The Bronchial Breath Sound
An I:E Ratio : 1:1 or 1:1 1/4 with a pause in
between inspiration & expiration
Thoracic Geography : over the manubrium
of the sternum
Sound Characteristics : high pitched,
tubular, hollow sound
Indication : pneumonia, atelectasis, fluid
infiltration
Vesicular Breath
Sound
An I:E Ratio : 1:0 or 1:1/4 with no pause in
between inspiration & expiration
Thoracic Geography : everywhere on the
thoracic wall
Sound Characteristics : low pitched, soft rustling
sound
Indication : pneumonia, atelectasis, fluid
infiltration
Bronchovesicular Breath Sound
An I:E Ratio : 1:1 or 1:1 1/4 with a pause in between
inspiration & expiration
Thoracic Geography : sternocostal margins, over the
verbral column between the scapulae
Sound Characteristics : high pitched, tubular, hollow
sound
Indication : pneumonia, atelectasis, fluid infiltration
Rales or crackles
discontinuous sound
Fine rales
sound that you hear when burning wood crackles
When fluid or mucus collects in the peripheral portions of the lung, the
alveoli collapse and the walls of the alveoli stick together
This is a sound heard during inspiration
course rales
Pleural Friction Rubs
Created when the visceral and parietal pleurae
become inflammed and roughened
The sound that a pleural friction rub makes is a
leather-on-leather type of sound
These sounds can be heard at the same points
in the inhalatory and the exhalatory cycles
Bronchovesicular Breath Sound
An I:E Ratio : 1:1 or 1:1 1/4 with a pause in between
inspiration & expiration
Thoracic Geography : sternocostal margins, over the
verbral column between the scapulae
Sound Characteristics : high pitched, tubular, hollow
sound
Indication : pneumonia, atelectasis, fluid infiltration
Rales or crackles
discontinuous sound
Fine rales
sound that you hear when burning wood crackles
When fluid or mucus collects in the peripheral portions of the lung, the
alveoli collapse and the walls of the alveoli stick together
This is a sound heard during inspiration
course rales
Pleural Friction Rubs
Created when the visceral and parietal pleurae
become inflammed and roughened
The sound that a pleural friction rub makes is a
leather-on-leather type of sound
These sounds can be heard at the same points
in the inhalatory and the exhalatory cycles
Stridor
High pitched wheezing that is caused by the
obstruction of the trachea either by inflammation
or an object
Just enough air passes the obstructed point to
cause a high-pitched whining wheeze
In children, stridor is most frequently caused by
croupe, a viral infection that causes the tracheal
membranes to swell to a near-closed position
The wheeze is produced much like a wind
instrument produces sound through a wooden
reed
Rhonchi or Wheezes
The wheezes are considered to be central
airway sounds caused by air passing through
mucus plugs in the upper divisions of the
tracheobronchial tree.
Stridor: Harsh, high-pitched, musical sound
produced by turbulent airflow through partially
obstructed upper airway
Supraglottic obstruction:
Inspiratory stridor (high-pitched)
 Extrathoracic trachea obstruction –
includes glottis & subglottis:
Biphasic stridor (intermediate pitch)
 Intrathoracic trachea obstruction:
Expiratory stridor (wheeze)
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Chest &Lung
Respiratory Rhythm(Asthma,..)
 Palpation
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Crepitation in subcutaneous emphysema
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Local tenderness , Axillary lymph node
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Percussion
Hyperresonance or redused cardiac dullness
in emphysema or pneumothorax
Decreased resonance in consolidation
Chest &Lung
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breathing sound:
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Reduced:bronchiolitis,emphysema,
pneumothorax, pleural effusion
Increased:consolidation,collapse
Bronchial:consolidation,collapse
Ronchi:bronchospasm,infection
Crepitation: infection
Wheezing:asthma
Vocal resonance:
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Physiology of Murmurs
first and second sounds, or S1 and S2,
which demarcate systole from diastole
 S1 is the sound which marks the
approximate beginning of systole, and is
created when the increase in
intraventricular pressure during contraction
exceeds the pressure within the atria,
causing a sudden closing of the tricuspid
and mitral, or AV valves.
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S2
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At the end of systole, the ventricles begin to
relax, the pressures within the heart become
less than that in the aorta and pulmonary
artery, and a brief back flow of blood causes
the semilunar valves to snap shut, producing
S2.
Because diastole takes about twice as long
as systole, there is a longer pause between
S2 and S1 than there is between S1 and S2
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During S1, the closing of the mitral valve
slightly precedes the closing of the tricuspid
valve, while in S2, the aortic valve closes just
before the pulmonary valve.
the pressure during systole in the left
ventricle is much greater than in the right, SO
the mitral valve closes before the tricuspid in
S1.
