Medicine 1 Thorax & Lungs PDF

PCC SOM 2026 MEDICINE 1 M.01 THORAX & LUNGS part II ■ ■ MEDICINE LECTURE: November 7, 2023 LECTURER: Dr. Emelie Grace Bautista-Ojascastro TOPIC OUTLINE I. Examination of the Posterior Chest II. Examination of the Anterior Chest III. Record of Findings GENERAL RULE ❖ Posterior thorax & lungs in si...

PCC SOM 2026 MEDICINE 1 M.01 THORAX & LUNGS part II ■ ■ MEDICINE LECTURE: November 7, 2023 LECTURER: Dr. Emelie Grace Bautista-Ojascastro TOPIC OUTLINE I. Examination of the Posterior Chest II. Examination of the Anterior Chest III. Record of Findings GENERAL RULE ❖ Posterior thorax & lungs in sitting position ➔ Patient's arms folded across the chest with hands resting on the opposite shoulders ❖ Anterior thorax & lungs → in supine position ❖ For patients who cannot sit up ➔ Ask assistance so you can examine the posterior chest in the sitting position. If not possible, roll the patient to one side and then to the other. ❖ Gown draping ➔ Male: expose full chest ➔ Female: cover anterior chest when examining the back; drape the gown over each half of the chest as you examine the other half ❖ Sequence: Inspection, Palpation, Percussion, Auscultation I. Examination of the Posterior Chest INSPECTION: POSTERIOR CHEST Position yourself in the midline position behind the patient. Note the shape of the chest and how the chest moves including the following: 1. Deformities or asymmetry in chest expansion. – Asymmetric lung expansion in large pleural effusion. 2. Abnormal muscle retraction of the intercostal spaces during inspiration, most visible in the lower intercostal spaces. – If retraction occurs, your patient might have severe asthma, COPD or upper airway obstruction. 3. Impaired respiratory movement on one or both sides or a unilateral lag (or delay) in movement. – These would suggest that your patient might have pleural disease from asbestosis or silicosis (a type of pulmonary fibrosis, a lung disease caused by breathing in tiny bits of silica, a common mineral found in sand, quartz and many other types of rock. -lung.org), or your patient might be having phrenic nerve damage or trauma. DEFORMITIES OF THE THORAX a) NORMAL CHEST: ■ Lateral diameter is greater than the antero- posterior diameter. Normal Ratio: 0.7:0.9 (AP:lateral) & increases with aging. The only way to accurately measure the diameter of the thorax is through chest CTscan. However, if you know the deformities of the thorax, you can initially assess it by inspection and not necessarily through chest CT scan. b) BARREL CHEST: ■ There is an increased AP diameter compared to lateral diameter. ■ Shape is usually normal during infancy and often accompanies aging and COPD c) FUNNEL CHEST (Pectus Excavatum) ■ Note the depression on the lower part of the sternum. ■ Compression in this area would compromise your heart and great vessels and might cause murmurs during MOST COMMONLY SEEN IN PEDIATRIC auscultation. WITH CONGENITAL HEART PROBLEM d) PIGEON CHEST (Pectus Carinatum) ■ The sternum is displaced anteriorly hence increasing AP diameter. ■ The costal cartilages adjacent to the protruding sternum are depressed. e) THORACIC KYPHOSCOLIOSIS ■ Abnormal spinal curvatures and vertebral rotation deform the chest. ■ Distortion of the underlying lungs may make interpretation of lung findings very difficult. f) TRAUMATIC FLAIL CHEST ■ Multiple rib fractures that may result in paradoxical movements of the thorax. As descent of the diaphragm decreases intrathoracic pressure, on inspiration the injured area caves inward; on expiration, it moves outward NOTE TAKER: JC ZAY JUDS LOR JANELLE EDMARL SANTIAGO Page 1 | 8 PCC SOM 2026 MEDICINE 1 M.01 THORAX & LUNGS part II PALPATION: POSTERIOR CHEST As we palpate, we have to focus on areas of tenderness or bruising and note for respiratory expansion and fremitus. 1. Identify the tender areas. – carefully palpate any area where the patient reports pain or visible lesions. DOC: “parang sa bubble ● “CREPITUS”: crackling or grinding sound over wrap na napuputok” bones, joints, or skin, with or without pain, due to air in the subcutaneous tissue. ● “FRACTURED RIBS”: tenderness, bruising and bony step-offs 2. Assess any skin abnormalities. – Masses or sinus tracts 3. Test chest expansion. – Place your thumbs at about the level of the 10th ribs, with your fingers loosely grasping and parallel to the lateral rib cage. – As you position your hands, slide them medially just enough to raise a loose fold of skin on each side between your thumb and the spine. 