INTERNAL MEDICINE INTRODUCTION – PROPEDEUTICS
CHEST – THORAX – RESPIRATORY SYSTEM

CHEST, THORAX
PATHOLOGY

INSPECTION
Size, shape, symmetry, type of breathing, changes of breathing, breathing movements, breath frequency
SHAPE  1/ inborn deformity (pectus carinatum/gallinaceum – pigeon chest - Pigeon-breasted. In Latin "pectus" means "chest" and "carina" keel = a chest shaped like the keel of a boat (looking at the keel from outside the boat) – in Marfan sy, kyphoscoliosis, pectus excavatum – funnel chest - "Caved-in" chest – in Marfan sy, rachitis). Pectus excavatum: Congenital posterior displacement of lower aspect of sternum. This gives the chest a somewhat "hollowed-out" appearance. The x-ray shows a subtle concave appearance of the lower sternum.
2/ acquired deformity (rachitis - D vitamin deficiency at an age between 6th and 19th month, barrel chest/pectus – in emphysema, senile kyphosis). Barrel chest: Associated with emphysema and lung hyperinflation. Accompanying xray also demonstrates
increased anterior-posterior diameter as well as diaphragmatic flattening.
3/ vertebral column deformity (kyphosis, gibus - humped back, in kyphoscoliosis)
SYMMETRY (contour) - configuration of the chest
1/ normosthenic - (symmetrical, epigastric angle 90 degree)
2/ hypersthenic - (short, wide, epigastric angle obtuse)
3/ asthenic - (long, narrow, epigastric angle sharp)
BREATHING/RESPIRATION TYPE
- abdominal (male)
- costal (female)
- costoabdominal
The direction of abdominal wall movement during inspiration. Normally, the descent of the diaphragm pushes intra-abdominal contents down and the wall outward. In cases of severe diaphragmatic flattening (e.g. emphysema) or paralysis, the abdominal wall may move inward during inspiration, referred to as paradoxical breathing. If you suspect this to be the case, place your hand on the patient's abdomen as they breathe, which should accentuate its movement.
CHANGES OF BREATHING (normal breath frequency 12-16 per min.)
1/ tachypnea (higher breath frequency - fever, exercise, pain, cardiac diseases, infectious diseases, anemia, obesitas)
2/ bradypnea (lower breath frequency - coma, poisoning,uremia)
3/ Kussmaul breathing (deep, regular - diabetic acidosis) (air hunger) – periodical - rapid, deep, regular and labored breathing.
4/ hyperpnea - (deep breathing)
5/ apnea - absent breathing/breath arrest
6/ Cheyne-Stokes breathing (periodic - gradually deep then decreased breathing with apnea - intervals of apnea and crescendo/decrescendo sequence of respiration. In: disorders of respiratory center, in healthy older people, children sometimes during sleep, severe cardiac failure, narcotic drug poisoning, neurologcial diseases.
7/ Biots breathing  (periodic - the same depth of breathing – followed with sudden apnea – irregular respirations varying in depth and interrupted by intervals of apnea, lacking the repetitive pattern of periodic respiration. In: meningitis.
8/ dyspnea (breathlessness) - (exertional, resting, orthopnea, paroxysmal, nocturnal - left heart insufficiency, paroxysm/attack of bronchial asthma, cardiac infarction, pulmonary edema, chronic obstructive lungs diseases, obstruction of big airways, anemia, hyperthyroidism)

PALPATION
Skin moisture and temperature, myotonus, tremor, frictional murmurs (sounds), thrills, respiratory movements
A/ unilateral decreased respiratory movement (breaked ribs, pneumothorax, pleuritis)
B/ fremitus vocalis/pectoralis, tactile fremitus - comparison, symmetry
1) decreased
a) physiologicaly (silent voice, thick chest wall, children, women)
b) pathologicaly (compressed/closed bronchus and tissue is non-aerial, emphysema, cavern, pneumothorax, hydrothorax, thickenned pleura, pyothorax, hemothorax)
2) increased - (inflamed lung tissue, above top margin of pleural exudate)
C/ palpable thrill (arterio-venous shunts – in Rendu-Osler disease)
D/ frictional sound (pleuritis, pleuropericarditis, pericarditis)
E/ subcutaneous emphysema - subcutaneous crepitus (pneumothorax, operation, fracture of rib)
F/ Tietze sy - painful palpation of costochondral junction

