2. 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

3. 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

4. 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

5. 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

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

7. 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

8. 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

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

10. 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 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

11. 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.

12. Stridor: Harsh, high-pitched, musical sound produced by turbulent airflow through partially obstructed upper airway Supraglottic obstruction: Supraglottic obstruction: Inspiratory stridor (high-pitched) Extrathoracic trachea obstruction – includes glottis & subglottis: Extrathoracic trachea obstruction – includes glottis & subglottis: Biphasic stridor (intermediate pitch) Biphasic stridor (intermediate pitch) Intrathoracic trachea obstruction: Intrathoracic trachea obstruction: Expiratory stridor (wheeze)

13. Chest &Lung Respiratory Rhythm(Asthma,..) Respiratory Rhythm(Asthma,..) Palpation Palpation Crepitation in subcutaneous emphysema Crepitation in subcutaneous emphysema Local tenderness, Axillary lymph node Local tenderness, Axillary lymph node Percussion Percussion Hyperresonance or redused cardiac dullness Hyperresonance or redused cardiac dullness in emphysema or pneumothorax in emphysema or pneumothorax Decreased resonance in consolidation Decreased resonance in consolidation

14. Chest &Lung breathing sound: breathing sound: Reduced:bronchiolitis,emphysema, pneumothorax, pleural effusion Reduced:bronchiolitis,emphysema, pneumothorax, pleural effusion Increased:consolidation,collapse Increased:consolidation,collapse Bronchial:consolidation,collapse Bronchial:consolidation,collapse Ronchi:bronchospasm,infection Ronchi:bronchospasm,infection Crepitation: infection Crepitation: infection Wheezing:asthma Wheezing:asthma Vocal resonance: Vocal resonance:

22. Physiology of Murmurs first and second sounds, or S1 and S2, which demarcate systole from diastole 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. 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.

23. S2 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. 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 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

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

25. The intensity of the murmur is next, graded according to the Levine scale: I - Lowest intensity, difficult to hear even by expert listeners I - Lowest intensity, difficult to hear even by expert 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 inexperienced listeners, but without a palpable thrill III - Medium intensity, easy to hear even by inexperienced listeners, but without a palpable thrill IV - Medium intensity with 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 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. VI - Loudest intensity with a palpable thrill. Audible even with the stethoscope raised above the chest.

26. 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. 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.

27. systole or diastole systole or diastole where it is heard best where it is heard best where it radiates to where it radiates to if the murmur completely fills that phase of the cycle (i.e., holosystolic) 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) 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 ) if this murmur is clinically significant or not(physiologic flow murmurs :Pregnancy, Anemia,thyrotoxicosis,Innocent murmur )

28. physiologic murmurs located between the apex and left lower sternal border located between the apex and left lower sternal border have minimal radiation have minimal radiation occur during early to mid-systole occur during early to mid-systole have a crescendo-decrescendo shape, and a vibratory quality have a crescendo-decrescendo shape, and a vibratory quality usually change intensity with positional maneuvers, becoming quieter on standing and louder with squatting 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. 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. Additionally, they will not be correlated with additional audiologic findings, such as an S3 or S4.

29. Heart sound Normal heart sound Normal heart sound

30. aortic stenosis aortic stenosis systolic murmurs,heard best over the “aortic area” or right second intercostal space, with radiation into the right neck 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 harsh quality and may be associated with a palpably slow rise of the carotid upstroke Symptoms: Angina, Syncope, Congestive heart failure Symptoms: Angina, Syncope, Congestive heart failure Early aortic stenosis Early aortic stenosis Late aortic stenosis Late aortic stenosis

31. Mitral Regurgitation best heard at the apex, with radiation into the axilla best heard at the apex, with radiation into the axilla holosystolic murmur holosystolic murmur congenital condition congenital condition rheumatic heart disease rheumatic heart disease marked left ventricular dilatation marked left ventricular dilatation acute infective endocarditis acute infective endocarditis acute or prior myocardial infarction acute or prior myocardial infarction

32. Pulmonary 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 border heard best in the pulmonic area, the second intercostal space on left sternal border radiating into the neck or the back radiating into the neck or the back has a crescendo-decrescendo shape, and a harsh quality 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 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. 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.

33. Aortic Regurgitation Diastolic Murmurs Diastolic Murmurs rheumatic heart disease, congenital,endocarditis rheumatic heart disease, congenital,endocarditis blowing, decrescendo, and heard best in the third left intercostal space blowing, decrescendo, and heard best in the third left intercostal space In severe regurgitation, it may be holodiastolic In severe regurgitation, it may be holodiastolic It radiates widely along the left sternal border It radiates widely along the left sternal border

34. Mitral Stenosis Diastolic Murmurs Diastolic Murmurs best heard at the apex with little radiation best heard at the apex with little radiation low-pitched, decrescendo, and rumbling low-pitched, decrescendo, and rumbling heard best with the patient in the left lateral decubitus position heard best with the patient in the left lateral decubitus position

35. Cardiovascular System Inspection : Inspection : Dyspnea,cyanosis,tachypnea,Edema, Clubbing,Apex beat,JVP,.. Dyspnea,cyanosis,tachypnea,Edema, Clubbing,Apex beat,JVP,.. Palpation: Palpation: Thrill, Apex beat (Point of maximal impulse), All Pulses (arrrhythmia, weak or bounding pulse,absent femoral pulse) Thrill, Apex beat (Point of maximal impulse), All Pulses (arrrhythmia, weak or bounding pulse,absent femoral pulse) Percussion: Percussion: Diminished dullness(Pneumothorax,Emphysema) Diminished dullness(Pneumothorax,Emphysema) Auscultation: Auscultation: Heart rate Heart rate Newborn=70-120 Preschool child =75-120 Newborn=70-120 Preschool child =75-120 Infant=80-160 school child = 70-110 Infant=80-160 school child = 70-110

36. Cardiovascular System Auscultation: Auscultation: Normal sinus dysrhythmia Normal sinus dysrhythmia Rhythm(sinus arrhythmia,gallop rhythm, Rhythm(sinus arrhythmia,gallop rhythm, Heart sound(splitting S2,Ejection click ) Heart sound(splitting S2,Ejection click ) Murmur Murmur site site Intensity: grade 0-6 Intensity: 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 position Variation with position

40. Cyanosis and clubbingCyanosis of the lips pectus excavatum deformity Pectus Carinatum

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

42. Breast Breast of newborns are often enlarged due to maternal estrogen Breast of newborns are often enlarged due to maternal estrogen Breast development 8-13 y/o Breast development 8-13 y/o Breast development before 8 y/o are abnormal Breast development before 8 y/o are abnormal Menarche occurs in breast stage 3 or 4 Menarche occurs in breast stage 3 or 4 In 10% of girls breasts develop asymmetry In 10% of girls breasts develop asymmetry

43. Tanner stages