INTERNAL MEDICINE INTRODUCTION – PROPEDEUTICS
CHEST – THORAX – RESPIRATORY SYSTEM

HISTORY TAKING – INTERVIEW – PHILOSOPHY

Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem. A large percentage of the time (70 %), you will actually be able make a diagnosis based on the history alone. Do not be judgemental. Be compassionate. Listen. Do not put patients on the defensive. Be gentle. Focus on the patient. Allow the patient to speak freely and in their own words. They will usually tell you the story. Try to learn how this illness has affected the patient.

What do I need to do to prepare myself prior to the interview? Dress. Equipment. Strategies - At  the bedside (Environment + Introduce yourself + Define your role). Elegant appearance. Decent manner. Kind attitude. Highly responsibility. Good medical morals. Begin. History Taking is Like Being a Detective.


1/  Chief complaint – concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s words. One sentence summation of why patient is seeking medical care (ambulance, emergency etc.). One complaint at a time. It should be recorded in patients own words.

2/ Communication impacts: (Diagnosis, Adherence, Patient satisfaction, Physician satisfaction, Malpractice litigation).

3/ Physician tasks: 
a/ Biomedical Tasks (Find it!, Fix it!).
b/ Communication Tasks (Engage the patient!, Empathize with the patient!, Educate the patient!, Enlist the patient in his/her own health care!).

4/ Pay attention to two „voices“:
a/ Physicians have a "voice," the voice of medicine. This voice... Wants to obtain a history. Asks close-ended questions to get "facts." Constructs a differential diagnosis.
b/ Patients have a voice, the voice of experience. This voice... Wants to tell the "story" of the illness. Is concerned with the personal meaning of the illness.
Translate - Converse in one "voice" while thinking in another.
Bridge - Acknowledge when topics are being changed and give the reasons for the changes.
Funnel - Direct the flow of conversation by asking for information about topics of specific concern

5/ Outcomes of Successful Engagement
a/ Develop a more accurate diagnosis (Obtain more information about the illness. Understand the effect of the illness upon the patient).
b/ Increase the likelihood of adherence (Establish an improved physician-patient relationship. Discover the health belief system of the patient).
c/ Establish an effective relationship (Create an opportunity for partnership. Demonstrate interest in the patient's point of view. Provide the patient with an opportunity to tell their story).

6/ Empathy (Being Seen, Being Heard, Being Accepted).
a/ Being Seen Techniques (See new patients with their clothes on at the beginning of the interview. "See" the patient - acknowledge... Facial and bodily expressions of feelings. Mode of dress and physical presentation. Notable physical characteristics. Eliminate physical barriers - desks, charts, etc)
b/ Being Heard Techniques (Use the language of the patient. Give feedback to the patient. Ask for feedback from the patient. Invite the patient to tell his/her story; welcome the story: Feelings + Values + Thoughts)
But There's a Problem... Physicians acquire more than 13,000 new words during their training. They use them with patients. Adapt to the patient's "voice" (language, beliefs, etc.). This requires concentration
c/ Being Accepted Techniques (If you must judge, judge the behavior not the person. Communicate your understanding of the patient's feelings and values - do so in a way that they can correct you. Use appropriate self-disclosure).
d/ Steps in Communicating Empathy: Recognize the emotional moment. Pause to question: "What's going on here?" Name the emotion you believe is present. Communicate your understanding of the emotion and validate its presence. Respect the patient's efforts with the emotion. Offer support and partnership.
e/ Outcomes of Establishing an Empathic Connection (Reduced anxiety related to isolation or abandonment. Improve adherence. Increased level of connection: Increased patient satisfaction + Increased physician satisfaction + Reduced physician frustration).

7/ Education (Assume the following questions and answer them as a matter of course: What has happened to me? Why has it happened to me? What is going to happen to me?).

8/ Mysteries of the Medical World (What are you (they) doing for me (to me)? Why are you (they) doing this rather than that? Will it hurt me or harm me? How much? How long? When and how will you know what all this (tests, procedures, etc.) means? When and how will I know what it means?). The Poor Adherence Myth -Myth - "Poor adherence can be attributed to patient characteristics." In fact, no consistent relationship has been shown between adherence and... Age, Gender, Social economic status, Marital status, Personality traits introverted, gregarious, etc.).