PERCUSSION

Size of thoracic organs, localization  and  extent of pathological changes in lungs and pleural cavity, symmetry, comparison in thoracic lines and topographic areas
- soft percussion (more superficial structures)
- more intensive percussion (structures in depth)

SOUNDS
Resonant sounds are low pitched, hollow sounds heard over normal lung tissue.
Flat or extremely dull sounds are normally heard over solid areas such as bones.
Dull or thudlike sounds are normally heard over dense areas such as the heart or liver. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors.
Hyperresonant sounds that are louder and lower pitched than resonant sounds are normally heard when percussing the chests of children and very thin adults. Hyperresonant sounds may also be heard when percussing lungs hyperinflated with air, such as may occur in patients with COPD, or patients having an acute asthmatic attack. An area of hyperresonance on one side of the chest may indicate a pneumothorax.
Tympanic sounds are hollow, high, drumlike sounds. Tympany is normally heard over the stomach, but is not a normal chest sound. Tympanic sounds heard over the chest indicate excessive air in the chest, such as may occur with pneumothorax.

Pathological condition percutoric sound is:
1/ abbreviated and fade/less resonant (liquid in pleural cavity, atelectasis, pneumonia, pleural thickenning, pulmonary infarction, pulmonary edema)
2/ dull - in non-aerial organ (heart, muscle, liver, a lot of liquid in pleural cavity, carcinoma, pulmonary edema)
3/ tympany resonance (big cavities, pneumothorax, above the compressed exudate)
4/ hyperresonant (emphysema, small pneumothorax, bronchiolitis)
5/ metallic (amphoric, cavernous) (superficial big pulmonary cavity with smooth wall, tension pneumothorax)
6/ nummular (big pulmonary cavity joined with airways)

AUSCULTATION
To hear the vibration of flowing air in airways transmitted to the body surface directly (ear) or indirectly (via stethoscope), main breathing sounds, accessory breathing sounds, quality of the sounds during inspiration/expiration, duration and rate of the inspiration/expiration during quiet and deepier breathing and after cough
A/ Main breathing/respiratory  sounds
I/ Vesicular breathing
1/ physiologically changed
a/ decreased/diminished (superficial breathing, obesitas, edema of the chest wall)
b/ exaggerated (puerile - in children)
2/ pathologically changed
a/ decreased/diminished (pain, pleural irritation, fracture of the rib, pleural exudate, pneumothorax, atelectasis, emphysema)
b/ exaggerated - increased expiratory phase, bronchovesicular/vesicobronchial breathing (bronchitis, diabetic coma-Kussmaul breathing)
c/ harshed (bronchitis)
d/ stridulous (stenosis/narrowing of larynx and trachea)
e/ alternated (metamorphic) - the changes of quality and intensity of breathing during inspiration and expiration (sudden opening of stenotic bronchus)
II/ tubular/bronchial breathing
1/ physiologically (in the areas - trachea, interscapularly C7 and Th4  vertebra, sternum, 3rd intercostal space bilaterally, axilla)
2/ pathologically - in the other areas of chest
a/ amphoric/cavernous (metallic sound and prolonged expiration) (bronchiectasis, pneumothorax, cavernae, pulmonary abscessus)
b/ compressive (quiet tubular breathing - above the upper border of exudate - pleuritis exudativa)

