Topographic landmarks of the chest.

The bony structures of the chest form a protective expandable cage around the lungs and heart. A, Anterior view.

B, Posterior view.

Thorax of healthy adult male. 

Note that the anteroposterior diameter is less than the lateral diameter.

Barrel chest. 

Note increase in the anteroposterior diameter.

Results from compromised respiration as in, for example, chronic asthma, emphysema, or cystic firrosis.

A. Pectus excavatum, "funnel chest"

An indication of the lower sternum above the xiphoid process

B. Pectus carinatum, "pigeon chest".

A prominent sternal protrusion

Patterns of respiration. The horizontal axis indicates the relative rates of these patterns. The vertical swings of the lines indicate the relative depth of respiration.

Palpating thoracic expansion. 

The thumbs are at the level of the tenth rib.

Palpating to evaluate midline position of the trachea.

Two methods for evaluating tactile fremitus, the palpable vibration of the chest wall that results from speech or other verbalization.

Fremitus is the best felt posteriorly and laterally at the level of the bifurcation of the bronchi.

There is a great variability depending on the intensity and pitch of the voice and the structure and thickness of the chest wall.

The scapulae obscure fremitus.

A. With palmar surface of both hands. 

B, With ulnar aspect.

Ask the patient to recite a few numbers or say a few words ("99" is a favorite, as is "Mickey Mouse,", depending perhaps on the age) while you systematically palpate the chest with the palmar surfaces of the fingers or with the ulnar aspects of the hand.

For comparison, palpate both sides simultaneously and symmetrically; or use one hand, alternating between the two sides.

 Percussion tones throughout chest. 

A, Anterior view. 

B, Posterior view.

A, Direct percussion using ulnar aspect of fist. 

B, Indirect percussion.

Measuring diaphragmatic excursion, the movement of the thoracic diaphragm that occurs with inhalation and exhalation. 

Excursion distance is usually 3 to 5 cm.

The diaphragm is usually higher on the right than on the left because it sits over the bulk of the liver.

Its descent may be limited by several types of pathologic processes: pulmonary (e.g. as a result of emphysema), abdominal (e.g. massive ascites, tumor), or superficial pain (e.g. fractured rib).

Suggested sequence for systematic percussion and auscultation of the thorax. The pleximeter finger or the stethoscope is moved in the numeric sequence suggested; however, other sequences are possible. It is beneficial to be systematic.

A, Posterior thorax.

Expected auscultatory sounds. A, Anterior view.

B, Posterior view.

Schema of breath sounds in the ill and well patient.

Auscultation Findings by UW Depart of Medicine

Lung 1

Lung 2