History Taking & Chest Examination

Dr. Waseem HAJJAR, MD. FRCS.

Assistant professor &

Consultant Thoracic Surgeon

A good history should be both:

Concise.

Cover the important points.

Rules:

1. Patient should be allowed to tell his history in his own words.

2. Leading questions must be avoided unless the information can’t be obtained by other means

Questions:

1. Complete the immediate description.

2. Elucidate the vague points.

3. Fill in the gaps the history not mentioned by patient.

4. Emphasize the important points.

Types of questions:

1. Neutral questions.

2. Simple direct questions (yes/No).

3. Leading questions.

WHAT SHOULD WE KNOW ABOUT THE EXAMINATION OF THE CHEST?

• HISTORY• SYMPTOMS • LANDMARKS• PERTINENT VOCABULARY • SIGNS• HOW TO PERFORM AN EXAM• HOW TO PRESENT THE INFORMATION • HOW TO FORMULATE A DIFFERENTIAL DIAGNOSIS

Personal data:

Name. Age. Sex. Occupation. Residence.

The patients complaint:

A simple statement in the patients own words and its duration.

HISTORY

Present History:

This means detailed history of the patients present illness which must provide answer for the following questions:

1. Duration

2. Mode of onset (acute, sub acute, chronic).

3. Sequence of events:I. Course (progressive, regressive or recurrent).

II. Appearance of new additional symptoms or disappearance of others.

III. Treatment received during the course & response.

4. Analysis of each particular symptom.

History

Acute/chronic disorder Preceding systemic disturbance Past medical history Drug history Social history Family history Occupational history

Past History:

Childhood diseases. Trauma. Residences or travel abroad. Drug therapy. Operations.

THE HISTORY

FAMILY HISTORY EMPHYSEMA AT AN EARLY AGE - CONSIDER

ALPHA – 1 ANTITRYPSIN RECURRENT RESPIRATORY INFECTIONS AND

STERILITY IN A YOUNG ADULT MALE – CONSIDER CYSTIC FIBROSIS, IMMOTILE CILIA OR YOUNG’S SYNDROME

PULMONARY NODULE AND HYPOXEMIA – CONSIDER OSLER WEBER RENDU

Family History:

Hereditary factor. Exposure to same etiological circumstances.

THE HISTORY

OCCUPATIONAL - CHRONOLOGIC ORDER EXPOSURE : BRAKE SHOES, PIPE FITTERS (ASBESTOS) SANDBLASTING, QUARRY (SILICOSIS) FARMING – (FARMERS LUNG) MILITARY – (BERYLLIOSIS) TRAVEL- FAR EAST (PARAGONIMIASES) SOUTH AMERICA (BRUCELLOSIS) SOUTHWEST USA (COCCIDIOMYCOSIS) DRUGS – INTERSTITIAL LUNG DISEASE

(NITROFURANTOIN) HABITS – TOBACCO, NOSE DROPS, ILLICIT DRUGS

Habits:

Smoking. Physical efforts. Addiction.

SYMPTOMS

History

Dyspnoea Wheeze Cough Sputum Haemoptysis Chest pain

MAIN SYMPTOMS OF PULMONARY DISEASE

COUGH DYSPNEA HEMOPTYSIS CHEST PAIN – PLEURITIC WHEEZING CYANOSIS SPUTUM PRODUCTION SNORING

LUNG

KIDNEY

SPLEENLIVER

SKIN

BRAIN

HEART

DESCRIBE THE COUGH

PRODUCTIVE – NONPRODUCTIVE ACUTE – CHRONIC TIME OF DAY PRECIPITANTS – RELIEF BLOODY – NON BLOODY BARKING – HACKY

COUGH

SYMPTOM

MORNING

NON-PRODUCTIVE

RECUMBENT

BARKING

NOCTURNAL

PRODUCTIVE

BLOODY

ETIOLOGY

CHRONIC BRONCHITIS

VIRAL, ILD,TUMOR

SINUSITUS, CHF,REFLUX

CROUP,LARYNGEAL

ASTHMA, CHF

INFECTIOUS

TUMOR,CHF

THE PNEA’S

DYSPNEA – SOB : ACUTE – (PULMONARY EMBOLISM, PNTX, ASTHMA) CHRONIC – (COPD, CHF, ILD) TACHYPNEA – RR>20 BR/MIN BRADYPNEA - RR< 8 BR/MIN (DRUGS, AGONAL) PND - PAROXYSMAL NOCTURNAL DYSPNEA SUDDEN

