The Bronchial Breath Sound The Bronchial Breath Sound

An I:E Ratio : 1:1 or 1:1 1/4 with a pause in An I:E Ratio : 1:1 or 1:1 1/4 with a pause in between inspiration & expiration between inspiration & expiration

Thoracic Geography : over the manubrium Thoracic Geography : over the manubrium of the sternum of the sternum

Sound Characteristics : high pitched, Sound Characteristics : high pitched, tubular, hollow sound tubular, hollow sound

Indication : pneumonia, atelectasis, fluid Indication : pneumonia, atelectasis, fluid infiltration infiltration

Vesicular Breath Vesicular Breath Sound Sound

An I:E Ratio : 1:0 or 1:1/4 with no pause in An I:E Ratio : 1:0 or 1:1/4 with no pause in between inspiration & expiration between inspiration & expiration

Thoracic Geography : everywhere on the thoracic Thoracic Geography : everywhere on the thoracic wall wall

Sound Characteristics : low pitched, soft rustling Sound Characteristics : low pitched, soft rustling sound sound

Indication : pneumonia, atelectasis, fluid Indication : pneumonia, atelectasis, fluid infiltration infiltration

Bronchovesicular Breath Sound Bronchovesicular Breath Sound

An I:E Ratio : 1:1 or 1:1 1/4 with a pause in between An I:E Ratio : 1:1 or 1:1 1/4 with a pause in between inspiration & expiration inspiration & expiration

Thoracic Geography : sternocostal margins, over the Thoracic Geography : sternocostal margins, over the verbral column between the scapulae verbral column between the scapulae

Sound Characteristics : high pitched, tubular, hollow Sound Characteristics : high pitched, tubular, hollow sound sound

Indication : pneumonia, atelectasis, fluid infiltration Indication : pneumonia, atelectasis, fluid infiltration

Rales or cracklesRales or crackles

discontinuous sound discontinuous sound Fine ralesFine rales

sound that you hear when burning wood crackles sound that you hear when burning wood crackles

When fluid or mucus collects in the peripheral portions of the lung, the When fluid or mucus collects in the peripheral portions of the lung, the alveoli collapse and the walls of the alveoli stick togetheralveoli collapse and the walls of the alveoli stick together

This is a sound heard during inspiration This is a sound heard during inspiration course rales course rales

Pleural Friction RubsPleural Friction Rubs

Created when the visceral and parietal pleurae Created when the visceral and parietal pleurae become inflammed and roughenedbecome inflammed and roughened

The sound that a pleural friction rub makes is a The sound that a pleural friction rub makes is a leather-on-leather type of soundleather-on-leather type of sound

These sounds can be heard at the same points These sounds can be heard at the same points in the inhalatory and the exhalatory cycles in the inhalatory and the exhalatory cycles

Bronchovesicular Breath Sound Bronchovesicular Breath Sound

An I:E Ratio : 1:1 or 1:1 1/4 with a pause in between An I:E Ratio : 1:1 or 1:1 1/4 with a pause in between inspiration & expiration inspiration & expiration

Thoracic Geography : sternocostal margins, over the Thoracic Geography : sternocostal margins, over the verbral column between the scapulae verbral column between the scapulae

Sound Characteristics : high pitched, tubular, hollow Sound Characteristics : high pitched, tubular, hollow sound sound

Indication : pneumonia, atelectasis, fluid infiltration Indication : pneumonia, atelectasis, fluid infiltration

Rales or cracklesRales or crackles

discontinuous sound discontinuous sound Fine ralesFine rales

sound that you hear when burning wood crackles sound that you hear when burning wood crackles

When fluid or mucus collects in the peripheral portions of the lung, the When fluid or mucus collects in the peripheral portions of the lung, the alveoli collapse and the walls of the alveoli stick togetheralveoli collapse and the walls of the alveoli stick together

This is a sound heard during inspiration This is a sound heard during inspiration course rales course rales

Pleural Friction RubsPleural Friction Rubs

Created when the visceral and parietal pleurae Created when the visceral and parietal pleurae become inflammed and roughenedbecome inflammed and roughened

The sound that a pleural friction rub makes is a The sound that a pleural friction rub makes is a leather-on-leather type of soundleather-on-leather type of sound

These sounds can be heard at the same points These sounds can be heard at the same points in the inhalatory and the exhalatory cycles in the inhalatory and the exhalatory cycles

