How to Palpate the Trachea

1. Position the Patient:
   Ask the patient to sit upright with their neck in a neutral position and their mouth closed.

2. Stand Facing the Patient:
   Stand directly in front of the patient at eye level.

3. Locate the Suprasternal Notch:
   Gently place the tips of your index and ring fingers on each side of the suprasternal notch (the dip at the top of the sternum, between the clavicles).

4. Use Your Middle Finger:
   Place your middle finger gently on the trachea itself, just above the suprasternal notch.

5. Assess Tracheal Position:

   • Gently move your fingers side-to-side to feel the space between the trachea and the sternocleidomastoid muscles on both sides.

   • The trachea should be equidistant from both sides of the sternomastoid muscles.

   • If the space is unequal, the trachea is deviated toward the side with less space.

6. Interpret Findings:

   • Central Trachea: Normal finding.

   • Deviation: May indicate underlying pathology (e.g., pulled toward fibrosis/collapse, pushed away by pleural effusion or mass).

How to Palpate the Apex Beat

1. Position the Patient:

   • Ask the patient to lie supine (on their back) with their head and chest slightly elevated, or sit at a 45-degree angle.

   • Ask the patient to relax and breathe normally. If the apex beat is not palpable, ask the patient to turn slightly to the left (left lateral decubitus position).

2. Expose the Chest:

   • Ensure adequate exposure of the chest, particularly the left precordial area.

3. Identify the Location:

   • The apex beat is normally located in the 5th left intercostal space, just medial to the midclavicular line.

4. Palpate with Fingertips:

   • Use the pads of your right index and middle fingers.

   • Place your fingers gently over the expected area and feel for a localized outward impulse with each heartbeat.

5. Confirm the Apex Beat:

   • If it is difficult to feel, ask the patient to hold their breath in expiration, which brings the heart closer to the chest wall.

   • Alternatively, use the palm of your hand to feel a larger area, then focus in with your fingertips once you sense the impulse.

6. Assess the Characteristics:

   • Note the location (intercostal space and distance from the midline/midclavicular line).

   • Assess the size (should be a small, localized impulse, less than 2 cm in diameter).

   • Assess the character (tapping, heaving, or thrusting).

   • Note if the apex beat is displaced (e.g., lateral or downward, which may suggest cardiac or respiratory pathology).

7. Document Your Findings:

   • Record the intercostal space, relation to the midclavicular line, and any abnormalities in position or character.

Summary:
To palpate the apex beat, use your fingertips to feel for the cardiac impulse in the 5th left intercostal space, just medial to the midclavicular line, noting its position, size, and character. Displacement or abnormal character can indicate underlying cardiac or respiratory disease.

How to Measure JVP

1. Position the Patient

   • Ask the patient to lie at a 45-degree angle (semi-recumbent position) with the head supported and turned slightly to the left.

2. Identify the Internal Jugular Vein

   • Look for pulsations in the right side of the neck, between the two heads of the sternocleidomastoid muscle, just above the clavicle.

   • The internal jugular vein is preferred over the external jugular vein because it is more reliable for JVP assessment.

3. Differentiate Venous from Arterial Pulsation

   • Venous pulsations are non-palpable, have a double waveform, and change with position and respiration.

   • Carotid (arterial) pulsations are palpable, have a single upstroke, and do not change with position.

4. Locate the Highest Point of Venous Pulsation

   • Identify the highest point of visible venous pulsation in the neck.

5. Measure the Vertical Height

   • Using a centimeter ruler, measure the vertical distance between the sternal angle (Angle of Louis) and the highest point of venous pulsation.

   • Place one end of the ruler at the sternal angle and hold it vertically.

   • Use another ruler or a card to form a right angle from the top of the pulsation to the vertical ruler.

   • The normal JVP is up to 3–4 cm above the sternal angle.

6. Interpret the Findings

   • A raised JVP (>4 cm above the sternal angle) suggests right heart failure, fluid overload, constrictive pericarditis, or superior vena cava obstruction.

Tips:

• Ensure good lighting and relax the patient.

• If pulsations are not visible, adjust the bed angle slightly.

• Always measure on the right side for consistency.

Summary:
To measure JVP, position the patient at 45°, identify the internal jugular vein, locate the highest point of venous pulsation, and measure the vertical distance above the sternal angle. A raised JVP indicates elevated right atrial pressure and possible cardiac or respiratory pathology.

How to Palpate Chest Movements in Different Chest Areas

1. Upper Anterior Chest

• Position: Stand facing the patient.

• Hand placement: Place your hands flat on both sides of the upper anterior chest, just below the clavicles (infraclavicular region), with your fingers spread and thumbs pointing towards each other but not touching.

• Instruction: Ask the patient to take a deep breath in and out.