ONSET OF SOB DURING SLEEP (CHF) ORTHOPNEA – SOB LYING FLAT (CHF) PLATYPNEA – SOB SITTING UP AND BETTER LYING FLAT

(R TO L SHUNT) TREPOPNEA – SHORTNESS OF BREATH IN ONE LATERAL

DECUBITUS POSITION WHICH IS IMPROVED BY TURNING ON THE OPPOSITE SIDE

DYSPNEA

MY CHEST FEELS TIGHT I CANNOT TAKE A DEEP BREATH I FEEL LIKE I HAVE A PILLOW OVER MY

MOUTH I AM SMOTHERING

THE NUMEROUS ETIOLOGIES OF CHEST PAIN PLEURITIC – PARIETAL PLEURA – SHARP

STABBING – INSPIRATION ESOPHAGEAL – REFLUX CARDIAC – MYOCARDIAL INFARCTION GALL BLADDER – CHOLECYSTITIS CHEST WALL – COSTOCHONDRITIS GREAT VESSELS – DISSECTION PULMONARY - PNEUMOTHORAX

SPUTUM - WHAT ARE ITS CHARACTERISTICS ?

YELLOW – GREEN (PNEUMONIA, BRONCHIECSTAIS) RUSTY (PNEUMOCCOAL PNEUMONIA) ANCHOVY PASTE (AMEBIASIS) PINK – BLOOD TINGED (EPISTAXIS, BRONCHITIS) FROTHY (CHF) BLOODY (MALIGNANCY, BRONCHIECSTASIS,

PULMONARY RENAL SYNDROME) SMELL – FOUL? (ANAEROBIC LUNG ABCESS) SANDLIKE (BRONCHOLITHIASIS) BLACK – COAL DUST INHALATION

HEMOPTYSIS - REQUIRES CAREFUL QUESTIONING THIS SYMPTOM USUALLY DENOTES A

SERIOUS ILLNESS. TB, TUMOR, BRONCHIECSTASIS, PE, CARDIAC DISEASE

THE PATIENT SHOULD BE QUESTIONED CAREFULLY REGARDING HOW MUCH, FREQUENCY WEIGHT LOSS ETC.

CLUES TO DIFFERENTIATING HEMOPTYSIS FROM HEMATEMESIS

HEMOPTYSIS

COUGH

FROTHY

COLOR- BRIGHT RED

PUS

DYSPNEA

CARDIAC DISEASE

HEMATEMESIS

NAUSEA – VOMITING

NOT FROTHY

COFFEE GROUNDS

FOOD

NAUSEA

GI DISEASE

THE PULMONARY EXAMINATION

SIGNS

WHAT SHOULD WE KNOW ABOUT THE EXAMINATION OF THE CHEST?

HISTORY SYMPTOMS LANDMARKS PERTINENT VOCABULARY SIGNS HOW TO PERFORM AN EXAM HOW TO FORMULATE A DIFFERENTIAL DIAGNOSIS HOW TO PRESENT THE INFORMATION

TOPOGRAPHY OF THE CHEST

TOPOGRAPHY OF THE BACK

The Chest

Inspection Palpation Percussion Auscultation

Inspection of the chest

Important:

- SHAPE

- MOVEMENT

- VISIBLE PULSATIONS!

SHAPE of the chest:

Deformities: - kyphosis

- scoliosis

- depressed sternum (pectus excavatum)

- bulges in left parasternal area

(congenital malformation)

e.g. VSD

of the thorax

Chest wall

Pectus carinatum Pectus excavatum

Pectus Excavatum

Inspection

Shape Scars Lesions Resp rate Resp depth Mode of breathing Abnormal inspiratory movements Abnormal expiratory movements Asymmetry of movement