StridorStridorHigh pitched wheezing that is caused by the High pitched wheezing that is caused by the obstruction of the trachea either by inflammation obstruction of the trachea either by inflammation or an objector an object

Just enough air passes the obstructed point to Just enough air passes the obstructed point to cause a high-pitched whining wheezecause a high-pitched whining wheeze

In children, stridor is most frequently caused by In children, stridor is most frequently caused by croupe, a viral infection that causes the tracheal croupe, a viral infection that causes the tracheal membranes to swell to a near-closed positionmembranes to swell to a near-closed position

The wheeze is produced much like a wind The wheeze is produced much like a wind instrument produces sound through a wooden instrument produces sound through a wooden reedreed

Rhonchi or WheezesRhonchi or WheezesThe wheezes are considered to be central The wheezes are considered to be central airway sounds caused by air passing through airway sounds caused by air passing through mucus plugs in the upper divisions of the mucus plugs in the upper divisions of the tracheobronchial tree. tracheobronchial tree.

Stridor: Harsh, high-pitched, musical sound produced by turbulent airflow through partially

obstructed upper airway

Supraglottic obstruction: Supraglottic obstruction:

Inspiratory stridor (high-pitched)Inspiratory stridor (high-pitched)Extrathoracic trachea obstruction – Extrathoracic trachea obstruction –

includes glottis & subglottis:includes glottis & subglottis:

Biphasic stridor (intermediate pitch)Biphasic stridor (intermediate pitch) Intrathoracic trachea obstruction: Intrathoracic trachea obstruction:

Expiratory stridor (wheeze)Expiratory stridor (wheeze)

Chest &Lung

Respiratory Rhythm(Asthma,..)Respiratory Rhythm(Asthma,..) PalpationPalpation CrepitationCrepitation in subcutaneous emphysema in subcutaneous emphysema Local tendernessLocal tenderness , , Axillary lymph nodeAxillary lymph node

PercussionPercussion Hyperresonance or redused cardiac dullnessHyperresonance or redused cardiac dullness in emphysema or pneumothoraxin emphysema or pneumothorax Decreased resonanceDecreased resonance in consolidation in consolidation

Chest &Lung

breathing sound:breathing sound: Reduced:bronchiolitis,emphysema, Reduced:bronchiolitis,emphysema,

pneumothorax, pleural effusionpneumothorax, pleural effusion Increased:consolidation,collapseIncreased:consolidation,collapse Bronchial:consolidation,collapseBronchial:consolidation,collapse Ronchi:bronchospasm,infectionRonchi:bronchospasm,infection Crepitation: infectionCrepitation: infection Wheezing:asthmaWheezing:asthma Vocal resonance:Vocal resonance:

Physiology of MurmursPhysiology of Murmurs

first and second sounds, or S1 and S2, first and second sounds, or S1 and S2, which demarcate systole from diastolewhich demarcate systole from diastole

S1 is the sound which marks the S1 is the sound which marks the approximate beginning of systole, and is approximate beginning of systole, and is created when the increase in created when the increase in intraventricular pressure during contraction intraventricular pressure during contraction exceeds the pressure within the atria, exceeds the pressure within the atria, causing a sudden closing of the tricuspid causing a sudden closing of the tricuspid and mitral, or AV valves.and mitral, or AV valves.

S2S2

At the end of systole, the ventricles begin to At the end of systole, the ventricles begin to relax, the pressures within the heart become relax, the pressures within the heart become less than that in the aorta and pulmonary less than that in the aorta and pulmonary artery, and a brief back flow of blood causes artery, and a brief back flow of blood causes the semilunar valves to snap shut, producing the semilunar valves to snap shut, producing S2.S2.

Because diastole takes about twice as long Because diastole takes about twice as long as systole, there is a longer pause between as systole, there is a longer pause between S2 and S1 than there is between S1 and S2S2 and S1 than there is between S1 and S2

During S1, the closing of the mitral valve During S1, the closing of the mitral valve slightly precedes the closing of the tricuspid slightly precedes the closing of the tricuspid valve, while in S2, the aortic valve closes just valve, while in S2, the aortic valve closes just before the pulmonary valve.before the pulmonary valve.

the pressure during systole in the left the pressure during systole in the left ventricle is much greater than in the right, SO ventricle is much greater than in the right, SO the mitral valve closes before the tricuspid in the mitral valve closes before the tricuspid in S1.S1.