4. Ask the patient to inhale deeply. – Watch the distance between your thumbs as they move apart during inspiration, and feel for the range and symmetry of the rib cage as it expands and contracts. – This movement is sometimes called “lung excursion”. PROCEDURE: (1) Ask the patient to repeat the words “ninety-nine” or “one-one-one”. If fremitus is faint, ask the patient to speak more loudly or in a deeper voice. (2) Use one hand until you have learned the feel of fremitus. Use both hands to palpate and compare symmetric areas of the lung. (3) Asymmetric decreased fremitus occurs in unilateral pleural effusion, pneumothorax, neoplasm due to decreased transmission of low frequency sounds. (4) Asymmetric increased fremitus occurs in unilateral pneumonia (increased transmission through consolidated tissue). TACTILE FREMITUS DETERMINATION: is a somewhat imprecise assessment technique, but it does direct your attention to possible asymmetries. Thumbs not in contact with chest wall Greater than 5 cm PERCUSSION: POSTERIOR CHEST Normal: It would normally expand → it would bring your thumbs apart during inspiration and closer during expiration 5. Palpate both lungs for symmetry tactile fremitus. “FREMITUS” are palpable vibrations transmitted thru the bronchopulmonary tree to the chest wall as the patient is speaking; normally symmetric. – It is typically more prominent in the interscapular area than in the lower lung fields and easier to detect on the right side than on the left. It disappears below the diaphragm. – To detect fremitus, use either: ○ BALL (bony part of the palm at the base of the fingers) ○ ULNAR SURFACE of your hand to optimize vibratory sensitivity of the bones in your hands. – One of the most important techniques of PE. It sets the chest wall and underlying tissues in motion, producing audible sound and palpable vibrations. ■ Helps you establish whether the underlying tissues are air-filled or consolidated. ■ “Percussion blow” penetrates only 5 to 7 cm into the chest, however, and will not aid in detection of deep seated lesions. ■ Position in percussion: stand somewhat to the side. In this position, it is easier to place your pleximeter finger more firmly on the chest, making your plexor strike more effective by creating a better percussion note NOTE TAKER: JC ZAY JUDS LOR JANELLE EDMARL SANTIAGO Page 2 | 8 PCC SOM 2026 MEDICINE 1 M.01 THORAX & LUNGS part II TECHNIQUE FOR A RIGHT-HANDED PERSON 1. Hyperextend the middle finger of your left hand, known as the pleximeter finger. Press its distal interphalangeal joint firmly on the lung surface to be percussed. “PERCUSSION NOTES” a) Use the lightest percussion that produces a clear note. **A thick chest wall requires a more forceful percussion blow than a thin one. b) If a louder note is needed, apply more pressure with the pleximeter finger – NOT THE BLOW. c) When comparing two areas, use the same percussion technique in both areas. Percuss or strike twice in each location and listen for differences in the percussion notes at the two locations. d) Learn to identify five percussion notes. Pointed by Dr. Ojascastro on the left image is the distal interphalangeal joint (DIJ) of the pleximeter finger (middle finger). On the right image, Dr. is showing how to properly press the DIJ on the surface of the skin to be percussed. NOTE: Avoid surface contact by any outer part of the hand because this dampens out vibrations. Note that the thumb and 2nd, 4th and 5th fingers are not touching the chest. 2. Position your right forearm quite close to the surface, with the hand cocked upward. The middle finger should be partially flexed, relaxed, and poised to strike You can practice four of them on yourself. These notes differ in their basic qualities of sound: intensity, pitch and duration. Train your ear by concentrating on one quality at a time as you percuss first in one location, then in another. Healthy lungs are resonant. NOTE: For the left-handed, switch the roles of the fingers such that the middle finger of the nondominant hand (right) shall serve as the pleximeter while the middle finger of the dominant hand (left) shall be the plexor. However, this is not a general rule. You may always choose to do it in the