The pressure at the start of diastole in the
aorta is much higher than in the pulmonary
artery, the aortic valve closes first in S2.
The intensity of the murmur is next,
graded according to the Levine
scale:
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I - Lowest intensity, difficult to hear even by expert
listeners
II- Low intensity, but usually audible by all listeners
III - Medium intensity, easy to hear even by
inexperienced listeners, but without a palpable
thrill
IV - Medium intensity with a palpable thrill
V - Loud intensity with a palpable thrill. Audible
even with the stethoscope placed on the chest
with the edge of the diaphragm
VI - Loudest intensity with a palpable thrill. Audible
even with the stethoscope raised above the chest.
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Some times it is difficult to discern which is
S1 and which is S2 ,So it is important to
always palpate the PMI or the carotid or
radial pulse when auscultating. The heart
sound you hear when you first feel the
pulse is S1, and when the pulse
disappears is S2.
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systole or diastole
where it is heard best
where it radiates to
if the murmur completely fills that phase of the
cycle (i.e., holosystolic)
The quality and shape of the murmur(rumbling,
blowing, machinery, scratchy, harsh, or musical)
The intensity of the murmur(Levine scale)
if this murmur is clinically significant or
not(physiologic flow murmurs :Pregnancy,
Anemia,thyrotoxicosis,Innocent murmur )
physiologic murmurs
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located between the apex and left lower sternal border
have minimal radiation
occur during early to mid-systole
have a crescendo-decrescendo shape, and a vibratory
quality
usually change intensity with positional maneuvers,
becoming quieter on standing and louder with squatting
A Valsalva maneuver will decrease the intensity of the
murmur because the increase in intrathoracic pressure
will decrease venous return, which will decrease flow
through the heart and lessen the turbulence.
Additionally, they will not be correlated with additional
audiologic findings, such as an S3 or S4.
Heart sound
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Normal heart sound
aortic stenosis
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systolic murmurs,heard best over the “aortic
area” or right second intercostal space, with
radiation into the right neck
harsh quality and may be associated with a
palpably slow rise of the carotid upstroke
Symptoms: Angina, Syncope, Congestive heart
failure
Early aortic stenosis
Late aortic stenosis
Mitral Regurgitation
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best heard at the apex, with radiation into the axilla
holosystolic murmur
congenital condition
rheumatic heart disease
marked left ventricular dilatation
acute infective endocarditis
acute or prior myocardial infarction
Pulmonary Stenosis
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congenital disorders, such as tetralogy of Fallot,
heard best in the pulmonic area, the second intercostal space on left sternal
border
radiating into the neck or the back
has a crescendo-decrescendo shape, and a harsh quality
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 delayed
maneuvers which increase venous filling and blood flow into the right
ventricle, such as deep inspiration, will tend to increase the intensity of the
murmur.
Aortic Regurgitation
Diastolic Murmurs
 rheumatic heart disease, congenital
,endocarditis
 blowing, decrescendo, and heard best in the
third left intercostal space
 In severe regurgitation, it may be holodiastolic
 It radiates widely along the left sternal border
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Mitral Stenosis
Diastolic Murmurs
 best heard at the apex with little radiation
 low-pitched, decrescendo, and rumbling
 heard best with the patient in the left
lateral decubitus position
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Cardiovascular System
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Inspection:
Dyspnea,cyanosis,tachypnea,Edema, Clubbing,Apex
beat,JVP,..
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Palpation:
Thrill, Apex beat (Point of maximal impulse), All
Pulses (arrrhythmia , weak or bounding pulse,absent
femoral pulse)
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Percussion:
Diminished dullness(Pneumothorax ,Emphysema)
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Auscultation:
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Heart rate
Newborn=70-120
Infant=80-160
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Preschool child =75-120
school child = 70-110
Cardiovascular System
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Auscultation:
Normal sinus dysrhythmia
Rhythm(sinus arrhythmia,gallop rhythm,
Heart sound(splitting S2,Ejection click )
Murmur
site
Intensity: grade 0-6
Timing:systolic(pan,early,late) or
diastolic(early,mid,presystolic)
Propagation:left axilla,neck,…
Variation with position
Cyanosis and clubbing
pectus excavatum deformity
Cyanosis of the lips
Pectus Carinatum
Pectus Carinatum (left) and Pectus Excavatum (right)
Breast
Breast of newborns are often enlarged due
to maternal estrogen
 Breast development 8-13 y/o
 Breast development before 8 y/o are
abnormal
 Menarche occurs in breast stage 3 or 4
 In 10% of girls breasts develop asymmetry
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Tanner stages