Nicotine staining

2 liters of O2

BARREL CHEST

Barrel Chest

AP Diameter = Transverse Diameter

PALPATION

FEELING WITH THE HAND – FINGERTIPS TEXTURES DIMENSIONS CONSISTENCY TEMPERATURE

Palpation

Chest expansion Tactile vocal fremitus

Chest Expansion

Chest Expansion

Chest Expansion

Trachea exam

Percussion

Illustrate resonance Compare both sides Map out abnormal area

METHODS OF PERCUSSION

DIRECT INDIRECT

DISEASE A MONTH 41;643-692:1995

METHODS OF PERCUSSION

METHODS OF PERCUSSION

Percussion

Impaired(dull)resonance obtained – Aerated lung tissue is separated from the

chest wall e.g. fluid, pleural thickening Lung tissue is airless e.g. consolidation,

collapse, fibrosis

“stony dullness”- pleural effusion

Hyperresonance - pneumothorax

Percussion technique

Place left hand on chest wall, palm downwards with fingers separated

2nd phalanx over area of intercostal space Right middle finger strikes the 2nd phalanx

producing hammer effect Entire movement comes from wrist

PERCUSSION SOUNDS

TYMPANY – HEARD OVER THE ABDOMEN RESONANCE – HEARD OVER NORMAL

LUNG DULLNESS – HEARD OVER LIVER OR

THIGH

Auscultation

Breath sounds Added sounds Vocal sounds (vocal resonance)

AUSCULTATORY PERCUSSION

METHOD THE STETHOSCOPE IS PLACED OVER

THE POSTERIOR CHEST WALL, THE CLINICIAN THEN TAPS LIGHTLY OVER THE MANUBRIUM, EQUIVALENT SOUNDS SHOULD BE HEARD OVER CORRESPONDING AREAS OF THE LUNG. ASYMETRY SUGGESTS DISEASE.

AUSCULTATORY PERCUSSION

MANGIONE PHYSICAL DIAGNOSIS SECRETS 2000

Auscultation of the front

Auscultation of the back

Breath Sounds

Vesicular - normal

Diminished - localised or diffuse

Bronchial - consolidation

FREMITUS =VIBRATION

TACTILE VOCAL

BRONCHOPHONYPECTORILOQUY

EGOPHONYE>A

TACTILE FREMITUS

A THRILL OR VIBRATION WHICH IS FELT ON THE CLINICIANS HAND WHILE RESTING IT ON THE PATIENTS CHEST WALL AT T HE SAME TIME THE PATIENT SPEAKS. 99 – 1-2-3

SYMETRY MAY BE SEEN IN NORMALS ASYMETRY – IS ABNORMAL

TACTILE FREMITUS

PNEUMONIA PNEUMOTHORAX PLEURAL EFFUSION COPD FAT

INCREASED DECREASED

VOCAL FREMITUS

THE PATIENTS VOICE IS HEARD THROUGH A STETHOSCOPE PLACED ON THE PATIENTS CHEST – NORMALLY THE SOUNDS ARE INDISTINCT

ABNORMALITIES – BRONCHOPHONY, PECTORILOQUY, EGOPHONY

CONSOLIDATION

VOCAL FREMITUS

BRONCHOPHONY – SOUND OF THE BRONCHI – SOUND MUCH LOUDER THAN NORMAL - WORDS INDISTINCT

PECTORILOQUY – VOICE OF THE CHEST – WHISPER – WORDS INDISTINCT

EGOPHONY – VOICE OF THE GOAT – BLEATING - E – A CHANGES – COMPARE SIDE TO SIDE

REMEMBER - ALL SUGGEST CONSOLIDATION OF THE LUNG

THORACIC EXPANSION

ASYMETRY IN EXPANSION OF THE THORAX CAN BE DETECTED DURING INSPECTION OF THE CHEST

DURING PROMPTED INHALATION OBSERVE THE MOVEMENT OF THE THORAX

PLEURAL EFFUSION, PNEUMOTHORAX

CYANOSIS

PERIPHERAL – HANDS, FEET – WARMING DECREASES CYANOSIS – DECREASED CARDIAC OUTPUT

CENTRAL- LIPS, TONGUE,SUBLINGUAL - RIGHT TO LEFT

SHUNTS

PSEUDOCYANOSIS – BLUE PIGMENTS IN SKIN - AMIODARONE

Central Cyanosis

Results from pulmonary dysfunction, the mucous membrane of conjunctiva and tongue are bluish.

