History%20Taking%20

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History Taking Chest Examination

• Dr. Waseem HAJJAR, MD. FRCS.
• Assistant professor
• Consultant Thoracic Surgeon

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• A good history should be both
• Concise.
• Cover the important points.

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Rules

1. Patient should be allowed to tell his history in
   his own words.
2. Leading questions must be avoided unless the
   information cant be obtained by other means

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Questions

1. Complete the immediate description.
2. Elucidate the vague points.
3. Fill in the gaps the history not mentioned by
   patient.
4. Emphasize the important points.

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Types of questions

1. Neutral questions.
2. Simple direct questions (yes/No).
3. Leading questions.

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WHAT SHOULD WE KNOW ABOUT THE EXAMINATION OF THE
CHEST?

• HISTORY
• SYMPTOMS
• LANDMARKS
• PERTINENT VOCABULARY
• SIGNS
• HOW TO PERFORM AN EXAM
• HOW TO PRESENT THE INFORMATION
• HOW TO FORMULATE A DIFFERENTIAL DIAGNOSIS

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Personal data

• Name.
• Age.
• Sex.
• Occupation.
• Residence.
• The patients complaint
• A simple statement in the patients own words and
  its duration.

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HISTORY
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Present History

• This means detailed history of the patients
  present illness which must provide answer for the
  following questions
• Duration
• Mode of onset (acute, sub acute, chronic).
• Sequence of events
• Course (progressive, regressive or recurrent).
• Appearance of new additional symptoms or
  disappearance of others.
• Treatment received during the course response.
• Analysis of each particular symptom.

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History

• Acute/chronic disorder
• Preceding systemic disturbance
• Past medical history
• Drug history
• Social history
• Family history
• Occupational history

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Past History

• Childhood diseases.
• Trauma.
• Residences or travel abroad.
• Drug therapy.
• Operations.

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THE HISTORY

• FAMILY HISTORY
• EMPHYSEMA AT AN EARLY AGE - CONSIDER ALPHA 1
  ANTITRYPSIN
• RECURRENT RESPIRATORY INFECTIONS AND STERILITY IN
  A YOUNG ADULT MALE CONSIDER CYSTIC FIBROSIS,
  IMMOTILE CILIA OR YOUNGS SYNDROME
• PULMONARY NODULE AND HYPOXEMIA CONSIDER OSLER
  WEBER RENDU

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Family History

• Hereditary factor.
• Exposure to same etiological circumstances.

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THE HISTORY

• OCCUPATIONAL - CHRONOLOGIC ORDER
• EXPOSURE
• BRAKE SHOES, PIPE FITTERS (ASBESTOS)
• SANDBLASTING, QUARRY (SILICOSIS)
• FARMING (FARMERS LUNG)
• MILITARY (BERYLLIOSIS)
• TRAVEL- FAR EAST (PARAGONIMIASES)
• SOUTH AMERICA (BRUCELLOSIS)
• SOUTHWEST USA
  (COCCIDIOMYCOSIS)
• DRUGS INTERSTITIAL LUNG DISEASE
  (NITROFURANTOIN)
• HABITS TOBACCO, NOSE DROPS, ILLICIT DRUGS

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Habits

• Smoking.
• Physical efforts.
• Addiction.

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SYMPTOMS
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History

• Dyspnoea
• Wheeze
• Cough
• Sputum
• Haemoptysis
• Chest pain

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MAIN SYMPTOMS OF PULMONARY DISEASE

• COUGH
• DYSPNEA
• HEMOPTYSIS
• CHEST PAIN PLEURITIC
• WHEEZING
• CYANOSIS
• SPUTUM PRODUCTION
• SNORING

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DESCRIBE THE COUGH

• PRODUCTIVE NONPRODUCTIVE
• ACUTE CHRONIC
• TIME OF DAY
• PRECIPITANTS RELIEF
• BLOODY NON BLOODY
• BARKING HACKY

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COUGH

• SYMPTOM
• MORNING
• NON-PRODUCTIVE
• RECUMBENT
• BARKING
• NOCTURNAL
• PRODUCTIVE
• BLOODY

• ETIOLOGY
• CHRONIC BRONCHITIS
• VIRAL, ILD,TUMOR
• SINUSITUS, CHF,REFLUX
• CROUP,LARYNGEAL
• ASTHMA, CHF
• INFECTIOUS
• TUMOR,CHF