9/ Factors Affecting Adherence (The objective severity of the disease does not affect adherence; what the physician believes has limited impact. The subjective perception of the seriousness of the disorder does affect adherence; what the patient believes is critical).
a/ What Does Affect Adherence? (The patient's perception of the seriousness of the disease. The patient's perception of the efficacy of the treatment. The duration of the treatment and the illness. The complexity of the regimen. The relationship with the physician).
b/ Enlistment Techniques (To improve adherence physicians must: Demonstrate compassion. Communicate: Personal concern for the patient. Personal interest in the patient's future well-being. Activate patient motivation. Share responsibility with the patient).

10/ You should always begin the physician-centered phase of the interview with "WH" questions (where? what? when?) directed at the chief complaint(s). Build on the information the patient has already given you. Flesh out areas of the story you don't fully understand. Try to quantify whenever possible (pain on a scale of 1 to 10, number of days instead of "a while," etc.). Be as specific as possible and try to record what the patient says accurately, without interpretation.

11/ Address as many of these details as appropriate: Location + Radiation + Quality + Quantity + Duration + Frequency + Aggravating Factors + Relieving Factors + Associated Symptoms + Effect on Function + etc.

12/ Building a relationship with your patient (PEARLS):- P – Partnership, E – Empathy, A – Apology, R – Respect, L  - Legitimization, S  - Support


General Considerations
The patient must be properly undressed and gowned for this examination.
Ideally the patient should be sitting on the end of an exam table.
The examination room must be quiet to perform adequate percussion and auscultation.
Observe the patient for general signs of respiratory disease (finger clubbing, cyanosis, air hunger, etc.).
Try to visualize the underlying anatomy as you examine the patient.

HISTORY OF PRESENT ILLNESS
Identifies the chief complaint and provides a full, clear, chronological account of the symptoms. A thorough HPI requires skill in:
Asking appropriate questions related to chief complaint. Interpreting patient's response to those questions.


SYMPTOMS
Symptom: Any subjective evidence of disease. E.g. anxiety, lower back pain and fatigue are all symptoms. They are sensations only the patient can perceive. Symptoms – this is what the patient feels, things the patient reports.
In contrast, a sign is objective evidence of disease. A bloody nose is a sign. It is evident to the patient, doctor, nurse and other observers. Signs – physical findings – what the examiner discovers, things you can see, hear or feel.

DYSPNEA
Purely subjective sensation of breathlessness, abnormally uncomfortable awareness of  breathing, not painful, varying degrees of unpleasantness, symptom elicited by  taking   the patients history. Difficult or labored breathing; shortness of breath. The word dyspnea comes the Greek "dys-", difficulty + "pnoia", breathing = difficulty breathing. Dyspnea is the American spelling and dyspnoea is the British (mis)spelling.
Questions: When it began (onset), during inspiration/expiration, frequency (frequent/infrequent), severity/intensity (mild/attack), character (exertional/at rest – if exertional, state type and intensity of exertion-walk upstairs/walk/common work/selfservice, sleep/orthopnea), (permanent/paroxysmal), dependence on (day-time/night-time/weather/season/working-living environment/nature/psychic condition/stress), provoking/aggravating/relieving/alleviating factors, duration (per day/week/year), duration at least 3 months per year, effect of medicaments, concomitant disease - (upper respiratory tract/lungs/heart).

COUGH
Cough is a rapid expulsion of air from the lungs typically in order to clear the lung airways of fluids, mucus, or material. Cough is also called tussis. Cough can be categorized as acute (less than 3 weeks) or chronic (greater than 3 weeks).
Questions: When it began (onset), character (exertional/at rest), (permanent/paroxysmal), duration (per day/week/year), productive/non-productive, duration at least 3 months per year, relief after cough, dependence on (day-time/night-time/weather/exertion/season/working-flat-nature environment/psychic condition), provoking/aggravating/relieving factors, type and effect of medicaments

EXPECTORATION (SPUTUM, MUCUS)
Bringing up and spitting out sputum. From the Latin expectorare, to expel from the chest, from ex-, out of + pectus, chest. Sptum - the mucus and other matter brought up from the lungs, bronchi and trachea that one may cough up and spit out or swallow. The word "sputum" is borrowed directly from the Latin "to spit." Called also expectoration.
Questions: When it began (onset), easily/hard, appearance, color, consistency/viscosity, volume, blood = hemoptysis (fresh-bright/clot-dark), other admixtures, duration (per day/week/year), provoking/aggravating/relieving/alleviating factors, dependence on (day-time/night-time/weather/season/working-living environment, nature).