B/ accessory breathing/respiratory sounds (all of them pathological)
1/ rhonchi  (dry sounds, thick secretions)
(vibrations  of  liquid  content  in  airways,  in dependence on liquid viscosity). Rhonchi (sonorous rhonchi,), sounds that resemble snoring, loud, low/deep, coarser, rumbling inspiratory/expiratory sounds. Coughing can clear sounds. Description - musical, groaning, snoring. Air movement through the small/large airways obstructed/narrowed or turbulent or filled with thick fluid (vibrations).
Wheezes – inspiratory-expiratory high/low-pitched, musical continuous sounds produced by narrowed/obstructed airways (bronchospasm/bronchoconstriction, mucus, edema): bronchial asthma, obstructive lung diseases, fibrosing diseases, bronchitis, obstructing foreign body, airway swelling, tumor). Sometimes can be heard without a stethoscope. Associated with forced airflow through abnormally collapsed airways with residual trapping of air. If during inspiration - this indicates a severe airway obstruction. 

2/ rales/crackles (moist/wet sounds, thin secretions/fluid)
a/ fine high-pitched c/r (fine sounds, end-inspiratory s., shorter/brief, bursts of popping bubbles, small clicking/bubbling/rattling sounds, discrete, discontinuous, scattered wet s., crepitation from smaller lung airways, origin – sudden openings of closed alveoli/airways + air movement through fluid-filled airways): bronchiolitis, pneumonia, bronchopneumonia, left ventricular failure, lung edema, congestive heart failure
b/ medium low-pitched c/r (mid-inspiratory s., more moist sounds, not cleared with cough, medium crepitation): lung edema, hemoptysis
c/ If the crackles are heard throughout it implies the secretions are in bronchi: coarse crackles.
Crepitation (soft little high-frequenced sounds heared "near  ears", origin - stretching of the alveoli with less exudate, similar to "hair friction" sound, better heared after cough)
a/ crepitus indux (1st stage of croupous pneumonia)
b/ crepitus redux (3rd stage of croupous pneumonia)
c/ parchment-like crepitus (subcutaneous emphysema)
d/ pulmonary venostasis in pulmonary edema, bronchopneumonia, pulmonary infarction, pulmonary tuberculosis
3/ pleural frictional sound (pleural rub) (origin - friction of fibrinous coating from pleural exudate on parietal and visceral pleura, similar to "walking in frozen snow", changing/alternating intensity). You hear it "near to ears", both during inspiration and expiration, non-alternating with cough, sometimes palpable, non-propagating, localized, painful sometimes during inspiration). In: pleural inflammation (pleuritis), pneumomediastinum, lung infarction, pneumonia.

Bronchophony (voice sounds)
comparison, symmetry, patient is speaking "raz, dva, tri, tridsaśtri“
1/ physiologically - dull sound, non-distinguishable sounds, words
2/ decreased/diminished bronchophony (between chest wall and lung tissue there is a thick layer of fluid, air or thickenned pleura). In: pleuritis exudativa - together with weakened breathing, pneumothorax)
3/ increased bronchophony – clear sounds, words not detectable but better audible. In: infiltrative processes - bronchopneumonia, pneumonia, pulmonary infarction (often connected with increased  fremitus pectoralis, abbreaviated percussion and bronchial breathing).

PATHOLOGICAL FINDINGS
- infiltrative diseases: alveoli filled with inflamed infiltrate (non-aerial), alveolar component decreased, bronchial component increased (pneumonia)
- destructive conditions: alveoli and little airways are destructed, the result is amphoric breathing (abscess)
- emphysema: alveoli are overstretched, the thorax is in inspiratory posture (similarly in asthma bronchiale), there is a bronchospasm - result - less air into the lung during inspiration, prolonged expiration
- atelectasis: no airflow, no breathing sounds (similar in the area of pleural exudate, pneumotorax)
- bronchitis and bronchiectasis: inflamed exudate in airways, increased breathing and accessory breathing sounds
- bronchogenic carcinoma: obturation of the lumen leads to the atelectasis

Crackles - These are high pitched, discontinuous sounds similar to the sound produced by rubbing your hair between your fingers. (also known as Rales)
Wheezes - These are generally high pitched and "musical" in quality.
Stridor is an inspiratory wheeze associated with upper airway obstruction (croup).
Rhonchi - These often have a "snoring" or "gurgling" quality. Any extra sound that is not a crackle or a wheeze is probably a rhonchi.