• Observation: Watch and feel for the outward movement of your hands. Both sides should move equally. Note any reduction or asymmetry.

2. Upper Posterior Chest

• Position: Move behind the patient.

• Hand placement: Place your hands on both sides of the upper back, just above the scapulae (suprascapular region), with fingers spread and thumbs pointing upwards.

• Instruction: Ask the patient to take a deep breath.

• Observation: Your hands should move upward symmetrically. Reduced movement may indicate upper lobe pathology.

3. Lower Anterior Chest

• Position: Stand facing the patient.

• Hand placement: Place your hands on the lower anterior chest (inframammary and infraaxillary regions), with your thumbs meeting at the midline over the xiphisternum or lower sternum.

• Instruction: Ask the patient to take a deep breath.

• Observation: Thumbs should move apart equally. Reduced movement suggests lower lobe or pleural pathology.

4. Lower Posterior Chest

• Position: Stand behind the patient.

• Hand placement: Place your hands on the lower back (infrascapular and infraaxillary regions), with your thumbs meeting at the midline over the spine.

• Instruction: Ask the patient to take a deep breath.

• Observation: Thumbs should move apart equally. Asymmetry or reduced movement may indicate lower lobe disease or pleural effusion.

5. Apical Region

• Position: Stand in front of or behind the patient.

• Hand placement: Gently place your fingertips over the supraclavicular fossa (just above the clavicle) on both sides.

• Instruction: Ask the patient to take a deep breath.

• Observation: Feel for the upward movement of the apex of the lung. Compare both sides for symmetry. Reduced movement may suggest apical fibrosis or collapse.

General Tips

• Always compare both sides for symmetry.

• Use gentle but firm pressure with flat hands or fingertips.

• Note and document any reduction, lag, or asymmetry in movement, and specify the area involved.

Summary:
To palpate chest movements in each region, place your hands or fingers appropriately, ask the patient to take a deep breath, and observe/feel for equal expansion. Any asymmetry or reduction in movement helps localize underlying pathology.

Measuring AP and Transverse Chest Diameters

1. Preparation

• Explain the procedure to the patient and ensure they are sitting or standing upright, with arms relaxed at their sides.

• Choose the level at which you will measure—commonly at the nipple level (4th intercostal space).

2. Measuring the Anteroposterior (AP) Diameter

• Step 1:
  Ask the patient to sit sideways on the examination couch or chair.

• Step 2:
  Take two flat, hard-bound books (or similar objects).

• Step 3:
  Place one book firmly against the patient's sternum (front of the chest).

• Step 4:
  Place the second book against the patient’s back, at the same horizontal level (over the spine).

• Step 5:
  Ensure both books are parallel and at the same level (nipple line).

• Step 6:
  Use a measuring tape or ruler to measure the distance between the inner surfaces of the two books.
  This distance is the AP diameter.

3. Measuring the Transverse Diameter

• Step 1:
  Ask the patient to sit facing you.

• Step 2:
  Place one book firmly against the lateral chest wall (mid-axillary line) on one side at the nipple level.

• Step 3:
  Place the second book against the opposite lateral chest wall at the same level.

• Step 4:
  Ensure both books are parallel and horizontal.

• Step 5:
  Measure the distance between the inner surfaces of the two books using a tape or ruler.
  This distance is the transverse diameter.

4. Interpretation

• Normal ratio: The transverse diameter is about twice the AP diameter (AP:Transverse ≈ 1:2).

• Abnormal findings:

  • Increased AP diameter: (barrel chest) seen in COPD/emphysema.

  • Decreased AP diameter: seen in restrictive lung disease or chronic fibrosis.

How to Measure Chest Expansion (Thoracic Expansion)

1. Explain the Procedure

• Tell the patient you will be measuring how much their chest expands when they breathe in and out.

2. Position the Patient

• Ask the patient to sit or stand upright with arms relaxed at their sides.

3. Place the Measuring Tape

• Use a flexible measuring tape.

• Wrap the tape horizontally around the chest at the level of the nipples (4th intercostal space) in males, or just below the breasts in females.

• Ensure the tape is flat against the skin and not twisted.

4. Mark Reference Points (Optional but Recommended)

• Use a skin marking pencil to mark the midline on the sternum anteriorly and the corresponding vertebral spine posteriorly. This helps ensure the tape is always placed at the same anatomical level for both measurements3.

5. Take Baseline Measurement

• Ask the patient to breathe out completely (full expiration) and note the chest circumference.

6. Take Maximum Expansion Measurement

• Ask the patient to breathe in as deeply as possible (full inspiration) and note the new chest circumference.

7. Calculate Chest Expansion

• Subtract the expiratory measurement from the inspiratory measurement.

• Normal chest expansion: 2–5 cm in adults2346.

• Reduced expansion may indicate restrictive or obstructive lung disease, pleural pathology, or musculoskeletal restriction.