comfortable position that you think is most effective. :) o PLEXIMETER = the finger placed on the surface of the skin o PLEXOR = the one that strikes 3. **DULLNESS ➔ Fluid or solid tissue replaces air containing lung or occupies the pleural space beneath your percussing fingers. ➔ Examples: ✓ Lobar pneumonia → alveoli are filled with fluid and RBC ✓ Pleural effusion ✓ Hemothorax ✓ Empyema ✓ Fibrous tissue ✓ Tumor With a quick, sharp but relaxed wrist motion, strike the pleximeter finger with the right middle finger, called the plexor finger. Aim at your distal interphalangeal joint. **HYPERRESONANCE ➔ Generalized hyperresonance: hyperinflated lungs of COPD or asthma ➔ Unilateral hyperresonance: large pneumothorax or an air-filled bulla. NOTE: Goal is to transmit vibrations through the bones of this joint to the underlying chest wall. Use the same force for each percussion strike and the same pleximeter pressure to avoid changes in the percussion note due to your technique rather than underlying STEPS ON PERCUSSION NOTES findings. 4. 5. Strike using the tip of the plexor finger, NOT the finger pad. The striking finger should be almost at right angles to the pleximeter. NOTE: A short fingernail is recommended to avoid injuring your knuckle. Withdraw your striking finger quickly to avoid damping the vibrations you have created. Remember: The movement is at the wrist. It is directed, Brisk yet relaxed, and slightly bouncy. 1. While the patient keeps both arms crossed in front of the chest, percuss the thorax in symmetric locations on each side from the apex to the base. 2. Percuss one side of the chest and then the other at each level in a ladder-like pattern (as shown on the figure). Identify the area and quality of any abnormal percussion note. NOTE TAKER: JC ZAY JUDS LOR JANELLE EDMARL SANTIAGO Page 3 | 8 PCC SOM 2026 3. MEDICINE 1 M.01 THORAX & LUNGS part II Identify the descent of the diaphragm or diaphragmatic excursion. – Identify the boundary between the resonant lung tissues and the other structures below the diaphragm. ● You are not percussing the diaphragm itself. You are just determining the boundaries of the chest wall and the lower parts of the diaphragm. – Determine the level of diaphragmatic dullness during quiet respiration. ● Holding the pleximeter finger above and parallel to the expected level of dullness, percuss downward in progressive steps until dullness clearly replaces resonance. Confirm this level of change by percussing downward from adjacent areas both medially and laterally. – ● Estimate the extent of diaphragmatic excursion. Determine the distance between the level of dullness on full expiration and the level of dullness on full inspiration, normally about 3-5.5 cm. You can watch: https://www.youtube.com/watch?v=gRWSyqatWQQ Sample video from the recorded lecture. Direct to 6:33s to 6:55s part of the video. Use of earphones is advised. TYPES OF PERCUSSION NOTES: a) Resonant: Normal b) Dullness: Consolidation or collapse c) Stony dullness: Pleural effusion d) Hyperresonant: Pneumothorax AUSCULTATION: POSTERIOR CHEST ■ ■ Most important examination technique for examining airflow It involves: 1) Listening to the sounds generated by breathing. 2) Listening for any adventitious (added) sounds. 3) Listening to the sounds of the patient’s spoken or whispered voice (if abnormalities are suspected). ■ TIPS ON AUSCULTATION 1) Ask the patient to cough once or twice to clear mild atelectasis or airway mucus that can produce unimportant extra sounds. 2) Use the “diaphragm side” of the stethoscope. 3) Instruct the patient to breathe deeply through an open mouth. 4) Always place the stethoscope directly on the skin. Rationale: Clothing alters the characteristics of the breath sounds and can introduce friction and added sounds. 5) Use the “ladder pattern.” Listen to at least one full breath in each location. If you hear or suspect abnormal sounds, auscultate adjacent areas to assess the extent of any abnormality. 6) If the patient becomes lightheaded from hyperventilation, allow the patient to take a few normal breaths. 