lies between the upper liver border and chest wall, the transition is more gradual.
Gastric tympany. The stomach usually contains an air bubble producing
tympany in Traube space. Because the left diaphragm is lower, the upper
tympanitic border is somewhat lower than the upper border of liver dullness
on the right.
Splenic dullness. The spleen produces a dull oval between the ninth and eleventh ribs in the left midaxillary line; it is often obscured by gastric or colonic
tympany. Dullness in this region may be enlarged by solid or liquid stomach
or colon contents or by pleural effusion. An enlarged spleen is seldom obscured by gas. Enlarged splenic dullness or dullness in Traube space requires
careful palpation for the spleen.
Sonorous Chest Percussion. Sonorous percussion is used to identify lung hyperination (increased resonance), as well as atelectasis and lung consolidation (decreased resonance).
Anterior lungs. Use sonorous percussion with heavy indirect bimanual percussion. Starting under the clavicles, compare the percussion sound from
each interspace sequentially with that from the contralateral region, working downward to hepatic dullness on the right and Traube space on the left
(Fig. 8-14). Also, percuss the lateral thorax. Except for cardiac dullness, the
anterior chest should be resonant.
Lung apices. The lung apices extending slightly above the clavicles can produce a band of resonance over each shoulder, widening at its scapular and
clavicular ends. The narrowest part, the Krönig isthmus, lies atop the shoulder. Reproducibility of this nding is low. With the patient sitting or standing, sound each supraclavicular fossa. On the right place the examiner’s left
thumb in the right supraclavicular fossa (Fig. 8-15A) where it is struck by the
plexor nger of the right hand. For the pleximeter in the left fossa, the examiner’s left arm is put around the patient’s back the left long nger is curling
anteriorly over the trapezius into the fossa (Fig. 8-15B). Apical lung brosis,
dense pleural scarring or tumor inltration diminishes the resonance.
Posterior lung and diaphragm excursion. Use sonorous percussion with the
patient sitting or standing, the spine slightly exed, and the shoulders pulled
forward. Begin at the top and work downward comparing right to left sequentially and listening for asymmetry. The scapula and muscles impair resonance in proportion to their mass, but should produce symmetric changes.
Switching from deep sonorous percussion to light denitive percussion technique, the inferior lung margins can normally be detected at about the ninth
Physical Exam of The Chest and Major Vessels 279
B. Percussion of left apex
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A. Percussion of right apex
FIG. 8-15 Percussion of the Lung Apices. Bimanual indirect percussion is applied in the usual fashion, except for the
use of the pleximeter. See the text for descriptions.
rib on the left and the eighth interspace on the right (Fig. 8-14). The transition
between lung resonance and muscle dullness (or atness) is gradual. Mark
the lung bases during quiet respiration, then have the patient inspire deeply
holding the breath while you percuss at full inspiratory capacity. The bases
should move downward 5–6 cm reecting attening of the diaphragm.
Chest auscultation. Air moving in the tracheobronchial tree produces vibrations perceived as sounds. Lung and heart sounds have a frequency between
60 and 3000 cycles per second. Sounds are produced by turbulent air movement in normal, dilated, or narrowed airways, or during passage through the
vocal cords. Diminished or absent breath sounds indicate airway obstruction
or pleural disease. Additional sounds such as wheezes, stridor or crackles
indicate airways disease, parenchymal disease or both.
Lung auscultation. If possible, have the patient sit. When recumbent, the back
should be examined by turning the patient from side to side. With the patient breathing through the mouth, deeper and slightly more forcefully than
usual, listen with the stethoscope’s diaphragm anteriorly at the apices working downward comparing right to left sequentially. Then, listen to the back,
again starting at the apices and working downward. Compare the lower lung
margins as determined by auscultation, percussion, and fremitus.
Breath sounds are described as vesicular, bronchovesicular, bronchial, asth-
matic, cavernous, or absent. Note also their quality and pitch and the relative
duration of inspiration and expiration (Fig. 8-16). If crackles are heard, note
whether they persist or disappear after a few deep breaths. If crackles are not
heard, test for posttussive crackles by listening after a cough, particularly at the
end of expiration. If an abnormality is found, test front and back for whispered
pectoriloquy by having the patient whisper test words, such as “one–two–
three.” Test similarly with the spoken voice for bronchophony (Auscultation
of Voice Sounds, page 307). Be alert for friction rubs, bone crepitus, and other
unusual sounds.