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THE PNEAS

• DYSPNEA SOB
• ACUTE (PULMONARY EMBOLISM, PNTX, ASTHMA)
• CHRONIC (COPD, CHF, ILD)
• TACHYPNEA RRgt20 BR/MIN
• BRADYPNEA - RRlt 8 BR/MIN (DRUGS, AGONAL)
• PND - PAROXYSMAL NOCTURNAL DYSPNEA SUDDEN ONSET
  OF SOB DURING SLEEP (CHF)
• ORTHOPNEA SOB LYING FLAT (CHF)
• PLATYPNEA SOB SITTING UP AND BETTER LYING FLAT
  (R TO L SHUNT)
• TREPOPNEA SHORTNESS OF BREATH IN ONE LATERAL
  DECUBITUS POSITION WHICH IS IMPROVED BY TURNING
  ON THE OPPOSITE SIDE

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DYSPNEA

• MY CHEST FEELS TIGHT
• I CANNOT TAKE A DEEP BREATH
• I FEEL LIKE I HAVE A PILLOW OVER MY MOUTH
• I AM SMOTHERING

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THE NUMEROUS ETIOLOGIES OF CHEST PAIN

• PLEURITIC PARIETAL PLEURA SHARP STABBING
  INSPIRATION
• ESOPHAGEAL REFLUX
• CARDIAC MYOCARDIAL INFARCTION
• GALL BLADDER CHOLECYSTITIS
• CHEST WALL COSTOCHONDRITIS
• GREAT VESSELS DISSECTION
• PULMONARY - PNEUMOTHORAX

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SPUTUM - WHAT ARE ITS CHARACTERISTICS ?

• YELLOW GREEN (PNEUMONIA, BRONCHIECSTAIS)
• RUSTY (PNEUMOCCOAL PNEUMONIA)
• ANCHOVY PASTE (AMEBIASIS)
• PINK BLOOD TINGED (EPISTAXIS, BRONCHITIS)
• FROTHY (CHF)
• BLOODY (MALIGNANCY, BRONCHIECSTASIS, PULMONARY
  RENAL SYNDROME)
• SMELL FOUL? (ANAEROBIC LUNG ABCESS)
• SANDLIKE (BRONCHOLITHIASIS)
• BLACK COAL DUST INHALATION

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HEMOPTYSIS - REQUIRES CAREFUL QUESTIONING

• THIS SYMPTOM USUALLY DENOTES A SERIOUS ILLNESS.
  TB, TUMOR, BRONCHIECSTASIS, PE, CARDIAC DISEASE
• THE PATIENT SHOULD BE QUESTIONED CAREFULLY
  REGARDING HOW MUCH, FREQUENCY WEIGHT LOSS ETC.

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CLUES TO DIFFERENTIATING HEMOPTYSIS FROM
HEMATEMESIS

• HEMATEMESIS
• NAUSEA VOMITING
• NOT FROTHY
• COFFEE GROUNDS
• FOOD
• NAUSEA
• GI DISEASE

• HEMOPTYSIS
• COUGH
• FROTHY
• COLOR- BRIGHT RED
• PUS
• DYSPNEA
• CARDIAC DISEASE

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THE PULMONARY EXAMINATION SIGNS
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WHAT SHOULD WE KNOW ABOUT THE EXAMINATION OF THE
CHEST?

• HISTORY
• SYMPTOMS
• LANDMARKS
• PERTINENT VOCABULARY
• SIGNS
• HOW TO PERFORM AN EXAM
• HOW TO FORMULATE A DIFFERENTIAL DIAGNOSIS
• HOW TO PRESENT THE INFORMATION

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TOPOGRAPHY OF THE CHEST
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TOPOGRAPHY OF THE BACK
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The Chest

• Inspection
• Palpation
• Percussion
• Auscultation

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Inspection of the chest

• Important
• - SHAPE
• - MOVEMENT
• - VISIBLE PULSATIONS!
• SHAPE of the chest
• Deformities - kyphosis
• - scoliosis
• - depressed sternum (pectus excavatum)
• - bulges in left parasternal area
• (congenital malformation)
• e.g. VSD

of the thorax
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Chest wall

• Pectus carinatum

• Pectus excavatum

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Pectus Excavatum
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Inspection

• Shape
• Scars
• Lesions
• Resp rate
• Resp depth
• Mode of breathing
• Abnormal inspiratory movements
• Abnormal expiratory movements
• Asymmetry of movement

