ChestPulmonary Exam Inspection palpation including tactile fremitus percussion

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 (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. Palpati on: For tactile fremitus Palpation: Alternates from side to side or may use both hands simultaneously

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

Posterior Chest 84. Inspection: For symmetry

Posterior Chest: Palpation A. B. A. Place hands on the patient’s posterior/lateral chest B. Ask the patient to take a deep breath Apply moderate pressure-- Your thumbs will move apart and the “dimple’ in the skin will go away Move hands up and towards the midline creating a “dimple” in the skin between the thumbs. - Feel and visualize the chest expanding 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 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 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 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 • 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

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