Bedside sputum inspection. Collect sputum from a productive cough in a
transparent plastic cup. Note the color, viscosity, presence of blood, or odor,
280 CHAPTER 8: The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts
Anterior Posterior
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Tracheal sound
FIG. 8-16 Breath Sounds Map in the Normal Chest. The areas of the lungs that are unlabeled have normal
vesicular breathing.
and estimate the daily volume. Attempt to identify any soft tissue elements,
mucous plugs, blood, bronchial casts, or concretions.
Examining the Heart and Precordium: Despite advances in diagnostic technol-
ogy, the cardiovascular physical exam remains an essential skill for the expert
physician. Practice with mentoring by an expert is critical for learning the heart
exam. Simulation technology also facilitates training. The physical exam is both
sensitive and relatively specic for the diagnosis of valvular heart disease.
The cardiovascular exam is presented here in a convenient sequence
emphasizing the precordium and careful neck and extremity exams. A complete cardiovascular evaluation also requires, if indicated, supplementary
procedures such as electrocardiography, echocardiography, CT, MRI, scintigraphy, or cardiac catheterization.
Precordial inspection. Stand or sit at the patient’s right-side shining a light
across the anterior chest, preferably from the left-side. Look for the apical
impulse which is visible in 20% of normal people. With your line of sight
across the sternum look for precordial heaves.
Precordial palpation. Pulsations, lifts, heaves, and thrills can be felt in the
precordium. Palpate with the palm, rst examining areas of visible pulsation.
Even when not visible try to identify the apical impulse in approximately the
left fth interspace 7–9 cm from the midline; it should be ≤2 cm in diameter.
The impulse is synchronous with early ventricular systole. Palpate the entire
precordium for the presence and strength of right and left ventricular thrusts.
When present, a thrill or friction rub can be identied as systolic or diastolic
by its relation to the apical impulse.
Precordial percussion. Percuss the precordium identifying the borders of
cardiac dullness (denitive percussion). With the left arm abducted, locate
the left border of cardiac dullness (LBCD): starting over resonant lung near the
axilla, percuss the fth, fourth, and third interspaces moving medially until
cardiac dullness is encountered (Fig. 8-17). Measure the distance from the
Physical Exam of The Chest and Major Vessels 281
Tricuspid
valve
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FIG. 8-17 Pattern of Precordial Percussion. The fifth, fourth, and third intercostal spaces on the left are percussed
sequentially, as indicated by the arrows, starting near the axilla and moving medially until cardiac dullness is encountered.
Pulmonic
areas
Aortic valve
areas
valve
areas
Mitral valve
areas
FIG. 8-18
Cardiac Valve Areas for Precordial Auscultation. These are the areas where the sounds originating
from each valve are best heard; the areas are not necessarily closest to the anatomic location of the valves.
midline to the LBCD in the fth interspace. The right border of cardiac dullness
(RBCD) is normally behind the sternum so its position is not certain. When
the heart border is displaced rightward, the RBCD can be identied. No conclusion about heart size can be drawn by percussing only the LBCD in isolation. With hydrothorax or thickened pleura, percussion of the heart border
may be impossible. Assess the width of retromanubrial dullness; in the adult a
width >6 cm suggests an anterior mediastinal mass or aortic aneurysm. All
suspected abnormalities require correlation with the clinical presentation and
conrmation by chest radiography, echocardiography or both.
Precordial auscultation. Proper stethoscope use is described in Chapter 3.
The same principles apply to heart and lung auscultation. Listen in each primary valve area (Fig. 8-18). Timing of heart sounds is especially important.
Use the apical impulse, or, if absent, the carotid upstroke to mark the onset of
ventricular systole. Map the radiation of abnormal sounds on the precordium.
Auscultating heart rate and rhythm. Auscultate the apical ventricular rate
comparing it with a peripheral arterial pulse. If the rate is regular and not bradycardic, counting for 15 seconds and multiplying by 4 is sufciently accurate.
282 CHAPTER 8: The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts
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Any difference between the auscultated apical and palpated arterial rates is
a pulse decit. Pulse decit occurs whenever ventricular systole generates a
stroke volume insufcient to produce an arterial pulse wave; it is frequent
with premature beats, bigeminal rhythm, and atrial brillation. The ECG is
the gold standard for heart rate, as not all electrical events produce an audible mechanical event, especially at high heart rates. After counting the heart
rate, listen carefully for an irregularity of rhythm. Dysrhythmias are harder to
detect when the diastolic intervals are either very long or very short, that is,
with particularly slow or fast heart rates. Determine if an irregularity has a
relation to respirations and if there is a repeating pattern of beats.