7) Note of the intensity of the breath sounds. a. BREATH SOUNDS are usually louder in the lower posterior lung fields. b. If the breath sounds seem faint, ask the patient to breathe more deeply. c. Shallow breathing or a thick chest wall can both alter breath sound intensity. d. Decreased breath sounds expected in: ● Obstructive lung disease ● Respiratory muscle weakness e. No breath sounds (poorly transmitted breath sounds). Examples: Pleural effusion; Pneumothorax; COPD f. Listen for pitch, intensity and duration of the inspiratory and expiratory sounds. NORMAL BREATH SOUNDS Only normal when located in their normal locations; nonetheless may be pathologic. 1) Vesicular: soft and low pitched; heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration. 2) Bronchovesicular, with inspiratory and expiratory sounds about equal in length, are at times separated by a silent interval. Detecting differences in pitch and intensity is often easier during expiration. 3) Bronchial: louder, harsher and higher in pitch, with a short silence between inspiratory and expiratory sounds. Expiratory sounds last longer than inspiratory sounds. 4) Tracheal: loud harsh sounds heard over the trachea in the neck In cold or tense patients, watch for muscle contraction sounds— muffled, low-pitched rumbling, or roaring noises. Changing the patient’s position may eliminate this noise. To reproduce these sounds on yourself, do a Valsalva maneuver (straining down) as you listen to your own chest. NOTE TAKER: JC ZAY JUDS LOR JANELLE EDMARL SANTIAGO Page 4 | 8 PCC SOM 2026 MEDICINE 1 M.01 THORAX & LUNGS part II Sample sounds continuation… FINE CRACKLES They have a shorter duration and higher frequency. COARSE CRACKLES They have a longer duration and lower frequency, change or disappear with coughing, and are transmitted to the mouth. Generated by the “sudden inspiratory opening of small airways held closed by surface forces during the previous expiration.” Results from “boluses of gas through airways as they open and close intermittently.” Ex: Pulmonary fibrosis and interstitial lung diseases (interstitial fibrosis and interstitial pneumonitis) Ex: Include COPD, asthma, bronchiectasis, pneumonia, and heart failure. https://www.youtube.com/watch?v=LHqqvrm2j6g https://www.youtube.com/watch?v=aSor2XBc9K8 Thickness of bars indicates intensity; Steeper incline = higher the pitch NOTE: If bronchovesicular or bronchial breath sounds are heard in locations distant from those listed, suspect that air-filled lung has been replaced by fluid-filled or solid lung tissue. 2) WHEEZES https://www.youtube.com/watch?v=T4qNgi4Vrvo ADVENTITIOUS OR ADDED BREATH SOUNDS 1) CRACKLES (or RALES) ➔ Discontinuous non-musical sounds that can be early inspiratory (as in COPD), late inspiratory (as in pulmonary fibrosis) or biphasic (as in pneumonia) ➔ Results from a series of tiny explosions when small distal airways, deflated during expiration, pop open during inspiration. ➔ Listen carefully for the following characteristics: 1. Loudness, pitch and duration (fine or coarse crackles) 2. Number (few to many) 3. Timing in the respiratory cycle 4. Location on the chest wall 5. Persistence of their pattern from breath to breath 6. Any change after a cough or change in the patient’s position. FINE CRACKLES Softer, higher pitched & more frequent per breath. COARSE CRACKLES Appear in early inspiration & last throughout expiration (biphasic). Mid to late inspiration, esp. Popping sound, are heard over any in the dependent areas of lung region, & do not vary with the lung. body position. Change according to body position. ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ “continuous” musical sounds that occur during rapid airflow when bronchial airways are narrowed almost to the point of closure. Wheezes can be inspiratory, expiratory, or biphasic. They may be localized (due to a foreign body, mucous plug, or tumor) or heard throughout the lung. Wheezes are typical of asthma, they can occur in a number of pulmonary diseases. “Silent asthma” is a clinical emergency. As the airways become narrower, this has become less audible, culminating finally in the silent chest. Seen in severe asthma that would require immediate intervention. Wheezes suggest narrowed airways, as in asthma, COPD, or bronchitis. 