HEMOPTYSIS - (admixture of blood in sputum, bloody sputum, spitting up blood or blood-tinged sputum.), hemoptoe – not used in world literature (pure blood, fresh – massive – bleeding – life threatening situation). The word "hemoptysis" comes from the Greek "haima" for "blood" + "ptysis" meaning "a spitting" = a spitting of blood. The source of the blood was originally not specified but now refers only to blood from the respiratory tract.
Questions: When/onset, frequency, how many times, appearance/color (bright/clotted blood), amount/volume, expectoration/vomiting of blood, concomitant  pain of thorax, provoking/aggravating/relieving factors, history of current/past  illness - (injuries, respiratory system, hemopoetic system), use of medicaments, suffusions and mucous membrane hemorrhages

FEVER

PAIN
1/ Site/location (somatic pain often well localized – e.g. sprained ankle, visceral pain more diffuse, e.g. angina pectoris), deep/superficial
2/ Onset (when it began)
3/ Character/type/quality (sharp/dull, burning/tingling, boring/stabbing, crushin/tugging – preferably using the patients own description rather than offering suggestions)
4/ Severity/intensity – (mild/attack), radiation, associated symptoms
5/ Timing/duration/course/pattern – (since onset, episodic/continuous, if episodic – duration and frequency of attacks, variation by day day/night, during the week/month)
6/ Exacerbating/provoking/aggravating/relieving/alleviating factors – (circumstances, specific activities, posture, effect of medication, dependence on day time/exertion/meal/stress)


HABIT
SMOKING
When, type (pipe, cigar, cigarette), how much cigarettes/day, packs/day, smoker, non-smoker, ex-smoker


THORAX (chest, pectus)
PHYSIOLOGY

INSPECTION (OBSERVATION) – (EYES)
compare, compare, compare – front/back side – whole chest

A. Check for related signs of pulmonary disease
1. facial expression
 a. anxiety, restlessness, drowsiness
2. changes in color
 a. cyanosis seen first in the nailbeds-periorally-in the tongue
 b. facial flushing-seen on the nose, malar prominences, earlobes
Color of the patient, in particular around the lips and nail beds. Obviously, blue is bad!
3. jugular venous distention: Is it constant or occurring only with expiration?
4. pursed lip breathing (on expiration)
 a. open-mouthed  breathing may occur  during severe dyspnea as it requires less work
5. clubbing of digits
 a. produces spoon-shaped nails and drumstick-shaped distal phalanx, the base of the nail will sink under finger pressure
 b. in congenital clubbing, the nail shape is  altered but the nailbed is firm
 c. this is not specific to pulmonary diseases alone

The position of the patient. Those with extreme pulmonary dysfunction will often sit up-right. In cases of real distress, they will lean forward, resting their hands on their knees in what is known as the tri-pod position.

B. Note the breathing pattern
1. for ease, regularity and rate
 a. watch  for interruption to  inspiration followed by a grunt or cough, it is usually caused by pain
2. Observe, rhythm, depth, and effort of breathing. Note whether the expiratory phase is prolonged.
3. further examination requires the chest to be bared
 a. portions may then be draped when inspection is completed

General comfort and breathing pattern of the patient. Do they appear distressed, diaphoretic, labored? Are the breaths regular and deep?

C. Observe the bony thorax
1. for sternal elevation or depression
2. for symmetry of rib motion
 a. best seen viewing the chest from about a 2 m distance - note full or restricted expansion - if you suspect asymmetry, observe again during deep inspiration
3. for motion of the costal angle
 a. it is normally about 90 degrees and widens with inspiration
 b. paradoxical motion (narrowing with inspiration) occurs with diaphragmatic depression from hyperinflation
4. check the slope of the ribs posteriorly
 a. are they angled 45 degrees to the spine or fixed horizontally?
 b. do the ribs move separately  with inspiration or as a single unit?
5. is there barrel-chesting?
 a. compare the anterior posterior distance with the lateral
 b. normally,  the anterior to  lateral ratio varies from 1 : 2 to  5 : 7. Barrel-chesting produces a ratio near 1 : 1.