BREASTS AND AXILLAE
BREASTS
size, shape, symmetry, contours, areolae, nipples
1/ pathologically - scars, red skin in inflammation, eczema in intraductal carcinoma, retraction of nipple in breast carcinoma, unilateral or bilateral gynecomastia in men (in hermaphroditism, hypothyreosis, thyreotoxicosis, acromegaly, bronchogenic carcinoma, dermatologic diseases, drugs)

AXILLAE
- lymphadenopathy with enlarged painful lymph nodes (tuberculosis, m. Hodgkin, metastases of carcinoma, infectious diseases)
- lymphangitis with red painful subcutaneous bands (abscessus, erysipelas, infectious diseases)
- lymphatic edema - (often together with lymphadenopathy), as a component of postthrombotic syndrome. Exaggerated edema = elephantiasis

PHYSICAL EXAMINATION - FLASH REVIEW

I N S P E C T I O N
A/ Check for related signs of pulmonary disease
 1/ facial expression (anxiety, restlessness etc.)
 2/ changes in color (cyanosis in nailbeds/periorally/tongue), facial
     flushing
 3/ jugular venous distension
 4/ pursed lip breathing on expiration (open-mouthed breathing)
 5/ clubbing of digits
B/ Note the breathing pattern
 1/ for ease, regularity, rate
 2/ type of breathing (abdominal, costal, costoabdominal)
 3/ changes of breathing (paradoxical/unilateral)
C/ Observe the (bony) thorax for
 1/ size, symmetry
 2/ shape/configuration (a-/normo-/hyperstenic)
 3/ sternal elevation/depression
 4/ symmetry of rib motion
 5/ slope of the ribs posteriorly
 6/ ratio anterior-posterior to lateral distance (barrel chest)
D/ Usage of accessory neck muscles during inspiration
E/ Fleeting inspiratory retractions (supraclavicularly/intercostally)
F/ Examination of the spine
    1/ from the side (thoracic kyphosis, lumbar lordosis)
    2/ from the backword (line,  elbow/waist distance, symmetry of theŤ
        shoulders/scapulas, for scoliosis)

P A L P A T I O N
Anteriorly/posteriorly, whole thorax, comparison/symmetry.
A/ Skin (moisture/temperature/turgor), myotonus, thrills
B/ Trachea
C/ Tactile fremitus - fremitus vocalis - pectoralis (33).
D/ Rib excursion (parasternally over the clavicles/lower margin of costal arch parasternally/midpont of each costal margin/10th rib level posteriorly paravertebrally)
E/ Frictional murmurs
F/ Palpable formation/nodule (location/size in centimeters/shape/consistency/delimitation/tenderness/mobility/erythema/edema/ dimpling over the mass)

P E R C U S S I O N
Anteriorly/posteriorly, across-and-down pattern, in reference lines/topographic areas, comparison of symmetry, whole thorax, main/accessory sounds.
A/ From apices to the level of the diaphragms
B/ Pulmonary borders
  a/ anteriorly (recumbent patient)
  b/ posteriorly (sitting patient)
C/ Diaphragmatic excursion

A U S C U L T A T I O N
A/ Changes  in  the  quality  of  breath  sounds (vesicular/bronchial breathing), during (inspiration/expiration, quiet/deep breathing)
B/ Amplitude of breath sounds
C/ The inspiration/expiration ratio
D/ Adventitious sounds (wet/dry rales, rhonchi, friction rubs)
E/ Additional tests
 1/ accentuate wheezing sounds during a forced expiration
 2/ disappearance of rales after a few deep breaths
 3/ elicit posttusive rales (inspire deeply-exhale-cough)
 4/ whispered pectoriloquy (raz, dva tri)
 5/ bronchophony (changes in intensity/clarity of the spoken voice - 33)

                        T H E   B R E A S T S
I N S P E C T I O N
A/ Size, shape, symmetry (nipple/areola)
B/ Nodules/ulcerations/edema/flushes
C/ Contour (masses/dimpling/flattening)
D/ Skin characteristics, color changes