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Nicotine staining
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2 liters of O2
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BARREL CHEST
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Barrel Chest
AP Diameter Transverse Diameter
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PALPATION

• FEELING WITH THE HAND FINGERTIPS
• TEXTURES
• DIMENSIONS
• CONSISTENCY
• TEMPERATURE

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Palpation

• Chest expansion
• Tactile vocal fremitus

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Chest Expansion
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Chest Expansion
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Chest Expansion
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Trachea exam
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Percussion

• Illustrate resonance
• Compare both sides
• Map out abnormal area

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METHODS OF PERCUSSION
DIRECT
INDIRECT
DISEASE A MONTH 41643-6921995
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METHODS OF PERCUSSION
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METHODS OF PERCUSSION
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Percussion

• Impaired(dull)resonance obtained
• Aerated lung tissue is separated from the chest
  wall e.g. fluid, pleural thickening
• Lung tissue is airless e.g. consolidation,
  collapse, fibrosis
• stony dullness- pleural effusion
• Hyperresonance - pneumothorax

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Percussion technique

• Place left hand on chest wall, palm downwards
  with fingers separated
• 2nd phalanx over area of intercostal space
• Right middle finger strikes the 2nd phalanx
  producing hammer effect
• Entire movement comes from wrist

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PERCUSSION SOUNDS

• TYMPANY HEARD OVER THE ABDOMEN
• RESONANCE HEARD OVER NORMAL LUNG
• DULLNESS HEARD OVER LIVER OR THIGH

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Auscultation

• Breath sounds
• Added sounds
• Vocal sounds (vocal resonance)

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AUSCULTATORY PERCUSSION

• METHOD
• THE STETHOSCOPE IS PLACED OVER THE POSTERIOR
  CHEST WALL, THE CLINICIAN THEN TAPS LIGHTLY OVER
  THE MANUBRIUM, EQUIVALENT SOUNDS SHOULD BE HEARD
  OVER CORRESPONDING AREAS OF THE LUNG. ASYMETRY
  SUGGESTS DISEASE.

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AUSCULTATORY PERCUSSION
MANGIONE PHYSICAL DIAGNOSIS SECRETS 2000
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Auscultation of the front
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Auscultation of the back
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Breath Sounds

• Vesicular - normal
• Diminished - localised or diffuse
• Bronchial - consolidation

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TACTILE FREMITUS

• A THRILL OR VIBRATION WHICH IS FELT ON THE
  CLINICIANS HAND WHILE RESTING IT ON THE PATIENTS
  CHEST WALL AT T HE SAME TIME THE PATIENT SPEAKS.
  99 1-2-3
• SYMETRY MAY BE SEEN IN NORMALS
• ASYMETRY IS ABNORMAL

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TACTILE FREMITUS
INCREASED
DECREASED

• PNEUMOTHORAX
• PLEURAL EFFUSION
• COPD
• FAT

• PNEUMONIA

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VOCAL FREMITUS

• THE PATIENTS VOICE IS HEARD THROUGH A STETHOSCOPE
  PLACED ON THE PATIENTS CHEST NORMALLY THE
  SOUNDS ARE INDISTINCT
• ABNORMALITIES BRONCHOPHONY, PECTORILOQUY,
  EGOPHONY
• CONSOLIDATION

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VOCAL FREMITUS

• BRONCHOPHONY SOUND OF THE BRONCHI SOUND MUCH
  LOUDER THAN NORMAL - WORDS INDISTINCT
• PECTORILOQUY VOICE OF THE CHEST WHISPER
  WORDS INDISTINCT
• EGOPHONY VOICE OF THE GOAT BLEATING - E
  A CHANGES COMPARE SIDE TO SIDE
• REMEMBER - ALL SUGGEST CONSOLIDATION OF THE LUNG

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THORACIC EXPANSION

• ASYMETRY IN EXPANSION OF THE THORAX CAN BE
  DETECTED DURING INSPECTION OF THE CHEST
• DURING PROMPTED INHALATION OBSERVE THE MOVEMENT
  OF THE THORAX
• PLEURAL EFFUSION, PNEUMOTHORAX

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CYANOSIS

• PERIPHERAL HANDS, FEET WARMING DECREASES
  CYANOSIS DECREASED CARDIAC OUTPUT
• CENTRAL- LIPS, TONGUE,SUBLINGUAL - RIGHT TO LEFT
  SHUNTS
• PSEUDOCYANOSIS BLUE PIGMENTS IN SKIN -
  AMIODARONE

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Central Cyanosis

• Results from pulmonary dysfunction, the mucous
  membrane of conjunctiva and tongue are bluish.
• If there was chronic hypoxemia and secondary
  erythrocytosis, you can detect the conjunctival
  and scleral vessels to be full, tortuous and
  bluish.

