Case of Bronchiectasis

BioData

• Name: Mrs. Laila

• Age: 40 years

• Sex: Female

• Occupation: Homemaker

• Address: Nagpur, Maharashtra

Auscultation Findings

1. Anterior Chest

• Supraclavicular and Infraclavicular Areas (Right and Left):
  Breath sounds are vesicular and normal in intensity. No added sounds detected in these uppermost regions.

• Mammary and Inframammary Areas (Right and Left):
  On the right mammary and inframammary regions, coarse crackles (crepitations) are heard, especially at the end of inspiration. These crackles partially clear after coughing, which is typical for bronchiectasis. Occasional low-pitched rhonchi are also noted, more on the right side. On the left, breath sounds remain vesicular with no added sounds.

2. Lateral Chest

• Right Axillary and Infra-axillary Areas:
  Coarse crackles are prominent in the infra-axillary region, increasing in intensity during deep inspiration and partially clearing after coughing. Mild rhonchi are also present.

• Left Axillary and Infra-axillary Areas:
  Breath sounds are vesicular. No added sounds detected.

3. Posterior Chest

• Suprascapular Areas (Right and Left):
  Breath sounds are vesicular, normal intensity, no added sounds.

• Interscapular Area:
  Vesicular breath sounds, no adventitious sounds.

• Infrascapular Areas (Right and Left):
  On the right infrascapular area, coarse crackles are clearly audible, especially during inspiration and expiration, and partially clear after coughing. Occasional rhonchi are also present. On the left, faint crackles may be heard but are less prominent than on the right.

Vocal Resonance:
Normal throughout all areas.

Summary

Mrs. L, a 40-year-old homemaker, presents with chronic productive cough and recurrent respiratory infections. On auscultation, she has coarse crackles that partially clear after coughing and occasional rhonchi, predominantly in the right lower and middle lung zones (mammary, inframammary, infra-axillary, and infrascapular areas). These findings are classic for bronchiectasis, especially when associated with a history of chronic cough and sputum production.

Case of Chronic Obstructive Pulmonary Disease (COPD)

BioData:

• Name: Mr. Sunil

• Age: 68 years

• Sex: Male

• Occupation: Farmer

• Address: Rural Maharashtra

Auscultation Findings (Detailed by Area)

1. Anterior Chest

• Supraclavicular and Infraclavicular Areas (Right and Left):
  Breath sounds are vesicular but diminished in intensity bilaterally. No added sounds in these uppermost regions.

• Mammary and Inframammary Areas (Right and Left):
  Vesicular breath sounds are further diminished. Bilateral expiratory wheeze is clearly audible, more pronounced during forced expiration. No crackles are heard.

2. Lateral Chest

• Right and Left Axillary and Infra-axillary Areas:
  Breath sounds remain vesicular but are reduced in intensity. Expiratory wheeze is present bilaterally, especially in the infra-axillary regions. No crepitations detected.

3. Posterior Chest

• Suprascapular Areas (Right and Left):
  Vesicular breath sounds are diminished. No added sounds.

• Interscapular Area:
  Breath sounds are faint and vesicular. Bilateral expiratory wheeze is noted.

• Infrascapular Areas (Right and Left):
  Markedly diminished vesicular breath sounds. Expiratory wheeze persists bilaterally. No crackles are heard.

Vocal Resonance:
Normal or mildly reduced throughout all areas.

Summary

Mr. S, a 68-year-old male with a long history of smoking, presents with chronic productive cough and progressive breathlessness. On auscultation, he has globally diminished vesicular breath sounds and bilateral expiratory wheeze, most prominent in the mammary, inframammary, infra-axillary, and infrascapular regions. There are no crackles. These findings, along with his clinical history, are characteristic of COPD.

Differential Diagnosis

• Chronic bronchitis

• Bronchial asthma (especially if wheeze predominates)

• Bronchiectasis (if productive cough with coarse crackles)

• Congestive cardiac failure (if associated with basal crackles)

• Interstitial lung disease (if fine end-inspiratory crackles)

• Asthma-COPD overlap syndrome

Note:
Auscultation in COPD typically reveals globally diminished breath sounds and bilateral expiratory wheeze, reflecting airflow limitation and airway narrowing.

Case of Pleural Effusion

BioData:

• Name: Mrs. Malini

• Age: 54 years

• Sex: Female

• Occupation: School Teacher

• Address: Nagpur, Maharashtra

Auscultation Findings

1. Anterior Chest

• Supraclavicular and Infraclavicular Areas (Right and Left):
  Breath sounds are vesicular and normal in intensity bilaterally. No added sounds detected.

• Mammary and Inframammary Areas (Right):
  On the right side, especially in the inframammary region, breath sounds are markedly reduced. No added sounds such as crackles or wheeze are heard. Vocal resonance is diminished.

• Mammary and Inframammary Areas (Left):
  Breath sounds are vesicular and normal. No adventitious sounds.