                        T H E   A X I L L A E
I N S P E C T I O N
A/ Skin (rashes/discoloration/edema/infection/bulging/retraction)

P A L P A T I O N
A/ Nodules (see part - palpation of the thorax)

PULMONARY SYMPTOMS AND SIGNS – FLASH REVIEW
COUGH
Possible Causes of Cough:
Pulmonary/Mechanical causes: Asthma, Irritants, aspiration
Infectious: Tuberculosis, Histoplasmosis, Pneumonia
Temperature: Inhaling cold air
Pulmonary Embolism, pulmonary edema.
Non-Pulmonary: external ear canal irritation.
Details:
Smoker's Cough usually occurs in morning and is productive.
Asthmatic Cough usually is non-productive.

SPUTUM
It is always abnormal.
PRODUCTIVE COUGHS are seen in: Chronic Bronchitis, Smoker's cough
Bronchiectasis: chronically dilated bronchioles.
Large volume of sputum, which separates into two or three layers upon standing.
Tumors: Bronchoalveolar Carcinoma
Infections: Pneumonia, tuberculosis, Lung Abscess
Will usually see yellow or green sputum.
Pulmonary Edema

HEMOPTYSIS
CAUSES:
Most common: Bronchitis, Bronchogenic Carcinoma, Pneumococcal Pneumonia
More rare infections:
Tuberculosis: Age over 60, crackles, few other symptoms
Coccidiomycosis, Histoplasmosis
Other Tumors: Weight loss, cigarettes, anorexia
Rare Immune Disorders: Goodpasture's Syndrome, Wegener's Granulomastosis
Pulmonary Embolism:
High V/Q Ratio. Lots of ventilation, poor perfusion. Excessive dead space.
Friction rub, accentuated P2.
Pleuritic chest pain.
MASSIVE HEMOPTYSIS = 600 ml/day. Usually associated with bronchiectasis, and may be indicative of lung cancer or pulmonary aspergillosis.

PLEURITIC CHEST PAIN
Chest pain upon breathing.
PULMONARY CAUSES: Bronchitis, pneumonia, pulmonary embolism, tuberculosis, lung carcinoma.
NON-PULMONARY CAUSES:
Tietze's Syndrome (Costochondritis): Superficial chest pain with local tenderness.
Tracheitis presents with retrosternal chest pain, made worse by coughing.

DYSPNEA
Difficult, labored breathing.
Differential Diagnosis: A laundry list of possible causes
Pulmonary Disease: COPD, cancer, asthma, chronic or acute bronchitis, emphysema, pneumonia, pulmonary emboli, pneumothorax
Cystic Fibrosis: Sweat test
Cardiac causes: CHF, Pulmonary edema, PND
Hematologic: Anemia, CO-Poisoning
Metabolic: Ketoacidosis
Salicylate poisoning
Symptoms: Dyspnea may be masked by tachypnea (shallow, rapid breathing).
Hyperpnea is not tachypnea -- it is hyperventilation (not labored breathing) usually caused by metabolic acidosis and is unrelated to dyspnea. Distinguish the two with pulmonary function studies.

ORTHOPNEA
Dyspnea with onset occurring while lying down, and which is immediately corrected upon restoring upright position. Breathlessness in dependence on body posture change.
Differential Diagnosis: Congestive Heart Failure or COPD
Also bilateral paralysis of diaphragms.

PAROXYSMAL NOCTURNAL DYSPNEA (PND)
Dyspnea at night, created by lying down, but which does not immediately improve upon standing up. Patient feels acutely air-hungry and frequently wakes up at night. Night sweats common.
Differential Diagnosis: Acute Pulmonary Edema secondary to congestive heart failure.

WHEEZING
High-pitched musical breath sound usually heard on expiration, but can be heard on inspiration.
CAUSED by air rushing past a constricted airway, constricted by secretions, mucous, edema, neurogenic, a tumor, or an aspirated foreign body.
Asthma: Wheezing is characteristic of asthma.
Silent Asthma is asthma without wheezing.