If there was chronic hypoxemia and secondary erythrocytosis, you can detect the conjunctival and scleral vessels to be full, tortuous and bluish.

Central Cyanosis

Corpulmonale

Sleep apnea syndrome

Clubbing

Hereditary

Interstitial Fibrosis

Tumor

Bronchiecstasis

Heart Disease

Endocarditis

Clubbing

Significance: Clubbing Observed In:

Intrathoracic malignancy: Primary or secondary (lung, pleural, mediastinal)

Suppurative lung disease: (lung abscess, bronchiectasis, empyema)

Diffuse interstitial fibrosis: Alveolar capillary block syndrome

In association with other systemic disorders

CLUBBING

PAINLESS – FINGERNAILS CURVED AND WARM

ENLARGEMENT OF THE CONNECTIVE TISSUES IN THE TERMINAL PHALANGES OF THE FINGERS >TOES

SCHAMROTH’S SIGN – LOSS OF THE SUBUNGUAL ANGLE

CLIN CHEST MED 8:287-298,1987

CLUBBING

LOVIBOND’S ANGLE – THE ANGLE BETWEEN THE BASE OF THE NAIL AND SURROUNDING

SKIN.

CLIN CHEST MED 8:287-298,1987

CLUBBING

DO NOT FORGET THE TRACHEA

TRACHEAL DEVIATION

AUSCULTATE - STRIDOR

TRACHEAL TUG (OLIVERS SIGN) – DOWNWARD DISPLACEMENT OF THE CRICOID CARTILAGE WITH VENTRICULAR CONTRACTION – OBSERVED IN PATIENTS WITH AN AORTIC ARCH ANEURYSM

TRACHEAL TUG (CAMPBELL’S SIGN) – DOWNWARD DISPACEMENT OF THE THYROID CARTILAGE DURING INSPIRATION – SEEN IN PATIENTS WITH COPD

ABNORMAL BREATHING PATTERNS

APNEA - CARDIAC ARREST

BIOTS – INCREASED INTRACRANIAL PRESSURE – DRUGS- MEDULLA

CHEYNE STOKES – CONGESTIVE HEART FAILURE – DRUGS – CEREBRAL

KUSSMAULS – METABOLIC ACIDOSIS

WHITE NOISE (NOISY BREATHING) THIS NOISE CAN BE HEARD AT THE BEDSIDE

WITHOUT THE STETHOSCOPE LACKS A MUSICAL PITCH AIR TURBULENCE CAUSED BY NARROWED

AIRWAYS CHRONIC BRONCHITIS

LUNG SOUNDS

BREATH SOUNDS ADVENTITIOUS

TRACHEALBRONCHIALVESICULAR

WHEEZERHONCHICRACKLE

PLEURAL RUBSTRIDORSQUEAK

BREATH SOUNDS VESICULAR – NORMAL BREATH SOUNDS - SITE OF PRODUCTION THE

ALVEOLI TRACHEAL – TUBULAR – LIKE BLOWING AIR THROUGH A HOLLOW

TUBE – PHYSIOLOGIC

BRONCHIAL – TUBULAR - ALWAYS PATHOLOGIC WHEN THEY OCCUR OVER POSTERIOR OR LATERAL CHEST WALL

BRONCHOVESICULAR – CHARACTERISTICS OF BOTH VESICULAR AND TUBULAR – DO THEY EXIST?

ADVENTITOUS – EXTRA SOUNDS

BREATH SOUNDS

TIMING

CHARACTERISTIC

TRACHEAL BRONCHIAL BV VESICULAR

INTENSITY VERY LOUD LOUD MODERATE LOW

I:E RATIO 1:1 1:3 1:1 3:1

Breath sounds

Vesicular breath sounds

Vibrations of the vocal cords caused by turbulent flow through the larynx

Transmitted along trachea, bronchi to chest wall

Rustling quality Inspiration continuous with expiration Intensity increases during inspiration & fades

during first 1/3rd expiration

Diminished breath sounds

Conduction limited by Airflow limitation

e.g. diffusely – asthma, emphysema

localised – tumour, collapse

Something separating chest wall from lung

e.g. effusion, fibrosis

Bronchial breathing

“blowing” inspiratory & expiratory sounds Expiratory phase as long as inspiration Distinct pause between phases High-pitched e.g. consolidation Low-pitched e.g. fibrosis