2. Lateral Chest

• Right Axillary and Infra-axillary Areas:
  Breath sounds are decreased to absent over the infra-axillary region. Vocal resonance is also reduced. No added sounds are present.

• Left Axillary and Infra-axillary Areas:
  Breath sounds are vesicular and normal. No added sounds.

3. Posterior Chest

• Suprascapular Areas (Right and Left):
  Breath sounds are vesicular and normal in intensity. No added sounds.

• Interscapular Area:
  On the right, breath sounds are diminished compared to the left. No added sounds.

• Infrascapular Areas (Right):
  Marked reduction or absence of breath sounds over the right infrascapular region. Vocal resonance is decreased. Occasionally, just above the upper border of the effusion, a nasal quality to vocal resonance (egophony) may be heard. No crackles or wheeze.

• Infrascapular Areas (Left):
  Breath sounds are vesicular and normal.

Summary

Mrs. M, a 54-year-old woman, presents with progressive breathlessness and right-sided chest discomfort. On auscultation, she has markedly diminished or absent breath sounds and vocal resonance over the right lower and lateral chest (mammary, inframammary, infra-axillary, and infrascapular areas), with possible egophony just above the upper border of the effusion. No adventitious sounds are heard. These findings are characteristic of a moderate to large right-sided pleural effusion.

Case of Pneumonia

BioData:

• Name: Mr. Rohan Sharma

• Age: 62 years

• Sex: Male

• Occupation: Retired Teacher

• Address: Urban Mumbai

• Auscultation Findings (Detailed by Area)

  1. Anterior Chest

     • Supraclavicular and Infraclavicular Areas (Right and Left): Breath sounds are vesicular with normal intensity bilaterally. No added sounds in these uppermost regions.

     • Mammary and Inframammary Areas (Right and Left):

       • Right Side: Over the middle lobe area, breath sounds show increased intensity with bronchial breathing noted. Coarse crackles are heard during inspiration. Over the lower lobe area, similar findings of increased intensity, bronchial breathing, and coarse crackles are present throughout inspiration and early expiration.

       • Left Side: Vesicular breath sounds are normal. Few scattered fine crackles are heard at the end of inspiration in the lower lobe area.

  2. Lateral Chest

     • Right Axillary and Infra-axillary Areas: Breath sounds show increased intensity and bronchial breathing in the mid and lower zones. Coarse crackles are audible during inspiration.

     • Left Axillary and Infra-axillary Areas: Vesicular breath sounds are normal in the upper zone. Few fine crackles are present in the lower zone.

  3. Posterior Chest

     • Suprascapular Areas (Right and Left): Vesicular breath sounds are normal bilaterally. No added sounds.

     • Interscapular Area: Breath sounds are vesicular. No added sounds.

     • Infrascapular Areas (Right and Left):

       • Right Side: Breath sounds show increased intensity and bronchial breathing. Coarse crackles are heard predominantly during inspiration.

       • Left Side: Vesicular breath sounds are normal. Possibly a few scattered fine crackles are present.

  • Vocal Resonance: Increased over the consolidated areas in the right middle and lower lobes (bronchophony, egophony can be elicited). Normal elsewhere.

Summary

Mr. S, a 62-year-old male with a history of smoking, presents with a productive cough and increasing shortness of breath. On auscultation, the most significant findings are localized to the right middle and lower lobes, characterized by increased intensity of breath sounds, bronchial breathing, and coarse crackles. These findings are consistent with pulmonary consolidation. Some fine crackles are also noted in the left lower lobe. These auscultatory findings, in the context of his clinical presentation, strongly suggest a diagnosis of pneumonia.

Lung Cavity

BioData

• Name: Mr. Ravi Kumar

• Age: 55 years

• Sex: Male

• Occupation: Farmer

• Address: Chennai, Tamil Nadu

• Socioeconomic status: Lower-middle class

• Relevant history: Smoker (20 pack-years), past exposure to tuberculosis

Auscultation Findings

• Supraclavicular:

  • Right: Diminished vesicular breath sounds

  • Left: Normal vesicular breath sounds

• Infraclavicular:

  • Right: Diminished breath sounds, coarse crackles

  • Left: Normal

• Mammary:

  • Right: Bronchial breath sounds, increased vocal resonance

  • Left: Normal

• Axillary:

  • Right: Bronchial breath sounds, coarse crackles

  • Left: Normal

• Infra-axillary:

  • Right: Cavernous breath sounds, amphoric quality, increased vocal resonance

  • Left: Normal

• Suprascapular:

  • Right: Diminished breath sounds

  • Left: Normal

• Interscapular:

  • Right: Bronchial breath sounds, occasional coarse crepitations

  • Left: Normal

• Infrascapular:

  • Right: Cavernous breath sounds, amphoric quality, increased vocal fremitus

  • Left: Normal

Summary
A 55-year-old male with a history of smoking and prior TB exposure presents with chronic cough, hemoptysis, fever, and weight loss. Auscultation reveals diminished or altered breath sounds with bronchial or cavernous quality, amphoric character, increased vocal resonance, and coarse crackles predominantly over the right mammary, axillary, infra-axillary, interscapular, and infrascapular areas. These findings are consistent with a right-sided lung cavity, most likely due to post-primary pulmonary tuberculosis or a cavitating malignancy

Lung Fibrosis

BioData

• Name: Mrs. Lakshmi Devi

• Age: 62 years

• Sex: Female

• Occupation: Retired school teacher

• Address: Coimbatore, Tamil Nadu

• Socioeconomic status: Middle class

• Relevant history: Non-smoker, insidious onset of progressive breathlessness for 1 year, dry cough for 8 months, no hemoptysis or chest pain, no significant past medical or occupational history.

Auscultation Findings (All Areas, Including Vocal Resonance)

• Supraclavicular:

  • Bilateral: Vesicular breath sounds, no added sounds, normal vocal resonance

• Infraclavicular:

  • Bilateral: Vesicular breath sounds, no added sounds, normal vocal resonance

• Mammary:

  • Bilateral: Vesicular breath sounds, no added sounds, normal vocal resonance

• Axillary:

  • Bilateral: Vesicular breath sounds, no added sounds, normal vocal resonance

• Infra-axillary:

  • Bilateral: Fine, end-inspiratory “Velcro” crackles; vocal resonance mildly increased

• Suprascapular:

  • Bilateral: Vesicular breath sounds, no added sounds, normal vocal resonance

• Interscapular:

  • Bilateral: Fine, end-inspiratory crackles (less prominent than at bases); vocal resonance mildly increased

• Infrascapular:

  • Bilateral: Fine, end-inspiratory “Velcro” crackles (most prominent); vocal resonance mildly increased

Summary
A 62-year-old woman with progressive exertional dyspnoea and dry cough is found to have fine, end-inspiratory “Velcro” crackles and mildly increased vocal resonance, predominantly at the infra-axillary, interscapular, and infrascapular (basal) lung zones bilaterally. These findings are characteristic of bilateral basal pulmonary fibrosis, most likely idiopathic pulmonary fibrosis, especially in the absence of significant occupational or connective tissue disease history

Viva Questions and Answers on Lung Auscultation

1. What is lung auscultation?
   Lung auscultation is the process of listening to the sounds produced within the lungs using a stethoscope to assess respiratory health.

2. Name the normal breath sounds heard during auscultation.
   Vesicular, bronchovesicular, and bronchial breath sounds.

3. Where are vesicular breath sounds best heard?
   Over the peripheral lung fields.

4. What is the character of vesicular breath sounds?
   They are soft, low-pitched, and heard mainly during inspiration.

5. Where are bronchial breath sounds normally heard?
   Over the trachea and manubrium.

6. What does the presence of bronchial breath sounds in the periphery indicate?
   It suggests lung consolidation, such as in pneumonia.

7. Define adventitious sounds.
   Adventitious sounds are abnormal lung sounds, such as crackles, wheezes, and pleural rubs, heard in addition to normal breath sounds.

8. What are fine crackles and where are they commonly heard?
   Fine crackles are brief, high-pitched sounds heard at the end of inspiration, commonly in pulmonary fibrosis.

9. What conditions are associated with coarse crackles?
   Coarse crackles are seen in bronchiectasis, pneumonia, and pulmonary edema.

10. What is a wheeze and what does it indicate?
    A wheeze is a high-pitched, musical sound usually heard during expiration, indicating airway narrowing, as in asthma or COPD.

11. What is a pleural rub?
    A pleural rub is a grating sound heard during both inspiration and expiration, caused by inflamed pleural surfaces rubbing together.

12. What is vocal resonance?
    Vocal resonance is the transmission of spoken voice through the lung fields, assessed during auscultation.

13. How is vocal resonance tested?
    By asking the patient to repeat a phrase (like "one, one, one") while listening with a stethoscope over the chest.

14. What does increased vocal resonance indicate?
    It indicates lung consolidation.

15. What does decreased vocal resonance suggest?
    It suggests conditions like pleural effusion or pneumothorax.

16. What is bronchophony?
    Bronchophony is increased clarity and loudness of spoken sounds over an area of consolidation.

17. What is egophony?
    Egophony is when the spoken "ee" is heard as "ay" over areas of consolidation or just above a pleural effusion.

18. What is whispered pectoriloquy?
    It is the increased transmission of whispered words over an area of consolidation.

19. Why should auscultation be performed in all lung zones?
    To ensure no abnormality is missed, as some pathologies are localized to specific areas.

20. What are common errors to avoid during lung auscultation?
    Listening through clothing, not comparing symmetrical areas, and failing to cover all lung fields.