STRIDOR
High-pitched sound occurring with inspiration.
Stridor portends total airway obstruction, a medical emergency.
Acute Epiglottitis: H. Influenza infection in kids. Stridor is characteristic. Have a chest-tube nearby before examining epiglottis to prevent (or treat imminent) aspiration.

CYANOSIS
Central Cyanosis: Face, lips, tongue. Results from systemic hypoxia due to poor perfusion or ventilation in the lungs.
Peripheral Cyanosis: May be found in extremities, ears, cheeks, etc. Can be caused by cold-induced vasoconstriction (Raynaud's Phenomenon) or poor circulation (shock, CHF).
Differential Diagnosis: Pulmonary hypoventilation, COPD
Cardiac causes: Shunt (Tetralogy of Fallot), pulmonary edema (cor pulmonale)

RHINORRHEA
Nasal discharge
CORYZA: Nasal discharge caused by a viral upper respiratory tract infection.
FAMILY / SOCIAL HISTORY:
Previous Tuberculosis infection, PPD test.
Poor dental hygiene is a risk for a lung abscess.
Environmental exposures revealed in social history
Travel
Psittacosis: Exposure to birds
Legionellosis: Exposure to water, air-conditioners
Tobacco use

EXTRAPULMONARY EXAMINATION
HALITOSIS: Some possible causes
Campylobacter Pylori colonization of stomach
Lung abscess or bronchiectasis (foul-smelling, fecal breath-odor)
Necrotic lesions of mouth or throat
Zenker's Diverticulum
Clubbing of fingernails:
Congenital Heart Disease: Chronic hypoxia of VSD or Tetralogy, in kids.
Adults: Systemic hypoxia, lung cancer, bronchiectasis, mesothelioma.
Chemosis: Conjunctival edema. Hyperthyroidism or obstruction of SVC.

BREATHING:
BRADYPNEA: Slow breathing rate, decreased respiratory rate. In: sleep, pathological – neurologic/electrolyte disturbance, infectious diseases, pleuritis, coma/unconsciousness, poisoning, uremia, insulin coma, drug-induced respiratory depression.
TACHYPNEA: Rapid/increased BF, raised respiratory rate, shallow breathing. In: physical/psychic exertion, pathological – pleurisy, fever, painful condition, broken ribs, cardiac/infectious diseases, anemia, obesity.
HYPERPNEA: Rapid, deep breathing; hyperventilation. In: physical/psychic exertion, pathological – anxiety, CNS and metabolic diseases, diabetic ketoacidosis compensation (to lower PCO2).
KUSSMAUL RESPIRATIONS: Central hyperventilation, deep rapid breaths characteristic of Diabetic hyperglycemic coma.
CHEYNE-STOKES RESPIRATION: Cyclic alternations between apnea and hyperpnea, in which PCO2 fluctuates and is unstable. It occurs when the respiratory centers of the brain become insensitive to changes in CO2
ASSOCIATED DISEASES: Congestive Heart Failure (CHF), Uremia, Meningitis, Pneumonia.
BIOT'S BREATHING: Ataxic breathing; unpredictable and irregular respirations.
Caused by meningitis or other cerebral dysfunction.
APNEA: disappeared breathing, breath stoppage/arrest, absent breathing. In: sleep apnea sy, obstruction of upper airways, coma.
SLEEP APNEA: Obesity, leading to airway obstruction at night and chronic fatigue during the day. Treat with CPAP.

