chest examination

2009/2010

Clinical Examination of the Chest !!

Manish Prabhakar

1

2009/2010


Manish Prabhakar

2

Personal History: As before, but put stress on the following points

Occupation: e.g.

– Silicosis which may be complicated by pulmonary T.B.

– Asbestosis which may be complicated by mesothelioma

In this respect it is important to ask about the following:

1-Duration of exposure: several years are needed for

pneumoconiosis to develop.

2- Adherence to safety measures as wearing special masks during

work to prevent inhalation of the dust.

Special Habits of medical importance especially smoking

cigarettes, shesha and goza.

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Manish Prabhakar

3

The six cardinal symptoms of chest diseases are:

1- Cough

2- Expectoration (sputum)

3- Hemoptysis

4- Chest pain

5- Dyspnea

6- Wheezes

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Manish Prabhakar

4

Other symptoms of importance in chest diseases or may

point to the possibility of the presence of a chest disease include:

1- Symptoms suggestive of mediastinal syndrome as dysphagia

and hoarseness of voice.

2- Symptoms suggestive of toxemia as night fever, night sweats,

loss of appetite and weight as in T.B.

3- Symptoms suggestive of RVF as LLs edema and pain in the

RUQ of the abdomen ( due to congested tender liver).

4- Fever as in upper and lower resp. tract infections.

Finally any other symptoms related to other systems.

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Manish Prabhakar

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Attack or disease similar to the present one:

e.g. - Asthma.

- Recurrent pneumonia

Allergic disorders: like eczema, urticaria,

angioedema and hay fever.

Acute abdominal conditions.

Admission in any hospital before and why?

Bilharziasis: bilharzial cor pulmonale.

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Chest injuries and operations.

Other Surgical Procedures.

Coma , convulsions….may predispose toaspiration lung abscess

Cardiac diseases and history of rheumaticfever.

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Manish Prabhakar

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Diabetes mellitus

Hypertension and history of intake ofantihypertensive drugs. Cough may result from ACE

inhibitors

T.B and history of admission to a chesthospital for treatment of T.B. Name of the medicines,

duration of the treatment and the adherence to it should beenquired about.

Previous radiological examination: comparison

with the current radiograph may be valuable in diagnosis.

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Similar condition in the family.

History of T.B.

History of allergy as eczema and hay fever.

History of DM

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Ask about the following:

The frequency

The severity

Dry or productive

Time of occurrence

Relation to posture

Character of cough (better observed by the physician)

Cough

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Sputum

Amount

Color

Character (seous, mucoid,purulent and mucopurulent)

Odor

Relation to posture

What increases or decreases it

Associated conditions

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Hemoptysis1:The most important causes of hemoptysis are

•Mitral stenosis

•Pulm tuberculosis

•Pulm infarction

•Brochiectasis

•Bronchogenic carcinoma

•Bronchial adenoma

•Bleeding tendency

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Manish Prabhakar

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1st differentiate between hemoptysis and hematemesis

2nd ask about :

•Type and Degree

•Frequency and Duration

3rd ask about the preceding events e.g. DVT or

chest infection

Hemoptysis2:

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Type and Degree

Hemoptysis3:

•Frank hemoptysis

•Blood-stained sputum

•Blood streaked sputum

•Rusty sputum

Frequency and duration

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Chest pain: as elsewhere ask about

The onset..

Site.

Character.

Radiation.

What brings or increases the pain and conversely what

relieves or decreases it.

The associated symptoms.

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Manish Prabhakar

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Wheeze

What dose the patient mean by wheezing?

You should be able to differentiate between

wheeze and stridor.

Wheezing may be intermittent as in asthma or

persistent as in chronic bronchitis.

Wheezing may be diffuse as in asthma and

chronic bronchitis or localized as in

bronchogenic carcinoma.

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Inspection

Palpation

Percussion

Auscultation

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Local examination of the chest

1-Shape of the chest.

2-Spine Deformity

3-Symmetry and Mobility

4-Respiratory movements

5-Skin

6-Pulsations

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1- Shape of the chest

Normal Shape

Barrel shaped chest

Pigeon chest

Rachitic chest

Funnel-shaped chest (Pectus Excavatum)


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Local examination of the Chest

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2-


Inspection

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2-


Inspection

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3-

Both sides of normal chest are

symmetrical in shape and mobility.

The diseased side or part is less

mobile than the healthy one.


Inspection

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3-


Inspection

Bulgiong Retraction

•Pleural effusion

•Pneumothorax

•Hydropneumothorax

•Empyema

•Precordial bulge

•Chest wall causes

•Pulmonary collapse

•Pulm. Fibrosis

•Pleural fibrosis

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Inspection

4-

Respiratory rate

Mode of Breathing

Respiratory Depth

Maximum Chest Expansion ( use a tape measure)

Abnormal Respiratory Movements

- Abnormal Inspiratory Movements

- Abnormal Expiratory Movements

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5-


Inspection & Palpation

Skin eruption e.g HZ

Nodules (inflammatory,metastatic,lipoma, neurofibroma…)

Subcutaneous emphysema

Purpuric spots,Vascular spiders, Bruises

Prominent bl vessels (arterial in coarctation of aorta and venous in SVC obstruction)

Scars (previous operation,trauma, intercostal tube…)

Discharging sinuses

Lesions of the breasts and enlargement of axillary LNs

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6-


Inspection & Palpation

Apical

Parasternal

Epigastric

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To confirm Respiratory Movements

Pulsations (see before)

Palpable Adventitious Sounds

Tactile Vocal Fremitus (TVF)

Position of the Trachea

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1. Respiratory movements in the

infraclavicular regions

2. Respiratory movements at the costal

margins

3. Respiratory movements of the lower ribs

posteriorly

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Palpation:Resp Movements

Unilateral reduction of chest wall movements•Pleural effusion

•Empyema

•Pneumothorax

•Pulmonary consolidation

•Pulmonary collapse

•Pleural or parenchymatous pulmonary fibrosis

Bilateral reduction of chest wall movements•Bronchial asthma

•Emphysema

•Diffuse pulmonary fibrosis

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Palpation

How to test for TVF?