3) RONCHI https://www.youtube.com/watch?v=T4qNgi4Vrvo ➔ a variant of wheezes, arising from the same mechanism, but lower in pitch. ➔ Unlike wheezes, rhonchi may disappear with coughing, so secretions may be involved. ➔ Rhonchi suggest secretions in large airways. NOTE TAKER: JC ZAY JUDS LOR JANELLE EDMARL SANTIAGO Page 5 | 8 PCC SOM 2026 MEDICINE 1 M.01 THORAX & LUNGS part II CRACKLES (or Rales) WHEEZES & RONCHI Discontinuous Continuous Intermittent, nonmusical and brief > 250 msec, musical, prolonged (but not necessarily persisting throughout the respiratory cycle) Like dashes in time Wheezes: relatively high-pitched Fine crackles: soft, high-pitched, (>400Hz) with hissing or shrill very brief (5-10 msec) quality Coarse crackles: somewhat Rhonchi: relatively low-pitched louder, lower in pitch, brief (<200Hz) with snoring quality (20-30 msec) TRANSMITTED VOICE SOUNDS 1) EGOPHONY ➔ Ask the patient to say “ee.” ➔ Normal = hear a muffled long E sound. ➔ Egophony = If “ee” sounds like “A” and has a nasal bleating quality, an E-to-A change Like dots in time 4) STRIDOR https://www.youtube.com/watch?v=JSdEK79J4dw ➔ a continuous, high-frequency, high pitched musical sound produced during airflow through a narrowing in the upper respiratory tract. ➔ stridor is best heard over the neck during inspiration, but can be biphasic. ➔ Causes of the underlying obstruction include tracheal stenosis from intubation, edema after device removal, epiglottitis, presence of foreign body, and anaphylaxis. ➔ Immediate intervention is warranted. 2) BRONCHOPHONY ➔ Ask the patient to say “ninety-nine.” ➔ Normal = the sounds transmitted through the chest wall are muffled and indistinct. ➔ Bronchophony = Louder voice sounds are called 3) WHISPERED PECTORILOQUY ➔ Ask the patient to whisper “ninety-nine” or “one-twothree.” ➔ Normall = whispered voice is heard faintly and indistinctly, if at all. ➔ Whispered pectoriloquy = Louder, clearer whispered sounds CONSOLIDATES NORMAL AIR– AIRLESS LUNG FILLED LUNG (Lobar Pneumonia) 5) PLEURAL RUB ➔ A discontinuous, low frequency, grating sound that arises from inflammation and roughening of the visceral pleura as it slides against the parietal pleura. ➔ This non-musical sound is biphasic, heard during inspiration and expiration, and often best heard in the axilla and base of the lungs. 6) MEDIASTINAL CRUNCH (Hamman Sign) ➔ Series of precordial crackles synchronous with the heartbeat, not with respiration. ➔ best heard in the left lateral position, it arises from air entry into the mediastinum causing mediastinal emphysema (pneumomediastinum). ➔ It usually produces severe central chest pain and may be spontaneous. ➔ It has been reported in cases of tracheo- bronchial injury, blunt trauma, pulmonary disease, and use of recreational drugs during childbirth and rapid ascent from scuba diving Breath Sounds Trans– mitted Voice Sounds Tactile Fremitus Notes NOTE: To distinguish the different adventitious breath sounds from one another → focus on pitch, intensity, and duration where it occurs (inspiratory, expiratory, or biphasic) + remember where it is commonly located. NOTE TAKER: JC ZAY JUDS LOR JANELLE EDMARL SANTIAGO Predominantly vesicular Spoken word muffled & indistinct; Bronchial or bronchovesicular over the involved area. Spoken “ee” heard as “ay” (egophony); Spoken “ee” heard as “ee”; Spoken words louder (bronchophony); Whispered words faint Whispered words and indistinct, if heard louder, clearer at all. (whispered Pectoriloquy) Normal Increased In the hyperinflated lung of COPD, breath sounds are decreased (muffled to distant) to absent & transmitted voice sounds, and fremitus are decreased. In the dull lung of pleural effusion, breath sounds are decreased to absent (bronchial sounds possible at upper margin of effusion). Transmitted voice sounds are decreased to absent (but may be increased at Upper margin of effusion). Fremitus has decreased. Page 6 | 8 PCC SOM 2026 MEDICINE 1 M.01 THORAX & LUNGS part II 4) Assessment of tactile fremitus. – Compare both sides of the chest, using the ball or ulnar surface of your hand. – Fremitus is usually decreased or absent over the precordium because of the presence of the heart. – When examining a woman, gently displace the breasts as necessary. II. Examination of the Anterior Chest Examination of the anterior chest is best done when the patient is at supine position. • The px should lie comfortably with arms somewhat abducted. • If the px is having difficulty in breathing, raise the head of the examining table or the bed, to increase respiratory excursion and ease of breathing. • You can also examine a patient having difficulty breathing in the sitting position. PERCUSSION: ANTERIOR CHEST INSPECTION: ANTERIOR CHEST Observe the shape of the patient’s chest and the movement of the chest wall. NOTES 1) Deformities or asymmetry of the thorax. 