Auscultating heart sounds: S1 and S2. Normally, auscultation reveals paired
sounds, usually distinct in intensity and pitch, with each cardiac cycle (Fig. 8-19).
Identication of the rst (S1) and second heart (S2) sounds is essential because they mark the beginning and end of ventricular systole. The sound synchronous with an apical impulse is S1. Without an apical impulse, palpate
the carotid pulse, allowing for a slight interval between the onset of cardiac
systole and the wave’s arrival in the neck. The radial pulse is too far from the
heart to reliably distinguish the heart sounds. At ventricular rates <100 bpm,
diastole is longer than systole, so the rst of the pair can be accepted as S1.
When the rate is >100 bpm try to slow the heart for a few beats with a Valsalva maneuver or by gently massaging either carotid sinus. The initial sound
after a long pause must be the rst heart sound. Finally, the second sound is
almost invariably louder than the rst at the base of the heart.
After identifying S1 and S2 at the apex, move the stethoscope short distances along the left sternal border and toward the base (inching) tracing each
sound across the precordium. Use separate passes concentrating sequentially
on the intensity (accentuated or diminished), the quality, the duration, and the
presence of splitting of the sounds. Prolonged sounds can be differentiated
from murmurs by their abrupt beginning and ending; murmurs have a gradual
onset and end. A sound that begins abruptly but ends gradually is probably a
heart sound followed by a murmur. Cardiac auscultation is difcult to master.
It requires mentored practice listening to many normal and abnormal hearts to
recognize the range of normal and correctly identify abnormal sounds.
Auscultating heart murmurs. Listen for heart murmurs only after S1 and S2
have been positively identied. Decide whether a sound of abnormal length
is a split heart sound or a heart sound and murmur. Now turn your attention to the systolic interval between S1 and S2. Decide if there is any audible
sound in this interval by assuming that a heart sound is the shortest perceptible sound and that anything appreciably longer may be heart sound and
murmur. A prolonged sound starting abruptly and dwindling is probably
a heart sound followed by murmur. One developing gradually and ending
abruptly is likely a murmur and heart sound. Carefully examine each valve
area using the diaphragm and listen at the apex and lower left sternal border
with the bell. Cover the intervening spaces by inching the stethoscope short
distances each time. Once a murmur is identied, ascertain its characteristics:
Timing. Determine in what part of the cardiac cycle the murmur occurs,
(i.e. systolic or diastolic), and whether it is early, middle, or late in the
interval, by reference to the rst and second heart sounds.
Physical Exam of The Chest and Major Vessels 283
Atrioventricular valves
systole
Ventricular
diastole
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0.10.2 0.30.4 0.50.6 0.70.8Seconds
R
T
S
UU
ECG
P
Q
Atrial cycle
Atrial pressure
Jugular pressure
Ventricular pressure
Ventricular outflow
Ventricular cycle
Heart sounds
Semilunar valves
Systole
diastole
Systole
diastole
Open
closed
Open
closed
a
c
c
a
v
v
Visible
sign
Audible
sign
FIG. 8-19 Relation of the Heart Sounds to Other Events in the Cardiac Cycle.
Location. Ascertain where on the precordium the murmur has maximum
intensity.
Intensity. Grade intensity by the following scale: Grade I, barely audible with
greatest difculty; Grade II, faint but heard immediately upon listening.
Grades III, IV, V, and VI are progressively louder: Grade IV requires the
presence of a palpable thrill; Grade V, loud enough to be heard with the
Ventricular
284 CHAPTER 8: The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts
Systolic murmurs
lo
(2nd L ICS)
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stethoscope placed on its edge; Grade VI, so loud it can be heard with the
stethoscope off the chest. The grade should be recorded as a fraction, for
instance, III/VI to show the scale being used.
Pattern or Conguration. Decide if the murmur is uniform in intensity
throughout or whether the loudness increases (crescendo), or diminishes
(decrescendo), or both (crescendo-decrescendo). The term diamond-shaped
murmur is taken from the graphic depiction with the maximum intensity
in mid-systole, with a crescendo preceding and decrescendo following
the peak.