The pressure at the start of diastole in the The pressure at the start of diastole in the aorta is much higher than in the pulmonary aorta is much higher than in the pulmonary artery, the aortic valve closes first in S2.artery, the aortic valve closes first in S2.

The intensity of the murmur is next, The intensity of the murmur is next, graded according to the Levine graded according to the Levine

scale: scale: I - Lowest intensity, difficult to hear even by expert I - Lowest intensity, difficult to hear even by expert

listeners listeners II- Low intensity, but usually audible by all listeners II- Low intensity, but usually audible by all listeners III - Medium intensity, easy to hear even by III - Medium intensity, easy to hear even by

inexperienced listeners, but without a palpable inexperienced listeners, but without a palpable thrill thrill

IV - Medium intensity with a palpable thrill IV - Medium intensity with a palpable thrill V - Loud intensity with a palpable thrill. Audible V - Loud intensity with a palpable thrill. Audible

even with the stethoscope placed on the chest even with the stethoscope placed on the chest with the edge of the diaphragm with the edge of the diaphragm

VI - Loudest intensity with a palpable thrill. Audible VI - Loudest intensity with a palpable thrill. Audible even with the stethoscope raised above the chest. even with the stethoscope raised above the chest.

Some times it is difficult to discern which is Some times it is difficult to discern which is S1 and which is S2 ,So it is important to S1 and which is S2 ,So it is important to alwaysalways palpate the PMI or the carotid or palpate the PMI or the carotid or radial pulse when auscultating. The heart radial pulse when auscultating. The heart sound you hear when you first feel the sound you hear when you first feel the pulse is S1, and when the pulse pulse is S1, and when the pulse disappears is S2.disappears is S2.

systole or diastolesystole or diastole where it is heard bestwhere it is heard best where it radiates towhere it radiates to if the murmur completely fills that phase of the if the murmur completely fills that phase of the

cycle (i.e., holosystolic) cycle (i.e., holosystolic) The quality and shape of the murmur(rumbling, The quality and shape of the murmur(rumbling,

blowing, machinery, scratchy, harsh, or musical) blowing, machinery, scratchy, harsh, or musical) The intensity of the murmur(Levine scale)The intensity of the murmur(Levine scale)

if this murmur is clinically significant or if this murmur is clinically significant or not(physiologic flow murmurs :Pregnancy, not(physiologic flow murmurs :Pregnancy, Anemia,thyrotoxicosis,Innocent murmur )Anemia,thyrotoxicosis,Innocent murmur )

physiologic murmurs physiologic murmurs located between the apex and left lower sternal borderlocated between the apex and left lower sternal border have minimal radiationhave minimal radiation occur during early to mid-systoleoccur during early to mid-systole have a crescendo-decrescendo shape, and a vibratory have a crescendo-decrescendo shape, and a vibratory

qualityquality usually change intensity with positional maneuvers, usually change intensity with positional maneuvers,

becoming quieter on standing and louder with squattingbecoming quieter on standing and louder with squatting A Valsalva maneuver will decrease the intensity of the A Valsalva maneuver will decrease the intensity of the

murmur because the increase in intrathoracic pressure murmur because the increase in intrathoracic pressure will decrease venous return, which will decrease flow will decrease venous return, which will decrease flow through the heart and lessen the turbulence.through the heart and lessen the turbulence.

Additionally, they will not be correlated with additional Additionally, they will not be correlated with additional audiologic findings, such as an S3 or S4.audiologic findings, such as an S3 or S4.

Heart soundHeart sound

Normal heart soundNormal heart sound

aortic stenosisaortic stenosis systolic murmurs,heard best over the “aortic systolic murmurs,heard best over the “aortic

area” or right second intercostal space, with area” or right second intercostal space, with radiation into the right neckradiation into the right neck

harsh quality and may be associated with a harsh quality and may be associated with a palpably slow rise of the carotid upstrokepalpably slow rise of the carotid upstroke

Symptoms: Angina, Syncope, Congestive heart Symptoms: Angina, Syncope, Congestive heart failure failure

Early aortic stenosisEarly aortic stenosis Late aortic stenosisLate aortic stenosis

Mitral RegurgitationMitral Regurgitation

best heard at the apex, with radiation into the axillabest heard at the apex, with radiation into the axilla holosystolic murmurholosystolic murmur congenital condition congenital condition rheumatic heart diseaserheumatic heart disease marked left ventricular dilatationmarked left ventricular dilatation acute infective endocarditisacute infective endocarditis acute or prior myocardial infarctionacute or prior myocardial infarction