2) Abnormal muscle retraction of the intercostal spaces during inspiration, or any supraclavicular retraction. – Abnormal retraction occurs in severe asthma, COPD, or upper airway obstruction. 3) Local lag or impairment in respiratory movement. – Underlying disease of lung or pleura. Percuss the anterior and lateral chest, again comparing both sides. • • • PALPATION: ANTERIOR CHEST • 1) Identification of tender areas. – Tender pectoral muscles or costal cartilages suggest, but do not prove, that chest pain has a musculoskeletal origin. Percuss for liver dullness and gastric tympany. • 2) Assessment of bruising, sinus tracts, or other skin changes. 3) Assessment of chest expansion. – Place your thumbs along each costal margin, your hands along the lateral rib cage. – As you position your hands, slide them medially a bit to raise loose skin folds between your thumbs. – Ask the patient to inhale deeply. – Observe how far your thumbs diverge as the thorax expands, and feel for the extent and symmetry of respiratory movement. Dullness to the left of the sternum from the 3rd to the 5th interspace: “the heart” Lungs should be resonant, but in the area where the heart is, there is dullness (which is normal). Dullness replaces resonance when fluid or solid tissue replaces air-containing lungs or occupies the pleural space. – Because pleural fluid usually sinks to the lowest part of the pleural space (posteriorly in a supine patient), only a very large effusion can be detected anteriorly. In a woman, to enhance percussion, gently displace the breast with your left hand while percussing with the right. – Alternatively, you may ask the patient to move her breast for you. – Identify and locate any area with an abnormal percussion note. • • With your pleximeter finger above and parallel to the expected upper border of liver dullness → percussed in progressive steps downward in the right midclavicular line → resonance normally changes to dullness due to the presence of liver. As you percuss down the chest on the left, the resonance of normal lungs usually changes to the tympany of the gastric air bubble. A lung affected by COPD often displaces the upper border of the liver downward and lowers the level of diaphragmatic dullness posteriorly. NOTE TAKER: JC ZAY JUDS LOR JANELLE EDMARL SANTIAGO Page 7 | 8 PCC SOM 2026 MEDICINE 1 M.01 THORAX & LUNGS part II INSPECTION: ANTERIOR CHEST Listen to the chest anteriorly and laterally as the px breathes with mouth open and somewhat more deeply than normal. Compare symmetric areas of the lungs using the pattern suggested for percussion (ladder-like pattern) and extending it to adjacent areas if indicated. • Listen to the breath sounds. o Breath sounds are usually louder in the upper anterior lung fields. Bronchovesicular breath sounds may be heard over the large airways, especially on the right. • Identify any adventitious sounds. o Time them in the respiratory cycle and locate them o Do they clear with deep breathing? • If indicated, listen for transmitted voice sounds. NOTE: Examination of the anterior and posterior chest wall is just the same. However, in examining the anterior chest wall, we just have to be concerned about the presence of the breast, the location of the heart, the dullness of the liver, and the tympanitic sound heard on the stomach area. III. RECORD OF FINDINGS **Record your findings as you see them. ** 1) Initial Survey → What is your respiratory assessment? → Are there any respiratory distresses? 2) Write your findings as to inspection, palpation, percussion, and auscultation. → When you record findings, it would be best to also record the normal findings and the abnormal findings together. SAMPLE: • “Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular, no crackles, wheezes, or rhonchi. Diaphragm descends 4 cm bilaterally.”. • “Thorax symmetric with moderate kyphosis and increased AP diameter, decreased expansion. Lungs are hyper resonant. Breath sounds distant with delayed expiratory phase and scattered expiratory wheezes. Fremitus decreased; no bronchophony, egophony, or whispered pectoriloquy. Diaphragms descend 2 cm bilaterally.” (These findings suggest COPD). NOTE TAKER: JC ZAY JUDS LOR JANELLE EDMARL SANTIAGO Page 8 | 8