D. See if the patient uses accessory neck muscles during inspiration
1. Visible as a tightening of the sternomastoid and strap muscles of the neck, or as a transient hollowing behind the clavicles
2. Patient may assume a  posture that aids the effect of accessory neck muscles
 a. patient sits upright, leaning slightly forward, arms are straight and propped onto knees, chair seat, or examination table

E. Watch for fleeting inspiratory retractions
1. true retractions are transient, disappearing before end-inspiration
 a. they are visible  as an indentation seen between the ribs, especially in the 6th through 9th interspaces between the sternum and anterior axillary line
 b. even if the patient holds his/her breath, true retractions will vanish, as they  last only as long as it takes air to enter
2. the normal contraction of intercostal muscles, however, will last as long as patient holds his/her breath
3. intercostal bulging may be visible constantly (pleural effusion or tension pneumothorax) or with expiration alone (airway narrowing)

F. Examine the spine
1. inspect  from  the  side,  checking  for  thoracic kyphosis and lumbar lordosis
2. check for scoliosis
 a. first posteriorly
    (1) with the  patient  standing, note the line formed by posterior spinous processes
      (a) if the spines are not visible, have patient bend slightly forward
      (b) if they  still  cannot  be seen, palpate and dot  each spine with a washable marker, then view the dots from a distance
 b. then anteriorly
   (1) note flank depth, the gap between the elbow and waist
      (a) is it equal on each side?
     (b) the gap will be greater on side of major curve concavity
   (2) note the level of the shoulders
     (a) does one droop lower than the other?
   (3) then, with the patient bending forward, check the level of the scapulas for symmetry
     (a) the scapula on the side of the major curve convexity is more prominent
Any obvious chest or spine deformities. These may arise as a result of chronic lung disease (e.g. emphysema), occur congenitally, or be otherwise acquired. In any case, they can impair a patient's ability to breathe normally.
Spine and shoulder examination (symmetry). Curvature from lateral view (thoracic kyphosis, lumbar lordosis). Curvature from back view (shoulder/scapula symmetry, symmetry of chest in body bending, elbow-waist distance + symmetry, spine line leaving, scoliosis, gibbus).


PALPATION (HANDS)
compare, compare, compare – front/back side – whole chest – ACCROSS AND DOWN PATTERN - from side to side and top to bottom – in orientation/reference chest lines. Palpation: The examiner touches and feels the patient’s body part with his hands to examine the size, consistency, texture, location, and tenderness of an organ or body part. Palpation plays a relatively minor role in the examination of the normal chest as the structure of interest (the lung) is covered by the ribs and therefore not palpable. Specific situations where it may be helpful include: Accentuating normal chest excursion: Place your hands on the patient's back with thumbs pointed towards the spine. Remember to first rub your hands together so that they are not too cold prior to touching the patient. Your hands should lift symmetrically outward when the patient takes a deep breath. Processes that lead to asymmetric lung expansion, as might occur when anything fills the pleural space (e.g. air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree. There has to be a lot of plerual disease before this asymmetry can be identified on exam.

A. Trachea
 1. see if one sternomastoid muscle insertion is more obvious than the other
 2. bend the patientřs head slightly forward, keeping the chin in the midline
 3. then gently slip your finger between the trachea and sternomastoid insertion on each side
   a. if the finger slips in more easily on one side, the trachea is deviating away from that side
4. then check for deviation with inspiration
   a. gently grasp the trachea with the thumb and fofinger just under the cricoid cartilage
   b. have the patient inspire deeply
     (1) the trachea should descend slightly in the midline