Pulmonary StenosisPulmonary Stenosis

congenital disorders, such as tetralogy of Fallot,congenital disorders, such as tetralogy of Fallot, heard best in the pulmonic area, the second intercostal space on left sternal heard best in the pulmonic area, the second intercostal space on left sternal

borderborder radiating into the neck or the backradiating into the neck or the back has a crescendo-decrescendo shape, and a harsh qualityhas a crescendo-decrescendo shape, and a harsh quality Because it takes longer for the right ventricle to eject its load of blood Because it takes longer for the right ventricle to eject its load of blood

through the stenotic valve, the closure of the pulmonary valve is delayedthrough the stenotic valve, the closure of the pulmonary valve is delayed maneuvers which increase venous filling and blood flow into the right maneuvers which increase venous filling and blood flow into the right

ventricle, such as deep inspiration, will tend to increase the intensity of the ventricle, such as deep inspiration, will tend to increase the intensity of the murmur.murmur.

Aortic RegurgitationAortic RegurgitationDiastolic Murmurs Diastolic Murmurs rheumatic heart disease, rheumatic heart disease,

congenital ,endocarditiscongenital ,endocarditisblowing, decrescendo, and heard best in the blowing, decrescendo, and heard best in the

third left intercostal spacethird left intercostal space In severe regurgitation, it may be holodiastolicIn severe regurgitation, it may be holodiastolic It radiates widely along the left sternal borderIt radiates widely along the left sternal border

Mitral StenosisMitral StenosisDiastolic MurmursDiastolic Murmursbest heard at the apex with little radiationbest heard at the apex with little radiation low-pitched, decrescendo, and rumblinglow-pitched, decrescendo, and rumblingheard best with the patient in the left heard best with the patient in the left

lateral decubitus positionlateral decubitus position

Cardiovascular SystemCardiovascular System InspectionInspection::

Dyspnea,cyanosis,tachypnea,Edema, Clubbing,Apex Dyspnea,cyanosis,tachypnea,Edema, Clubbing,Apex beat,JVP,..beat,JVP,..

PalpationPalpation:: Thrill, Apex beat (Point of maximal impulse), All Thrill, Apex beat (Point of maximal impulse), All

Pulses (arrrhythmia , weak or bounding pulse,absent Pulses (arrrhythmia , weak or bounding pulse,absent femoral pulse)femoral pulse)

PercussionPercussion:: Diminished dullness(Pneumothorax ,Emphysema)Diminished dullness(Pneumothorax ,Emphysema) AuscultationAuscultation:: Heart rate Heart rate Newborn=70-120 Preschool child =75-120 Newborn=70-120 Preschool child =75-120 Infant=80-160 school child = 70-110Infant=80-160 school child = 70-110

Cardiovascular SystemCardiovascular SystemAuscultation:Auscultation: Normal sinus dysrhythmiaNormal sinus dysrhythmia

Rhythm(sinus arrhythmia,gallop rhythm,Rhythm(sinus arrhythmia,gallop rhythm,

Heart sound(splitting S2,Ejection click )Heart sound(splitting S2,Ejection click )

MurmurMurmur

sitesite

Intensity: grade 0-6Intensity: grade 0-6

Timing:systolic(pan,early,late) or Timing:systolic(pan,early,late) or

diastolic(early,mid,presystolic)diastolic(early,mid,presystolic)

Propagation:left axilla,neck,…Propagation:left axilla,neck,…

Variation with positionVariation with position

Cyanosis and clubbing Cyanosis of the lips

pectus excavatum deformity Pectus Carinatum

Pectus Carinatum (left) and Pectus Excavatum (right)Pectus Carinatum (left) and Pectus Excavatum (right)

BreastBreast

Breast of newborns are often enlarged due Breast of newborns are often enlarged due to maternal estrogento maternal estrogen

Breast development 8-13 y/oBreast development 8-13 y/oBreast development before 8 y/o are Breast development before 8 y/o are

abnormalabnormalMenarche occurs in breast stage 3 or 4Menarche occurs in breast stage 3 or 4 In 10% of girls breasts develop asymmetryIn 10% of girls breasts develop asymmetry

Tanner stagesTanner stages