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Central Cyanosis
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Corpulmonale
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Sleep apnea syndrome
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Clubbing
Hereditary Interstitial Fibrosis Tumor Bronchiecst
asis Heart Disease Endocarditis
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Clubbing
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Significance Clubbing Observed In

• Intrathoracic malignancy Primary or secondary
  (lung, pleural, mediastinal)
• Suppurative lung disease (lung abscess,
  bronchiectasis, empyema)
• Diffuse interstitial fibrosis Alveolar capillary
  block syndrome
• In association with other systemic disorders

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CLUBBING

• PAINLESS FINGERNAILS CURVED AND WARM
• ENLARGEMENT OF THE CONNECTIVE TISSUES IN THE
  TERMINAL PHALANGES OF THE FINGERS gtTOES

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CLUBBING
SCHAMROTHS SIGN LOSS OF THE SUBUNGUAL
ANGLE CLIN CHEST MED 8287-298,1987
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CLUBBING
LOVIBONDS ANGLE THE ANGLE BETWEEN THE BASE OF
THE NAIL AND SURROUNDING SKIN. CLIN CHEST MED
8287-298,1987
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DO NOT FORGET THE TRACHEA

• TRACHEAL DEVIATION
• AUSCULTATE - STRIDOR
• TRACHEAL TUG (OLIVERS SIGN) DOWNWARD
  DISPLACEMENT OF THE CRICOID CARTILAGE WITH
  VENTRICULAR CONTRACTION OBSERVED IN PATIENTS
  WITH AN AORTIC ARCH ANEURYSM
• TRACHEAL TUG (CAMPBELLS SIGN) DOWNWARD
  DISPACEMENT OF THE THYROID CARTILAGE DURING
  INSPIRATION SEEN IN PATIENTS WITH COPD

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ABNORMAL BREATHING PATTERNS
APNEA - CARDIAC ARREST BIOTS INCREASED
INTRACRANIAL PRESSURE DRUGS- MEDULLA CHEYNE
STOKES CONGESTIVE HEART FAILURE DRUGS
CEREBRAL KUSSMAULS METABOLIC ACIDOSIS
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WHITE NOISE (NOISY BREATHING)

• THIS NOISE CAN BE HEARD AT THE BEDSIDE WITHOUT
  THE STETHOSCOPE
• LACKS A MUSICAL PITCH
• AIR TURBULENCE CAUSED BY NARROWED AIRWAYS
• CHRONIC BRONCHITIS

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BREATH SOUNDS

• VESICULAR NORMAL BREATH SOUNDS - SITE OF
  PRODUCTION THE ALVEOLI
• TRACHEAL TUBULAR LIKE BLOWING AIR THROUGH A
  HOLLOW TUBE PHYSIOLOGIC
• BRONCHIAL TUBULAR - ALWAYS PATHOLOGIC WHEN
  THEY OCCUR OVER POSTERIOR OR LATERAL CHEST
  WALL
• BRONCHOVESICULAR CHARACTERISTICS OF BOTH
  VESICULAR AND TUBULAR DO THEY EXIST?
• ADVENTITOUS EXTRA SOUNDS

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BREATH SOUNDS TIMING
CHARACTERISTIC TRACHEAL BRONCHIAL BV VESICULAR
INTENSITY VERY LOUD LOUD MODERATE LOW
IE RATIO 11 13 11 31
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Breath sounds

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Vesicular breath sounds

• Vibrations of the vocal cords caused by turbulent
  flow through the larynx
• Transmitted along trachea, bronchi to chest wall
• Rustling quality
• Inspiration continuous with expiration
• Intensity increases during inspiration fades
  during first 1/3rd expiration

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Diminished breath sounds

• Conduction limited by
• Airflow limitation
• e.g. diffusely asthma, emphysema
• localised tumour, collapse
• Something separating chest wall from lung
• e.g. effusion, fibrosis

