The pulmonary exam is one of the most important and often exercised exam through clinicians. While auscultation is most commonly practiced, both percussion and inspection space equally valuable techniques that deserve to diagnose a number of lung abnormalities such as pleural effusions, emphysema, pneumonia and also many others.

Though taught extensively in early on medical cultivate the pulmonary exam is often neglected except auscultation.

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The "5-7-9 rule"

The upper border the liver dullness is characterized by:5th intercostal an are in the midclavicular line7th intercostal an are in the midaxillary line9th intercostal room in the scapular lineNote: nine intercostal space is located approximately at the inferior border of the scapulaHyperresonance the continues listed below these limits can be suggestive the hyperinflation (e.g. Emphysema)

Cardiac dullness

Be maybe to overview the area the "absolute" cardiac dullness— a fist size area simply to the left the the sternum. If it is not there it suggests emphysema.

Traube"s space

Surface markings:Superiorly: Left 6th ribInferiorly: Left costal marginLaterally: Anterior axillary lineUsually, traube"s space is hyperresonant because of the location of the gastric bubble, however, ns of this hypersonance deserve to be checked out in following conditions:Left pleural effusion (however not in left reduced lobe pneumonia there is no effusion together it is the effusion that falls into the costophrenic recess that is over the gastric bubble)Splenomegally (less reliable contrasted to Castell’s Sign)Very complete colonRecently consumed (i.e. Stomach is full)

Click below to read an article on the Ludwig Traube.

Tidal Percussion

Percuss under the earlier until the regular hyperresonance the the lung becomes dull over the diaphragm. Climate simply have the patient breath in and also out deep while proceeding to percuss. The sound need to wax and wane.Loss the tidal percussion:Pleural effusionHyperinflation such as emphysema native a maximally contract diaphragm
The significant fissure have the right to be situated by drawing a heat from the T2 spinous process to whereby the sixth rib meets the sternum. The boy fissure have the right to be approximated by drawing a horizontal heat from the fourth rib attachments of the sternum come the major fissure.Easier method: merely ask the patience to placed their hands over your head. The scapula will rotate externally and its medial border will synopsis the major fissure (see figure below).


Percussion was an initial described by Dr. Josef Leopold Auenbrugger, an Austrian doctor who an initial observed his dad tapping on alcohol barrels in the cellar of his hotel to determine how much wine to be left. The son applied this an approach to patients as soon as he came to be a physician. He is credited with happen the method of percussion to the field of medicine. Lot of his work-related occurred about 1760 whereby he explained that by percussing the thorax he could accurately predict the materials of what to be inside, as confirmed with post-mortum research studies he conducted.

Signs that COPD

Inspiratory descent of trachea.Use of accessory muscles.Pursed lips ~ above exhalation (provides a small amount the PEEP).Increased AP diameter (barrel chest).Normal in infancy and increased v aging.Prominent edge of louis (or sternal angle).Flaring of the reduced costal margins.Dahl Sign: above the knee, spot of hyperpigmentation or bruising led to by constant "tenting" position of hands or elbows.Hoover"s sign: briefly, during inspiration a paradoxical medial motion of the chest.The "subcostal angle" is the angle between the xiphoid procedure and the appropriate or let costal margin. Normally, throughout inhalation the chest broadens laterally, raising this angle. As soon as the diaphragms space flattened (as in COPD), inhalation paradoxically causes the angle to decrease.Harrison"s sulcus: a horizontal grove whereby the diaphragm attaches to the ribs; associated with chronic asthma, COPD, & Rickets.

REMEMBER : "The side that moves less, is the side of disease!"

Look for indications of volume ns (or gain) top top the side the moves less(hollow supraclavicular fossae, intercostal spaces prominent, shoulder droopy, scapula outline an ext prominent).


Dr. Peadar Noone

Dr. Peadar Noone trained in Galway, Dublin, Boston, the UK and also Chapel Hill, wherein he is now Associate Professor of Medicine and Medical director of the Lung Transplant regimen at the college of north Carolina, Chapel Hill.

Clinical Pearl

Insert (in a common individual) 3 fingers vertically in the room under the cricoid cartilage, and above the sternal notch. Together the human breathes in, the an are may mitigate to two fingers at many (i.e. The fingers gain "squeezed" as the sternum rises with inspiration). In a patience with severe hyperinflation, the crico-sternal street is much much shorter (because the sternum is elevated), perhaps 1-2 finger at most. With impetus one"s fingers obtain "squeezed" out together the already "high" sternum rises as much as the level that the cricoid, thus, in numerous cases, obliterating the crico-sternal distance altogether. Some clinicians brand this sign "tracheal shortening" however strictly speaking, the yes, really tracheal size does not obtain shorter. Classically this is watched with serious emphysema / hyperinflation, or significant air trapping. Frequently accompanied by diminished hepatic and also cardiac dullness top top percussion, a widened / flared costal angle, and Hoover"s sign.
Pectus Excavatum (Funnel Chest)
: depression that sternum; in severe instances may compress love and great vessels.Pectus Carinatum (Pigeon chest): anterior displacement that sternum, usually benign.

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Flail Chest: secondary to multiple rib fractures, depression of diaphragm reasons injured area to cavern inward developing a "paradoxical thoracic movement" in breathing.