INSPECTION
BACK SIDE
Buffalo Hump: Fatty deposit overlying C7, characteristic of Cushing's Syndrome
Barrel Chest: Chronically inflated lungs characteristic of COPD.
Kyphosis: Excessive anterior curvature of spine, as in hunchback.
Cause: normal or from aging, osteoporosis.
Scoliosis: Lateral curvature of spine. Scoliosis: Condition where the spine is curved to either the left or right. In the pictures below, scoliosis of the spine causes right shoulder area to appear somewhat higher than the left. Curvature is more pronounced on x-ray.
May be detected by patient bending forward and noting uneven paravertebral back muscles.
Lordosis: Excessive posterior curvature of spine. Bowing of lumbar and cervical spines together.
Gibbus Deformity: Sharp change of angle of spine instead of gradual change. Characteristic of Pott's Disease, or Vertebral Tuberculosis

FRONT SIDE
Pectus Carinatum (Pigeon Chest): Sternum placed forward, increased anteroposterior chest measurement.
Found in Marfan's Syndrome, Rickets
Pectus Excavatum (Funnel-Chest): Lower end of sternum is depressed inward. May also be found in Marfan's Syndrome or Rickets.
Flail Chest: Caused by multiple fractures ribs. One side of chest moves paradoxically relative to the other side of the chest.

PALPATION
Assess chest excursion by placing fingers at costovertebral angle and having patient inhale.
Subcutaneous Emphysema: Air in subcutaneous space. Can occur in tracheostomy patients, or people with ARDS who have an endotracheal tube.
Oliver's Sign: Tracheal tug when patient lifts his chin up.
Indicative of Aortic Aneurysm, pulling trachea downward by pressure of left main bronchus.
Tactile Fremitus: Vibration on lungs when you have patient say "ninety-nine" (33). Tactile Fremitus: You should feel the vibrations transmitted through the airways to the lung. Normal lung transmits a palpable vibratory sensation to the chest wall. This is referred to as fremitus and can be detected by placing the ulnar aspects of both hands firmly against either side of the chest while the patient says the above mentioned words. This maneuver is repeated until the entire posterior thorax is covered. The bony aspects of the hands are used as they are particularly sensitive for detecting these vibrations. Pathologic conditions will alter fremitus. In particular: Lung consolidation: Consolidation occurs when the normally air filled lung parenchyma becomes engorged with fluid or tissue, most commonly in the setting of pneumonia. If a large enough segment of parenchyma is involved, it can alter the transmission of air and sound. In the presence of consolidation, fremitus becomes more pronounced. Pleural fluid: Fluid, known as a pleural effusion, can collect in the potential space that exists between the lung and the chest wall, displacing the lung upwards. Fremitus over an effusion will be decreased.
Decreased tactile fremitus: compressed/closed bronchus and/or tissue is non-aerial: advanced emphysema, cavern/cavity, pleural effusion, massive pulmonary edema, pneumothorax, thickened pleura, pyothorax, hemothorax, fibrosis, collapse, bronchial asthma, atelectasis.
Increased fremitus is found with pulmonary consolidation in pneumonia, above top margin of pleural exudate/fluids, above solid mass, above compressed lungs, early emphysema.
Fremitus cannot be heard below the level of fluid in emphysema or pleural effusion, because the fluid stops the sound from being transmitted further.

PNEUMOTHORAX: Trachea will shift toward opposite side as the pneumothorax. The side of the pneumothorax acquires positive pressure, thus trachea deviates to the other side.
Tracheal Deviation: Tracheal deviation can be caused by other things than pneumothorax.
Pleural Effusion, Emphysema may also cause trachea to deviate to the opposite side.
Atelectasis of lung may cause trachea to deviate toward same side as diseased lung.
Tension Pneumothorax: Medical emergency in which air enters the pleural cavity and is trapped during expiration
Intrathoracic pressure builds to values higher than atmospheric pressure, compresses the lung, and may displace the mediastinum and its structures toward the opposite side, with consequent disadvantageous effects on blood flow.

PERCUSSION
Resonance: Normal breath sound
Hyperresonance: Increased resonance over thorax.
May be found in emphysema, small pneumothorax, bronchiolitis, bronchial asthma.

Decreased resonance (hyporesonance): fluid in pleural cavity, atelectasis, pneumonia, pleural thickening, pulmonary infarction, pulmonary edema, abscess, tumour, lung collapse.

Tympany: Percussion of gastric air-bubble or air-filled bowel. Increased resonance.