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Bronchial breathing

• blowing inspiratory expiratory sounds
• Expiratory phase as long as inspiration
• Distinct pause between phases
• High-pitched e.g. consolidation
• Low-pitched e.g. fibrosis

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Added sounds

• Rhonchi (wheeze)
• Crepitations (crackles)
• Pleural sounds

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Rhonchi

• Due to passage of air through narrowed bronchus
  e.g. bronchospasm, mucosal oedema
• Musical quality
• High or low pitched
• Usually expiratory
• Expiration prolonged

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Crepitations

• Inspiratory noises, usually 2nd half
• Non-musical
• Due to explosive reopening of peripheral small
  airways during inspiration which have become
  occluded during expiration

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Pleural Rub

• Creaking noise
• Movement of visceral pleura over parietal pleura
• Surfaces roughened by exudate
• 2 separate phases at end inspiration and early
  expiration

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ADVENTITIOUS SOUNDS

• THESE ARE SOUNDS HEARD DURING AUSCULTATION OTHER
  THAN BREATH SOUNDS OR VOCAL RESONANCE
• NOMENCLATURE HAS BEEN CONFUSING
• CRACKLES DISCONTINUOUS SOUNDS
• WHEEZES AND RHONCHI CONTINUOUS SOUNDS

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ADVENTITIOUS LUNG SOUNDS (BRUITS ETRANGERS
FOREIGN SOUNDS)

• WHEEZE HIGH PITCHED
• RHONCHI LOW PITCHED
• CRACKLE RALES - HAIR VELCRO (FINE
  COARSE)
• PLEURAL RUBS CREAKING LEATHER
• STRIDOR
• SQUEAK HIGH PITCHED WHEEZE HEARD AT THE END OF
  INSPIRATION

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CRACKLES
EARLY AND MID INSPIRATORY LATE INSPIRATORY
COARSE FINE
LOW PITCHED HIGH PITCHED
CLEAR WITH COUGHING DO NOT CLEAR WITH COUGHING
SCANTY PROFUSE
GRAVITY IN DEPENDENT GRAVITY DEPENDENT
TRANSMITTED TO THE MOUTH POORLY TRANSMITTED TO THE MOUTH
ASSOCIATED WITH OBSTRUCTION ASSOCIATED WITH RESTRICTION
BRONCHITIS- BRONCHIECSTASIS INTERSTITIAL FIBROSIS - INTERSTITIAL EDEMA
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SIGNIFICANCE OF LATE AND EARLY CRACKLES

• EARLY CENTRAL AIRWAYS (BRONCHITIS)
• LATE PERIPHERAL AIRWAYS (FIBROSIS,EDEMA)

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WHEEZING

• ASTHMA
• BRONCHITIS
• VOCAL CORD DYSFUNCTION
• FOREIGN BODY ASPIRATION
• INFECTIONS CROUP LARYNGITIS

• CONGESTIVE HEART FAILURE
• COPD
• FORCED EXPIRATION IN NORMAL SUBJECTS
• CYSTIC FIBROSIS

NOT ALL THAT WHEEZES IS ASTHMA
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COPD
PINK PUFFERS
BLUE BLOATERS
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DAHLS SIGN NICOTINE STAINS SMOKERS FACE
THORAX 38595-600, 1983
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BLUE BLOATER
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PURSED LIPS BREATHING

• COPD DECREASES DYSPNEA
• DECREASES RR
• INCREASES TIDAL VOLUME
• DECREASES WORK OF BREATHING

CHEST 10175-78, 1992
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HOOVERS SIGN

• COPD
• IN COPD THE DIAPHRAGM MAY BE FLATTENED, DURING
  THE INSPIRATORY PHASE OF A BREATH THE RIBS ARE
  PULLED INWARD AND MEDIALLY RATHER THAN OUTWARD
  AND LATERALLY

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RESPIRATORY ALTERNANS

• NORMALLY BOTH CHEST AND ABDOMEN RISE DURING
  INSPIRATION
• PARADOXICAL RESPIRATION IMPLIES THAT DURING
  INSPIRATION THE CHEST RISES AND THE ABDOMEN
  COLLAPSES
• IMPENDING MUSCLE FATIGUE