How to Measure Hemithorax Expansion (Unilateral/Side-to-Side Expansion)

1. Position and Marking

• Keep the patient in the same upright position.

• Use a skin marking pencil to mark the midline on the sternum (anteriorly) and the corresponding spinous process (posteriorly) at the 4th intercostal space3.

2. Place the Measuring Tape

• Hold one end of the tape at the midline (spinous process) on the back.

• Wrap the tape horizontally around one side of the chest (hemithorax) to the midline on the sternum in front.

• Ensure the tape is at the same level for both inspiration and expiration.

3. Measure Expansion

• Ask the patient to exhale fully and record the measurement.

• Ask the patient to inhale fully and record the measurement.

• Calculate the difference for that hemithorax.

4. Repeat for Opposite Side

• Repeat the same process for the other hemithorax.

5. Compare Both Sides

• Normally, both sides should expand equally (difference should be similar).

• Asymmetrical or reduced hemithorax expansion suggests unilateral pathology such as pleural effusion, pneumothorax, collapse, fibrosis, or consolidation2346.

Clinical Tips

• Always ensure the tape is horizontal and at the same level for both inspiration and expiration.

• Marking the midline with a skin pencil and anchoring the tape at the vertebral spine improves accuracy and reproducibility3.

• Instruct the patient to breathe in and out as deeply as possible for best results.

• Document your findings, noting any reduction or asymmetry and the measured values.

Summary:
To examine chest expansion, measure the change in chest circumference at the nipple level between full expiration and inspiration. For hemithorax expansion, measure from the vertebral spine to the sternum on each side separately, comparing both sides. Marking anatomical landmarks with a skin pencil and consistent tape placement ensures accuracy and helps detect both bilateral and unilateral abnormalities

How to Examine Tactile Vocal Fremitus

1. Explain the Procedure

• Tell the patient you will be placing your hands on their chest and back to feel vibrations while they speak.

2. Position the Patient

• Ask the patient to sit upright comfortably, with arms relaxed at their sides.

3. Ask the Patient to Speak

• Instruct the patient to repeat a phrase such as “ninety-nine” or “one-one-one” in a normal voice each time you place your hands on a new area.

4. Placement of Hands

• Use the ulnar (outer) border or the palmar surface of your hands, or the base of your fingers.

• Place your hands symmetrically on corresponding areas of the chest wall.

Areas to Examine (as per your document):

• Supraclavicular

• Infraclavicular

• Mammary

• Inframammary

• Axillary

• Infraaxillary

• Suprascapular

• Infrascapular

• Interscapular

5. Palpate for Fremitus

• As the patient repeats the chosen phrase, feel for the vibrations transmitted through the chest wall.

• Compare the intensity of the vibrations side to side in each area.

6. Interpret the Findings

• Normal: Vibrations are felt equally on both sides.

• Increased fremitus: Seen in areas of lung consolidation (e.g., pneumonia).

• Decreased/Absent fremitus: Seen in pleural effusion, pneumothorax, thickened pleura, or airway obstruction.

7. Repeat for All Regions

• Systematically move your hands to each of the areas listed above, always comparing right and left sides.

8. Document Your Findings

• Note any areas where fremitus is increased, decreased, or absent, and specify the location.

How to Measure Spinoacromion Distance

Purpose

• The spinoacromion distance is the distance between the spinous process of a specific vertebra (usually the 7th cervical or a thoracic vertebra) and the tip of the acromion process (the bony prominence at the top of the shoulder).

• It is measured to detect asymmetry, which may indicate volume loss (e.g., fibrosis, collapse) or other pathology affecting one side of the thorax.

Method

1. Position the Patient

   • Ask the patient to sit or stand upright with both arms relaxed at their sides.

2. Identify Landmarks

   • Spinous Process: Palpate and identify the spinous process of the vertebra at the level you want to measure (commonly the 7th cervical [C7] or a prominent thoracic vertebra).

   • Acromion Process: Palpate and identify the tip of the acromion process on the shoulder (the lateral-most point of the scapula).

3. Measurement

   • Use a flexible measuring tape or a ruler.

   • Place one end of the tape at the spinous process (midline of the back).

   • Stretch the tape horizontally to the tip of the acromion process on the same side.

   • Record the distance in centimeters.

4. Repeat on the Other Side

   • Measure from the same spinous process to the acromion process on the opposite side.

5. Compare Both Sides

   • Normally, the spinoacromion distances should be equal or nearly equal on both sides.

   • A decreased distance on one side suggests volume loss (e.g., fibrosis, collapse), while an increased distance may be seen in cases of volume gain (e.g., massive pleural effusion).

Documentation

• Record the measured distances for both the right and left sides.

• Note any significant asymmetry and correlate with clinical findings.