Added sounds

Rhonchi (wheeze) Crepitations (crackles) Pleural sounds

Rhonchi

Due to passage of air through narrowed bronchus e.g. bronchospasm, mucosal oedema

Musical quality High or low pitched Usually expiratory Expiration prolonged

Crepitations

Inspiratory noises, usually 2nd half Non-musical Due to explosive reopening of peripheral

small airways during inspiration which have become occluded during expiration

Pleural Rub

Creaking noise Movement of visceral pleura over parietal

pleura Surfaces roughened by exudate 2 separate phases at end inspiration and

early expiration

ADVENTITIOUS SOUNDS

THESE ARE SOUNDS HEARD DURING AUSCULTATION OTHER THAN BREATH SOUNDS OR VOCAL RESONANCE

NOMENCLATURE – HAS BEEN CONFUSING

CRACKLES – DISCONTINUOUS SOUNDS WHEEZES AND RHONCHI – CONTINUOUS

SOUNDS

ADVENTITIOUS LUNG SOUNDS (BRUITS ETRANGERS – FOREIGN SOUNDS)

WHEEZE – HIGH PITCHED RHONCHI – LOW PITCHED CRACKLE RALES - HAIR VELCRO

(FINE – COARSE) PLEURAL RUBS – CREAKING LEATHER STRIDOR SQUEAK – HIGH PITCHED WHEEZE

HEARD AT THE END OF INSPIRATION

EARLY AND MID INSPIRATORY LATE INSPIRATORY

COARSE FINE

LOW PITCHED HIGH PITCHED

CLEAR WITH COUGHING DO NOT CLEAR WITH COUGHING

SCANTY PROFUSE

GRAVITY IN DEPENDENT GRAVITY DEPENDENT

TRANSMITTED TO THE MOUTH POORLY TRANSMITTED TO THE MOUTH

ASSOCIATED WITH OBSTRUCTION

ASSOCIATED WITH RESTRICTION

CRACKLES

BRONCHITIS- BRONCHIECSTASIS

INTERSTITIAL FIBROSIS - INTERSTITIAL EDEMA

SIGNIFICANCE OF LATE AND EARLY CRACKLES

EARLY – CENTRAL AIRWAYS (BRONCHITIS)

LATE – PERIPHERAL AIRWAYS (FIBROSIS,EDEMA)

WHEEZING

ASTHMA BRONCHITIS VOCAL CORD

DYSFUNCTION FOREIGN BODY

ASPIRATION INFECTIONS – CROUP

LARYNGITIS

CONGESTIVE HEART FAILURE

COPD FORCED EXPIRATION IN

NORMAL SUBJECTS CYSTIC FIBROSIS

NOT ALL THAT WHEEZES IS ASTHMA

COPD

PINK PUFFERS BLUE BLOATERS

THORAX 38:595-600, 1983

DAHL’S SIGN

NICOTINE STAINS

SMOKERS FACE

BLUE BLOATER

PURSED – LIPS BREATHING

COPD – DECREASES DYSPNEA DECREASES RR INCREASES TIDAL VOLUME DECREASES WORK OF BREATHING

CHEST 101:75-78, 1992

HOOVERS SIGN

COPD IN COPD THE DIAPHRAGM MAY BE

FLATTENED, DURING THE INSPIRATORY PHASE OF A BREATH THE RIBS ARE PULLED INWARD AND MEDIALLY RATHER THAN OUTWARD AND LATERALLY