B. Tactile fremitus
 1. the spoken voice vibrates lung tissue and, in turn, the chest wall
    a. a loud, low-pitched voice produces the most vibration
    b. fremitus  is often softer when  the adult voice is high pitched, as in many women
    c. in children, however, the thorax is smaller and vibrates well even from a voice of higher pitch
    d. the most vibration is produced by the consonant "n" and prompts use of the words "ninety-nine" or "one-one" (in Slovak "tridsaťtri - 33")  2. press firmly  onto the skin with the  base of the fingers or the ulnar side of the hand
    a. have the patient say "ninety-nine" or "one-one" each time you touch (in Slovak "tridsaťtri-33")
 3. use  the across-and-down pattern, as each patient has a chest wall slightly different from another
    a. an acceptable guide  for normalcy is to compare each side of the thorax for symmetry of findings
      (1) this pattern allows the thorax to be examined side vs. side, level by level, moving down stepwise
  4. begin anteriorly
    a. start by comparing each apex
    b. then continue across-and-down staying in the MCLs
    c. use only one hand to palpate untill you become accustomed to the sensation of fremitus
    d. in the female, gently displace the breast as needed to reach the chest wall
  5. posteriorly
    a. have the patient fold his/her arms in front
      (1) this retracts the scapulas laterally and exposes more posterior lung field
    b. always stay at the medial edge of the scapula, as scapular bone will muffle vibration
    c. follow the across-and-down pattern
      (1) once under the scapulas, descend in the midscapular line
      (2) continue untill the vibration ceases
        (a) this point, the approximate level of the diaphragm, is lower posteriorly than anteriorly
    d. then estimate the diaphragmatic level more precisely by applying the ulnar hand downward in 5 cm steps until the vibration fades
  6. expect more fremitus normally over the upper right lung fields and decreased fremitus over increased thickness of fat or muscle

C. Rib excursion
  1. begin anteriorly near the upper lobes
    a. drape the fingers  over the clavicle and medial shoulders
      (1) extend the thumbs
      (2) place the palms on the upper anterior chest wall near the clavicles
      (3) give some slack to the skin by moving the thumbs toward each other, they should nearly touch
      (4) ask the patient to inspire deeply and allow the hands to move
      (5) note divergence of the thumbs
  2. then check near the right middle lobe and lingular segment
    a. place the fingers high in the midaxillary line
    b. rest the palms on the chest wall
      (1) extend the thumbs at the level of the 5th interspace
    c. move the thumbs medially again to raise some slack in the skin
    d. watch for divergence of the thumbs on inspiration
  3. then at the costal margin
    a. place a thumb in the midpoint of each costal margin and press firmly on the cartilage
    b. watch for divergence with inspiration
      (1) also observe for paradoxical motion (narrowing of the costal angle with inspiration)
  4. then examine posteriorly over the lower lobes
    a. use the same method, placing the fingers at the 10th rib level
    b. another method is to place a thumb in the posterior axillary line at the 10th rib level
      (1) nestle your thumb firmly in the interspace
      (2) with inspiration, it will be  moved by the surrounding two ribs
      (3) normal motion here is 1 to 3 cm
  5. always note whether decreased excursion is symmetric or unilateral

Palpable nodule/mass (place/location, size in cm, shape, consistency-rigidity, boundary, sensitivity, painfulness, movability, edema, surface changes, dimplings).
Spine: sensitivity, painfulness, nodules, deformities.

PERCUSSION (HANDS + EARS)
compare, compare, compare – front/back side – whole chest – ACCROSS AND DOWN PATTERN - from side to side and top to bottom - in orientation/reference chest lines – soft/stronger percussion – from apices to the diaphragm, direct/indirect.
Percuss over the intercostal space and note the resonance and the feel of percussion. Keep the middle finger firmly over the chest wall along intercostal space and tap chest over distal interphalangeal joint with middle finger of the opposite hand. The movement of tapping should come from the wrist. Tap 2-3 times in a row. Do not leave the percussing finger on chest , otherwise you will dampen the sound. Stand on one side and with your flat of hand, tap the chest from top to bottom and from side to side to compare. I use this method as a screening step to identify the area of abnormality. Percussion: This technique makes use of the fact that striking a surface which covers an air-filled structure (e.g. normal lung) will produce a resonant note while repeating the same maneuver over a fluid or tissue filled cavity generates a relatively dull sound. If the normal, air-filled tissue has been displaced by fluid (e.g. pleural effusion) or infiltrated with white cells and bacteria (e.g. pneumonia), percussion will generate a deadened tone. Alternatively, processes that lead to chronic (e.g. emphysema) or acute (e.g. pneumothorax) air trapping in the lung or pleural space, respectively, will produce hyper-resonant (i.e. more drum-like) notes on percussion. Initially, you will find that this skill is a bit awkward to perform. Allow your hand to swing freely at the wrist, hammering your finger onto the target at the bottom of the down stroke. A stiff wrist forces you to push your finger into the target which will not elicit the correct sound. In addition, it takes a while to develop an ear for what is resonant and what is not. A few things to remember: If you're percussing with your right hand, stand a bit to the left side of the patient's back.
Ask the patient to cross their hands in front of their chest, grasping the opposite shoulder with each hand. This will help to pull the scapulae laterally, away from the percussion field.
Work down the "alley" that exists between the scapula and vertebral column, which should help you avoid percussing over bone.
Practice percussion! Try finding your own stomach bubble, which should be around the left costal margin. Note that due to the location of the heart, tapping over your left chest will produce a different sound then when performed over your right. Percuss your walls (if they're sheet rock) and try to locate the studs. Tap on tupperware filled with various amounts of water. This not only helps you develop a sense of the different tones that may be produced but also allows you to practice the technique.