Dullness: Decreased resonance, normally found over liver, spleen, and below lung.
Causes: emphysema, pneumonia with consolidation, pleural effusion, pericardial effusion, lung consolidation, carcinoma/cancer/tumor, pulmonary edema, bronchiectasis, pleural thickening, diaphragm paralysis, eventration of diaphragm, subdiaphragmatic abscess, big ascites, tumour of the chest wall.

Flatness: Extreme dullness with few or no ringing tones.
Pleural effusions, massive pulmonary consolidations with tumor, pneumonia.

AUSCULTATION
General Properties:
Stethoscope Sounds: Use the bell side to listen to breath sounds.
Press lightly: hear low-pitched sounds.
Press hard: hear high pitched sounds.
Tracheal Breath Sounds: Loud, harsh, high pitched.
Bronchial Breath Sounds: Loud, high-pitched with air swishing past.
Bronchovesicular Sounds: Heard near branching of main bronchi, combination of bronchial and vesicular sounds.
Vesicular Sounds: Soft, low-pitched, airy, swishing, heard below the level of the bronchi.
CRACKLES (RALES, CREPITATIONS): Soft, short, high-pitched fine sounds.
CAUSES: Congestive heart failure, bronchitis, pneumonia, pulmonary edema, bronchiectasis.
RHONCHUS: Snoring sound, characteristic of Asthma. It indicates fluid or mucus in airways.
WHEEZE: On expiration, squeaking high pitched sound, often audible to unaided ear.
Caused by air passing by obstructed airway.
Characteristic of Asthma, but also found in Emphysema, bronchitis.
PLEURAL FRICTION RUB: Grating sound heard during breathing that stops when the breath is held. Caused by friction of visceral and parietal pleura.
PULMONARY CONSOLIDATION: Occurs with late-stage lobar pneumonia.
BRONCHOPHONY: The sounds you hear should be muffled and indistinct. Increased transmission of sound to the lung periphery. Indicative of pulmonary consolidation.
WHISPERED PECTORILOQUY:
Normal whisper - poorly heard with a stethoscope. With whispered pectoriloquy one can hear words that are whispered with the stethoscope (pneumonia). 
Ask the patient to whisper "ninety-nine" (33) several times.
Auscultate several symmetrical areas over each lung.
You should hear only faint sounds or nothing at all. If you hear the sounds clearly this is referred to as whispered pectoriloquy
Words being understood better when whispered. Also indicative of pulmonary consolidation.
EGOPHONY: "E" to "A" sound-changes.
Normal individual says "E" - heard as an "E" with a stethoscope. With egophony this "E" becomes "A„ - listening through a stethoscope. Heard the same conditions as bronchial breath sounds and bronchophony and has similar meanings. Egophony can also be heard if there are both consolidation (pneumonia) of the lung and a pleural effusion.
HAMMAN'S SIGN: Crunching, crackling sound over chest heard synchronous with the heart beat. Occurs with mediastinal emphysema -- air in the mediastinum.
CAUSES: Can follow thoracic surgery, trauma.
Boerhaave's Syndrome: Esophageal rupture causing air in mediastinum. Rare.


LUNG DISEASES
Asthma
Atelectasis: Bronchial plug - decreased lung volume - higher lung density - lung mass is pulled toward chest wall by negative pressure
Tracheal deviation toward affected side
crackles, maybe
no breath sounds
Bronchiectasis: Chronic bronchial dilation.
Caused by frequent pulmonary infections or pneumonia.
Large amounts of sputum will be expectorated when patient lies prone hanging toward floor.
Bronchitis: Acute (infectious) or chronic (smoker's)
Bronchiolitis: Common in infants and children.
Lung Cancer
Cor Pulmonale
Croup: Kids under 3 years old. Rapid, staccato coughs.
Differential Diagnosis is between inflammatory Croup or Spasmodic Croup.
Cystic Fibrosis
Pleural Effusion: Dullness on percussion. Decreased fremitus. Reduced breath sounds.
Emphysema
Epiglottitis: In kiddies, don't inspect the pharynx without an endotracheal tube nearby.
Pneumonia

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