This documentation indicates that the expected sound (vesicular) was heard, specifies where it was heard (majority of the lung fields), notes the absence of any additional (adventitious) sounds, and explicitly mentions some of the specific sounds you listened for but did not hear (wheezing, crackles, rhonchi, stridor). Strictly speaking, wheeze is used for musical lung sounds which are heard at the mouth or at a distance from the patient, whereas rhonchi is reserved for. No wheezing, crackles, rhonchi, or stridor.” Similar to documentation for other body systems, the more specific you can be about where a respiratory abnormality lies, and the quality of the abnormality itself, the better. Resonance is normal upon percussion of all lung fields. “Normal vesicular breath sounds heard over the majority of the lung fields. Lung sounds are clear in all lobes bilaterally without rales, ronchi, or wheezes. This means that you heard the expected breath sounds and there were no abnormal or extra sounds. If lung sounds are normal, they’re often described as “clear to auscultation bilaterally” or “CTAB” (an abbreviation of the same phrase). Normal lung sounds occur in all parts of the chest area, including above the. When charting normal lung sounds, it’s important to be concise, clear, and descriptive. The lung sounds are best heard with a stethoscope. To tell if the sound youre hearing is a wheeze or not, you have to listen to the lungs, Walsh says. Crackles that dont clear after a cough may.
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