A. Technique
  1. there is a separate technique for each hand
  2. the nondominant hand, which receives the strike, is called the pleximeter
    a. the key point is to press the end of the middle finger firmly into the surface
    b. firm contact produces a clear sound, whereas light contact muffles it
    c. the remaining fingers are  slightly  raised from the skin surface
  3. the dominant hand is called the plexor
    a. it strikes the middle finger perpendicularly
    b. if it hits at any lesser angle, the volar pad is used and dampens the sound
  4. the two hands are held perpendicular to each other
    a. this is the most comfortable position and prevents the fingermail from striking your finger
  5. the motion is a snapping one
    a. the wrist is thrown slightly forward by the forearm
    b. as the wrist flexes, the middle finger extends
    c. after the strike, the finger bounces off
    d. use the lightest strike that will produce a clear sound
  6. stand slightly to the side of your patient, reaching your hands over
    a. in this way, your pleximeter hand can stay fairly horizontal while your plexor hand can hang vertically
  7. as you percuss, it is useful to remember locations of the underlying viscera: heart,  liver, gastric air buble and diaphragm
    a. in this way, you can roughly predict which areas should be resonant or tympanic

B. Examination sequence
  1. begin anteriorly
    a. the apice are only 5 cm across
      (1) place a thumb over the right apex and strike the thumbnail
      (2) reach a middle finger behind the neck to the left apex
    b. then continue across and down
      (1) stay in the MCL and descend in  5 cm steps
      (2) continue until you reach dullness on each side
  2. then laterally
    a. percuss  high  in the  midaxillary line,  moving downward in 5 cm steps
  3. then check posteriorly
    a. remember to have the patient fold his arms to retract the scapulas
      (1) check the apices above each medial scapular border
    b. then follow the medial scapular border, using the across-and-down pattern
      (1) under the scapulas, stay in the midscapular line
      (2) percuss downward until the resonance fades
    c. determine the approximate level of the diaphragms with quiet breathing
      (1) percuss downward in 5cm steps, noting the onset of dullness
      (2) percuss medial and lateral to the midscapular line
    d. determine diaphragmatic excursion
      (1) on each side, percuss the onset of dullness inferiorly
      (2) compare the level found in full expiration vs. full inspiration (it is normally 4 to 6 cm)

Physiological condition/findings - percussion sound in lungs is resonant.
Types of percussion sounds:
1/ resonant sound (resonance) – over aerial lung tissue. Resonance:  percussion over a structure containing air within a tissue, such as the lung, produces a resonant, higher-amplitude, lower-pitched note.
2/ decreased/shortened sound – the area of lung tissue transition to liver, lung tissue transition to heart (aerial vs. non-aerial organs).
3/ dull/dullness (dampen) sound – non-aerial tissue – over a solid organ - liver, heart. Appreciate the dullness of the left anterior chest due to heart and right lower chest due to liver. Dullness: percussion over a solid organ, produces a dull, low-amplitude, short-duration note without resonance. It occurs also when the air content of the underlying tissue is decreased and its solidity is increased.

4/ Flatness: very short, and high pitched (absolute dullness). Flatness occurs when there is no air present in the underlying tissue. For example, flatness is found over the muscle of the arm or thigh, bone.
5/ Tympany:  percussion over a hollow air-containing structure, such as  the stomach (stomach bubble), produces a tympanic, higher-pitched, hollow quality note.