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PUTTING IT ALL TOGETHER

• PNEUMONIA
• PNEUMOTHORAX
• PLEURAL EFFUSION
• ASTHMA

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PNEUMONIA
PNEUMONIA
INSPECTION SPLINTING PALPATION INCREASED
FREMITUS PERCUSSION DULL AUSCULTATION
BRONCHIAL BREATH SOUNDS, CRACKLES, EGOPHONY,
PECTORILOQUY, RHONCHI
ENDOBRONCHIAL OBSTRUCTION MAY MASK THE USUAL
PHYSICAL FINDINGS OF PNEUMONIA
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Consolidation Chest xray
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PLEURAL EFFUSION
PLEURAL EFFUSION
INSPECTION LAG AFFECTED SIDE PALPATION ABSENT
FREMITUS PERCUSSION FLAT, DULL AUSCULTATION
ABSENT OVER EFFUSION, BRONCHIAL IMMEDIATELY ABOVE
EFFUSION, RUB OCCASIONALLY
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PNEUMOTHORAX
PNEUMOTHORAX
INSPECTION LAG AFFECTED SIDE PALPATION ABSENT
FREMITUS PERCUSSION TYMPANIC AUSCULTATION
ABSENT BREATH SOUNDS
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PNEUMOTHORAX
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PNEUMOTHORAX
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Interpretation of findings

• Pleural effusion
• reduced tactile vocal fremitus
• reduced chest expansion
• stony dull
• reduced air entry
• no added sounds
• reduced vocal resonance

• Consolidation
• increased tactile vocal fremitus
• reduced expansion
• dull percussion
• bronchial breathing
• coarse creps
• increased vocal resonance
• whispering pectoriloquy

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• Pleural effusion

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Pleural Effusion
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Interpretation of findings

• Pneumothorax
• deviated trachea
• reduced tactile vocal fremitus
• hyper-resonance
• reduced air entry
• reduced vocal resonance

• Collapse
• deviated trachea
• reduced tactile vocal fremitus
• dull percussion
• reduced air entry
• /- creps

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• pneumothorax

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Symptoms of Cardiac disorders
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1. Symptoms due to lung congestion

• Dyspnea.
• Acute pulmonary edema.
• Cough, hemoptysis.
• Recurrent chest infections.

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2. Symptoms due to lung congestion

• Pain in the right hypochondrium.
• Dyspepsia.
• Swelling of lower limb.
• Swelling of the abdomen.
• Oliguria.

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3. Symptoms due to low cardiac output(tissue
hypoxia ?brain, muscles, kidneys)

• Exertional fatigue.
• Blurring of vision.
• Dizziness / Syncope.
• Oliguria, Angina.

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4. Chest pain

• Of Cardiac Origin
• Ischemia, pericarditis, Dissecting aorta, Aortic
  Aneurysm.
• Other Causes
• Chest wall
• Neurological
• Mediastinum
• Diaphragm
• Abdominal. ( esophagus, stomach, gall bladder,
  pancreas).

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• Analysis
• Site radiation.
• Provocation relief.
• Duration.
• Character.
• Associated features.

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5. Symptoms due to changes in rate, Rhythm, or
force ? palpitation.

• ( time, mode of onset offset, relation to
  exertion, duration, irregularity).

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6. Symptoms due to pressure on surrounding
structures.

• ( esophagus, bronchi , nerves, spine)

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General Examination

• General appearance.
• Vital signs pulse, temp. Blood pressure,
  respiration.
• Hands (cold, warm, clubbing, cyanosis,
  sweating)
• Eyes
• Neck
• Neck veins.
• Pulsations (arterial vs. venous).
• Carotid arteries.
• Trachea, thyroid gland.

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1. Lower Limbs ( edema, pulsations).
2. Abdomen.

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Local Examination
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1. Combined Inspection and palpation

• Shape.
• Cardiac impulses (apex beat, parasternal
  pulsations, epigastric, to the right of sternum,
  suprasternal notch, 2nd left space)
• Thrills.
• Palpable heart sounds.
• Position of the mediastinum
• Tactile vocal fremitus
• Chest movements
• Local tenderness,pulsations,wheezes.

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Apex beat
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2. Percussion

• Types of percussion notes
• Apices of the lungs
• Anterior chest wall
• Lateral chest wall
• Posterior chest wall
• Cardiac and hepatic dullness

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3. Auscultation

• Apex, lower end of sternum (tricuspid area),
  aortic area and pulmonary area .
• Murmurs
• Timing
• Character
• Point of maximum intensity and propagation
• Relation to respiration
• Intensity
• Thrill.

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• Breath sounds.
• Adventitious sounds.
• Vocal resonance .

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