Chest/Pulmonary Exam Inspection, palpation (including tactile fremitus), percussion, auscultation of the posterior, lateral, and anterior chest. Examination of the anterior chest may be conducted with the patient supine or sitting Examination of the lateral chest may be incorporated into examination of the anterior and/or posterior chest Chest/Pulmonary Exam Inspection, palpation (including tactile fremitus), percussion, auscultation of the posterior, lateral, and anterior chest. Examination of the anterior chest may be conducted with the patient supine or sitting Examination of the lateral chest may be incorporated into examination of the anterior and/or posterior chest

Anterior Chest Anterior Chest (lying or sitting or at 30 0) 73. Inspection: For symmetry, fully exposed (in female patient may cover with gown as in photo) Anterior Chest (lying or sitting or at 30 0) 73. Inspection: For symmetry, fully exposed (in female patient may cover with gown as in photo)

Anterior Chest 74,75. Palpation: For tactile fremitus Palpation: Alternates from side to side or may use both hands simultaneously Anterior Chest 74,75. Palpation: For tactile fremitus Palpation: Alternates from side to side or may use both hands simultaneously

Anterior Chest: Percussion: 76-78 Must be done: Bilaterally Symmetrically Good tone Must alternate from side to side Anterior Chest: Percussion: 76-78 Percussion: Must be done: Bilaterally Symmetrically Good tone Must alternate from side to side

Anterior Chest: Auscultation (Starting above clavicles, 3-4 places, listens throughout inspiration and expiration) Patient instructed slow, deep breath, mouth open Auscultation: Alternates from side to side Auscultation: At least 3-4 areas auscultated on each side Anterior Chest:Auscultation: 79-83 Auscultation: Done correctly (Starting above clavicles, 3-4 places, listens throughout inspiration and expiration) Auscultation: Patient instructed slow, deep breath, mouth open Auscultation: Alternates from side to side Auscultation: At least 3-4 areas auscultated on each side

Posterior Chest Posterior Chest 84. Inspection: For symmetry

A. B. Posterior Chest: Palpation A. Place hands on the patient’s posterior/lateral chest Apply moderate pressure-- Move hands up and towards the midline creating a “dimple” in the skin between the thumbs.- B.Ask the patient to take a deep breath Feel and visualize the chest expanding Your thumbs will move apart and the “dimple’ in the skin will go away 85. Chest Expansion: A. Place hands on the patient’s posterior/lateral chest Apply moderate pressure-- Move hands up and towards the midline creating a “dimple” in the skin between the thumbs.-- Arrows indicate direction of hand movement B. Ask the patient to take a deep breath Feel and visualize the chest expanding Your thumbs will move a part and the “dimple’ in the skin will go away Note the patient’s position during the posterior chest exam: Ask the patient to cross his/her arms in front and to place their hands on the opposite shoulder. This position moves the scapula apart and allows for a better exam Arrows denote direction of hand movement

Posterior chest: Palpation 86-87:Tactile Fremitus Start above the scapula Use the ulnar aspects of the hands May use one hand and alternate from side to side or may use both hands moving inferiorly Ask the pt to say “99” and feel the vibrations 86-87:Tactile Fremitus Start above the scapula Use the ulnar aspects of the hands May use one hand and alternate from side to side or may use both hands moving inferiorly Ask the pt to say “99” and feel the vibrations

Posterior Chest--Percussion 88-91: Percussion: includes percussion, diaphragmatic excursion, and percussion over the costovertebral angle Posterior Chest--Percussion 88-91: Percussion: includes percussion, diaphragmatic excursion, and percussion over the costovertebral angle Percussion--(At level of the diaphragm) This is done during normal (tidal) breathing Start above the scapula Alternate from side to side Continue inferiorly until dullness of percussion occurs Percussion--(At level of the diaphragm) This is done during normal (tidal) breathing Start above the scapula Alternate from side to side Continue inferiorly until dullness of percussion occurs

Posterior Chest-Percussion Diaphragmatic movement Once the level of the diaphragm has been detected during tidal respiration ask the patient to take a deep breath and hold it This will move the diaphragm more inferiorly Begin to percuss moving more inferiorly until dullness is encountered again Posterior Chest-Percussion 88-91: Diaphragmatic movement Once the level of the diaphragm has been detected during tidal respiration ask the patient to take a deep breath and hold it This will move the diaphragm more inferiorly Begin to percuss moving more inferiorly until dullness is encountered again The distance between the initial area of dullness during tidal respiration and the area of dullness during full inspiration is the diaphragmatic excursion (movement) Repeat this process for the other side Begin to percuss moving more inferiorly until dullness is encountered again Repeat this process for the other side

Anterior Percussion over costovertebral angle Place the ball of one hand firmly over the patient’s costovertebral angle. Use the ulnar side of your other hand to strike the hand you have placed on the patient. Use enough force to cause a perceptible but painless jar or “thud” Repeat on the opposite side Place the ball of one hand firmly over the patient’s costovertebral angle. Use the ulnar side of your other hand to strike the hand you have placed on the patient. Use enough force to cause a perceptible but painless jar or “thud” Repeat on the opposite side

Posterior Chest Auscultation: 92-96 Patient needs to be in the correct position with arms folded and hands on opposite shoulders Use the diaphragm of the stethoscope Start above the scapula Ask the patient to take deep breaths with his/her mouth open Listen to complete inspiration and expiration Move from side to side working your way inferiorly Listen to at least 3-4 places Posterior Chest Auscultation: 92-96 Patient needs to be in the correct position with arms folded and hands on opposite shoulders Use the diaphragm of the stethoscope Start above the scapula Ask the patient to take deep breaths with his/her mouth open Listen to complete inspiration and expiration Move from side to side working your way inferiorly Listen to at least 3-4 places Lateral Chest Do not forget to include tactile fremitous, percussion, and auscultation of the lateral chest.