Examination:
1/ apices of lungs - Kronig-Syllab bands (from clavicle to scapula 4-6 cm)
2/ determination of pulmonary borders
a/ anteriorly (recumbent patient)
aa/ sternal border - upper margin of the 6th rib
ab/ parasternal b. - lower margin of the 6th rib
ac/ midclavicular b. - 6th intercostal space
ad/ midaxillar b. - 8th rib
b/ posteriorly (sitting patient)
ba/ midscapular b. - 9th-10th rib
bb/ right paravertebral b. - 10th thoracic vertebra
left paravertebral b. - 11th thoracic vertebra


AUSCULTATION (STETHOSCOPE + EARS)
compare, compare, compare – front/back side – whole chest – ACCROSS AND DOWN PATTERN - from side to side and top to bottom - in orientation/reference chest lines – maneuvers (coughing, deep/shallow breathing).
Breath sounds are produced by turbulent air flow. They are categorized by the size of the airways that transmit them to the chest wall (and your stethoscope). The general rule is, the larger the airway, the louder and higher pitched the sound. Vesicular breath sounds are low pitched and normally heard over most lung fields. Tracheal breath sounds are heard over the trachea. Bronchovesicular and bronchial sounds are heard in between. Inspiration is normally longer than expiration. Auscultation: Many disease processes (e.g. pulmonary edema, bronchoconstriction) are diffuse, producing abnormal findings in multiple fields. Put on your stethoscope so that the ear pieces are directed away from you. Adjust the head of the scope so that the diaphragm is engaged. If you're not sure, scratch lightly on the diaphragm, which should produce a noise. If not, twist the head and try again. Gently rub the head of the stethoscope on your shirt so that it is not too cold prior to placing it on the patient's skin.
Few additional things worth noting.
Don't get in the habit of performing auscultation through clothing.
Ask the patient to take slow, deep breaths through their mouths while you are performing your exam. This forces the patient to move greater volumes of air with each breath, increasing the duration, intensity, and thus detectability of any abnormal breath sounds that might be present.
Sometimes it's helpful to have the patient cough a few times prior to beginning auscultation. This clears airway secretions and opens small atelectatic (i.e. collapsed) areas at the lung bases.
If the patient cannot sit up (e.g. in cases of neurologic disease, post-operative states, etc.), auscultation can be performed while the patient is lying on their side.
Requesting that the patient exhale forcibly will occasionally help to accentuate abnormal breath sounds (in particular, wheezing) that might not be heard when they are breathing at normal flow rates.

A. Begin by demonstrating proper breathing to the patient
  1. say "breathe through your mouth like this when I touch my scope"
  2. breath in deeply and exhale in a relaxed way, mouth open
  3. ask the patient to demonstrate back to you
B. Using the diaphragm, follow the same across and down pattern as for percussion
  1. tape it lightly to make sure you are set to the diaphragm
  2. pace yourself to apply the scope once each 3 or 4 seconds
    a. this will induce a respiratory rate between 15 and 20 breaths per minute, preventing symptoms of hyperventilation
  3. in each case, the breath sounds will fade as you reach the level of the diaphragm
C. Start anteriorly over the apices
  1. then down the MCLs
  2. then laterally down the midaxillary line
  3. then posteriorly
    a. have him/her fold his arms in front
    b. listen first over the apices
    c. then follow the medial scapular borders
  4. listen for changes in the quality of breath sounds
    a. vesicular vs. bronchial breathing
    b. amplitude of breath sounds
    c. the inspiration/expiration ratio
    d. adventitious sounds
      (1) rales, rhonchi and friction rubs

During physiological conditions – normal sounds:
1/ vesicular breathing - the origin of sounds – area of lung tissue - distension of alveoli on inspiration = alveolar, main inspiratory component of the breath circle/sound. Fine/soft sounds, low-frequency sounds (low-pitched s.), duration of inspiration > expiration (3 : 1), no pause between inspiration-expiration.
2/ bronchovesicular breathing - transition area between lung tissue and small bronchi, mixture of vesicular and bronchial breathing, moderately loud, medium pitch, rustling sounds, duration of inspiration = expiration, no pause between phases.
3/ bronchial breathing - area of bigger bronchi (upper manubrium). Loud sounds, expiratory phase of breath cycle, duration of inspiration < expiration (1 : 2). Main expiratory component of the breathing sound. Area of sternum, 1st-2nd intercostal spaces, between the scapula and over the lung apices. At these locations expiratory sounds are also heard more clearly.
4/ tracheal (tubular) breathing - the origin of sounds-big airways - true glottis, larynx, trachea. Loud, coarse, high-frequency sounds (high-pitched s.), harsh/hollow quality sounds, duration of inspiration = expiration, pause between phases.