RESPIRATORY ALTERNANS

NORMALLY BOTH CHEST AND ABDOMEN RISE DURING INSPIRATION

PARADOXICAL RESPIRATION IMPLIES THAT DURING INSPIRATION THE CHEST RISES AND THE ABDOMEN COLLAPSES

IMPENDING MUSCLE FATIGUE

PUTTING IT ALL TOGETHER

PNEUMONIA

PNEUMOTHORAX

PLEURAL EFFUSION

ASTHMA

PNEUMONIA

INSPECTION – SPLINTING

PALPATION – INCREASED FREMITUS

PERCUSSION – DULL

AUSCULTATION – BRONCHIAL BREATH SOUNDS, CRACKLES, EGOPHONY, PECTORILOQUY, RHONCHI

ENDOBRONCHIAL OBSTRUCTION MAY MASK THE USUAL PHYSICAL FINDINGS OF PNEUMONIA

PNEUMONIA

Consolidation Chest xray

PLEURAL EFFUSION

INSPECTION – LAG AFFECTED SIDE

PALPATION – ABSENT FREMITUS

PERCUSSION – FLAT, DULL

AUSCULTATION – ABSENT OVER EFFUSION, BRONCHIAL IMMEDIATELY ABOVE EFFUSION, RUB OCCASIONALLY

PLEURAL EFFUSION

PNEUMOTHORAX

INSPECTION – LAG AFFECTED SIDE

PALPATION – ABSENT FREMITUS

PERCUSSION – TYMPANIC

AUSCULTATION – ABSENT BREATH SOUNDS

PNEUMOTHORAX

PNEUMOTHORAX

PNEUMOTHORAX

Interpretation of findings

Pleural effusion reduced tactile vocal

fremitus reduced chest expansion stony dull reduced air entry no added sounds reduced vocal resonance

Consolidation increased tactile vocal

fremitus reduced expansion dull percussion bronchial breathing coarse creps increased vocal resonance whispering pectoriloquy

Pleural effusion

Pleural Effusion

Interpretation of findings

Pneumothorax deviated trachea reduced tactile vocal

fremitus hyper-resonance reduced air entry reduced vocal

resonance

Collapse deviated trachea reduced tactile vocal

fremitus dull percussion reduced air entry +/- creps

pneumothorax

Symptoms of Cardiac disorders:

1. Symptoms due to lung congestion:

Dyspnea. Acute pulmonary edema. Cough, hemoptysis. Recurrent chest infections.

2. Symptoms due to lung congestion:

Pain in the right hypochondrium. Dyspepsia. Swelling of lower limb. Swelling of the abdomen. Oliguria.

3. Symptoms due to low cardiac output:(tissue hypoxia →brain, muscles, kidneys) Exertional fatigue. Blurring of vision. Dizziness / Syncope. Oliguria, Angina.

4. Chest pain:

1. Of Cardiac Origin:

Ischemia, pericarditis, Dissecting aorta, Aortic Aneurysm.

2. Other Causes: Chest wall Neurological Mediastinum Diaphragm Abdominal. ( esophagus, stomach, gall bladder,

pancreas).

Analysis:

1. Site & radiation.

2. Provocation & relief.

3. Duration.

4. Character.

5. Associated features.

5. Symptoms due to changes in rate, Rhythm, or force → palpitation.

( time, mode of onset & offset, relation to exertion, duration, irregularity).

6. Symptoms due to pressure on surrounding structures.

( esophagus, bronchi , nerves, spine)

General Examination

1. General appearance.

2. Vital signs: pulse, temp. Blood pressure, respiration.

3. Hands: (cold, warm, clubbing, cyanosis, sweating)

4. Eyes

5. Neck:I. Neck veins.

II. Pulsations (arterial vs. venous).

III. Carotid arteries.

IV. Trachea, thyroid gland.

6. Lower Limbs ( edema, pulsations).

7. Abdomen.

Local Examination

1. Combined Inspection and palpation:

1. Shape.

2. Cardiac impulses (apex beat, parasternal pulsations, epigastric, to the right of sternum, suprasternal notch, 2nd left space)

3. Thrills.4. Palpable heart sounds.5. Position of the mediastinum6. Tactile vocal fremitus7. Chest movements8. Local tenderness,pulsations,wheezes.

Apex beat

2. Percussion

Types of percussion notes Apices of the lungs Anterior chest wall Lateral chest wall Posterior chest wall Cardiac and hepatic dullness

3. Auscultation:

Apex, lower end of sternum (tricuspid area), aortic area and pulmonary area .

Murmurs:1. Timing 2. Character3. Point of maximum intensity and propagation4. Relation to respiration5. Intensity6. ± Thrill.

Breath sounds. Adventitious sounds. Vocal resonance .