Pitch. Determine whether the murmur is high- or low-pitched. Is the murmur
better heard with the bell (low-pitched) or the diaphragm (high-pitched)?
Remember, the bell should be applied lightly, and the diaphragm should
be pressed rmly against the skin. Is the pitch more like a murmur or a
friction rub? Rubs are frequently misdiagnosed as murmurs; they are
distinguished by the quality of the sound.
Posture and Exercise. When possible, auscultate the heart in both the supine
and erect positions. Listen in the left lateral decubitus position at
the cardiac apex to detect the murmur of mitral stenosis and gallop
rhythms. After the systolic interval has been thoroughly explored, listen
in the diastolic interval carrying out the same procedures while asking
the same questions.
Listening for extra systolic sounds. After identifying systole and diastole,
and noting any murmurs, listen for extra sounds in the systolic interval. Any
abnormal sound must be either a murmur or a systolic click (Fig. 8-20).
Listening for diastolic sounds. After examining the systolic interval, listen in
diastole, between S2 and S1, for a murmur, opening snap, third heart sound
(S3), fourth heart sound (S4), or pericardial knock (Fig. 8-20).
(anywhere)
Ejection clicks
(2nd L and R ICS, apex)
Diastolic decrescendo blow murmurs
( R SB, L SB and apex)
S-1 (apex,
wer L SB)
Mid & late
Systolic clicks
(lower L SB and apex)
S2-A S2-P
(2nd L ICS)
S2-A S2-P
Diastolic rumbling murmurs
(lower L SB and apex)
S-3 and/or
Opening snap and/or
pericardial knock
(apex, lower L SB)
FIG. 8-20 Timing of Heart Sounds, Clicks, Opening Snap, and Murmurs Within the Cardiac Cycle.
ICS, intercostal space; SB, sternal border; S2-A, S2-in aortic area; S2-P, S2 in pulmonic area.
S-
x, w
L SB)
er
S-1
Physical Exam of The Chest and Major Vessels 285
Clavicle
+12.3 cm
+12.3 cm
+12.3 cm
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A.
Jugular vein filled and visible
Jugular vein partially filled
Visible part of
jugular vein empty
0
45°
B.
Response of the Jugular Blood Column to Changes in Posture. The anteroposterior diameter of the
FIG. 8-21
thorax at the fourth interspace is ~20 cm; from this point, the ver tical distance to the superior border of the clavicle is ~15 cm
in the erect position. The right atrium is located at the midpoint of an anteroposterior line from the fourth interspace to the
back. In any posture, a horizontal plane through this point is the zero-pressure level. In this figure, a slightly elevated venous
pressure of 12.3 cm is assumed. A. With the patient supine, the horizontal plane 12.3 cm above the zero level is above the
neck; a t normal venous p ressure the j ugular vein is fi lled. B. With the thorax at 45 degrees, the blood column extends midway
up the jugular, so the head of the column is visible. C. In the erect position, the head of the column is concealed within the
thorax, 2.7 cm below the upper border of the clavicle.
C.
0
-10 cm
0
Examining the Blood Vessels: Clinicians must be familiar with the accessible
arteries and veins. These arteries are usually palpable: temporal, common
and external carotid, axillary, brachial, radial, ulnar, common iliac, femoral,
popliteal, dorsalis pedis, and posterior tibial (Chapter 4, Fig. 4-2). The abdominal aorta may be palpable. Visible veins are the external jugular, cephalic,
basilic, median basilic, great saphenous, and veins on the hands and feet.
Measurement of arterial blood pressure. See Chapter 4, page 64.
Venous pressure. Central venous pressure (CVP) is measured at the level of
the right atrium (RA). When erect, this is at the anterior fourth intercostal
space. Proximal and superior to the RA are, in order, the SVC, the two subclavian veins, and the two subcutaneous external jugular veins in the neck above
the clavicles. The vertical height of the blood column above the RA is the
CVP, normally about 10 cm (Fig. 8-21A). Peripheral veins below CVP level
are lled with blood; those above are collapsed. In adults, the upper clavicular border is ~13–18 cm above the RA, so the external jugular veins collapse
when the patient is erect (Fig. 8-21C). As the thorax reclines blood rises into
the neck veins becoming visible in the jugular veins (Fig. 8-21B). The arm
and forearm veins distend to the same level as the SVC. In the horizontal
position, all peripheral veins are lled (Fig. 8-21A). Raising the arm above
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