AUSCULTATION - ADDITIONAL TESTS
A. Accentuate wheezing sounds by listening again during a forced expiration
B. If rales are heard, see if they disappear after a few deep breaths
  1. they may also be caused by hair rubbing on the diaphragm, wetting the skin will reduce this
C. Elicit posttussive rales
  1. have patient inspire deeply, then exhale, then cough
  2. listen for rales as the patient inspires after that cough
D. Observe for whispered pectoriloquy
  1. listen over the suspected lung field as the patient whispers "one two three" (jeden dva tri)
  2. with bronchial breathing (abnormal), the whispered voice will be heard more clearly
E. Listen for bronchophony
  1. have the patient speak, note a change in intensity or clarity of the spoken voice
  2. it will become more distinct over an area of lung tissue consolidation or compression
F. Listen for egophony
  1. have patient vocalize the vowel E
  2. over consolidated or compressed lung tissue, it will be heard through the stethoscope as A.
G. finally, if the patient complains of chest pain with breathing
listen over the site of pain for a possible pleural friction rub

THE BREASTS AND AXILLAE
    A. lymphatic drainage: important because of the frequent spread of breast cancer through these channels
       1. visualize the axilla as a four-sided pyramid
         a. anterior (pectoral) nodes drain the anterior chest wall  and most of the breast
            (1) they are located within the anterior axillary fold
         b. posterior (subscapular) nodes drain the posterior chest wall and part of the arm
            (1) they are felt deep within the posterior axillary fold
         c. lateral nodes drain most of the arm
            (1) they are felt against the upper humerus
         d. medial (central) nodes drain all of the above
            (1) these are located high in the axilla and are the most frequently palpable
      2. from the central nodes, lymph drains into the infraclavicular and supraclavicular nodes
         a. also, depending on the location of the lesion, spread may proceed directly to deeper channels or to the opposite breast
    B. Inspection
       1. observe the skin for rashes, discoloration, edema, infection, bulging or retraction
    C. Palpation (demonstrated for the left axilla)
       1. support her left wrist or hand with your left arm
         a. this relaxes the muscles as well as abducting the arm
            (1) your right fingers should lie directly  behind the pectoral muscles, pointing toward the midclavicle
       2. lift your fingers high into the axilla, then press inward
       3. maintaining pressure against the ribs, slide your fingers downward over the central nodes (the maneuver is actually performed with the arm lowered)
       4. then feel inside the anterior axillary fold behind the lower edge of the pectoral muscle, feeling for pectoral nodes
       5. feel inside the posterior axillary fold for the subscapular nodes, this is more easily done from behind
       6. from the same posterior position, feel against the humerus for the lateral nodes
       7. finally, feel above and below the clavicle for supraclavicular and infraclavicular nodes
       8. repeat on the right axilla, palpating with your left hand.

Literature:
1/ Novey, D.W. Rapid Access Guide To Physical Examination. Mosby.1999, ISBN:0323001289
2/ Chandrasekhar, A. Screening Physical Examination.
 http://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/pd/pdmenu.htm
3/ A Practical Guide to Clinical Medicine. http://medicine.ucsd.edu/clinicalmed/index.htm
4/ Rathe, R. Basic Clinical Skills Archive. http://medinfo.ufl.edu/year1/bcs96/index.html
5/ Zelenková, J. Internal Propedeutic Workbook. http://www.lf2.cuni.cz/Projekty/interna/aindex.htm
6/ Pathological Conditions, Signs and Symptoms. Karolinska Institute. http://www.mic.ki.se/Diseases/C23.html
7/ General Practioner Notebook. http://www.gpnotebook.co.uk/homepage.cfm
8/ Clinical Diagnosis. Tulane School of Medicine. http://www2.som.tulane.edu/courses/clinicaldx/Tier%20I%20Lung%20Exam.htm