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Local examination of the Chest: Palpation

Increased TVF Decreased TVF

•Consolidation

•Cavitation

•Collapse with patent main

bronchus

•Thick chest wall

•Pleural effusion

•Pleural fibrosis

•Pneumothorax

•Emphysema

•Collapse

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Palpable Rhonchi

•Diffuse

•Localized and Persistent

Palpable Pleural Rub

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How to test for the position of the

trachea?

Trill’s sign:Bulging of the sternomastoid

muscle in front of the deviated trachea.

To evaluate the position of the upper mediastinum.

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Causes of deviation of the trachea

Ipsilateral

(To pull)

Contralateral

( To push)

•Collapse

•Fibrosis

•Apical mass

•Pleural effusion

•Pneumothorax

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Cut your nails

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1. Percuss from side to side

and top to bottom using

the pattern shown in the

illustration.

2. Compare one side to the

other looking for

asymmetry.

3. Note the location and

quality of the percussion

sounds you hear.

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1. Percuss from side to side and

top to bottom using this

pattern. Omit the areas covered

by the scapulae.

2. Compare one side to the other

looking for asymmetry.

3. Note the location and quality of the

percussion sounds you hear.

4. Find the level of the diaphragmatic

dullness on both sides.

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1. Find the level of the diaphragmatic dullness on

both sides.

2. Ask the patient to inspire deeply.

3. The level of dullness (diaphragmatic excursion)

should go down 3-5cm symmetrically.

4. Decreased or asymmetric diaphragmatic

excursion may indicate paralysis or emphysema.

Local examination of the chest: percussion

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1. It is used to differentiate supra-diaphragmatic from

infra-diaphragmatic dullness.

2. While the patient seated find the upper level of

dullness

3. Ask the patient to take deep inspiration and to hold it

then percuss again.

4. If the note becomes resonant infra-diaphragmatic

cause.

5. If there is no change of the note supra-diaphragmatic

cause as pleural effusion.

Local examination of the chest: percussion

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Intensity of breath sounds

Type of breath sounds

Adventitious sounds

Voice sounds (vocal resonance)

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•While the patient relaxed and breathes normally with

mouth open, auscultate the lungs, making sure to auscultate

the apices and middle and lower lung fields posteriorly,

laterally and anteriorly.

•Alternate and compare both sides at each site.

•Listen to at least one complete respiratory cycle at each site.

•First listen with quiet respiration. If breath sounds are

inaudible, then have him take deep breaths.

•First describe the breath sounds and then the adventitious

sounds.

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•Note the intensity of breath sounds and make a

comparison with the opposite side.

•Assess length of inspiration and expiration. Listen for a

pause between inspiration, expiration and the quality of

pitch of the sound

•Also compare the intensity of breath sounds between

upper and lower chest in upright position. Compare the

intensity of breath sounds from dependent to top lung in

the decubitus position.

•Note the presence or absence of adventitious sounds.

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The normal breath sounds heard over the lung

tissue are called vesicular breathing.

The vesicular breathing is heard over the lungs,

lower pitched and softer than bronchial breathing.

Expiration is shorter (I > E) and there is no pause

between inspiration and expiration.

The breath sounds are symmetrical and louder in

intensity in bases compared to apices in erect

position and dependent lung areas in decubitus

position.

No adventitious sounds are heard.

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The breath sounds heard over the tracheobronchial

tree are called bronchial breathing.

The only place where tracheobronchial trees are

close to chest wall without surrounding lung tissue

are trachea, right sternoclavicular joints and posterior

right interscapular space. These are the sites where

bronchial breathing can be normally heard. In all

other places there is lung tissue and vesicular

breathing is heard.

The bronchial breath sounds have a higher pitch,

louder, inspiration and expiration are equal and there

is a pause between inspiration and expiration.

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A prolonged expiratory phase (E > I)

indicates airway narrowing, as in:


Bronchial asthma.

Chronic bronchitis

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Bronchial breathing may be heard in

pathological conditions as:

Consolidation

Collapse with patent large airways

Compressed lung by a large pl effusion or a

tension pneumothorax

Pulmonary fibrosis

Cavitation

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Crepitations: types

Rhonchi: sibilant and sonorous

Pleural rub

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Voice Transmission Tests: are only used in special

situations. All these tests become abnormal in

consolidation. They include:

Bronchophony

Whispered Pectoriloquy

Egophony

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1. Ask the patient to say "ninety-nine“ or 44 in

arabic several times in a normal voice.

2. Auscultate several symmetrical areas over

each lung.

3. The sounds you hear should be muffled and

indistinct. Louder, clearer sounds are

called bronchophony.

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1. Ask the patient to whisper "ninety-nine“ or 44

in arabic several times.


each lung.

3. You should hear only faint sounds or nothing

at all. If you hear the sounds clearly this is

referred to as whispered pectoriloquy.

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1. Ask the patient to say "ee" continuously.


each lung.

3. You should hear a muffled "ee" sound. If you

hear an "ay" sound this is referred to as

"E -> A" or egophony.

chest examination

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