Principles of Chest Examination

Natalie HarperRespiratory Advanced Nurse Practitioner – Dorset County HospitalFoundation Trust

UK/KOL/17/0009 Date of Preparation: February 2017

The views expressed in this presentation are those of the speaker and are not necessarily those of the meeting sponsors.

This presentation may contain off-licence information. Please refer to the product SmPCs for the approved indication for use.

Disclosures:

• Teva UK Limited

Chest examination

• Always start with a general examination

• Then focus on respiratory aspects of a chest examination

PLEASE NOTE: Being competent at chest examination takes a lot of time and practice.

This is an introductory session only, so please seek the support and guidance of someone in your practice or workplace to help you develop your chest examination skills further.

Landmarks

Anterior chest

Lateral chest

Posterior chest

Physical exam techniques

Inspection

Palpation

Percussion

Auscultation

Inspection

Pectus excavatum

Pectus carinatum

Kyphosis

Scoliosis

Kyphoscoliosis

Symmetry of chest movement

Ease/difficulty of breathing including use of accessory muscles

Audible sounds – wheeze, stridor etc

Colour – do they look cyanotic?

Pectus excavatum and carinatum

Assessing for spinal deformities

Assessing for spinal deformities

Inspection/palpation

From the hand upwards:

HANDS

Clubbing

Tar staining

Peripheries and capillary refill time

Clubbing Tar staining

Capillary refill

Inspection/palpation

WRISTC02 retention flapPulseRespiratory rate (done immediately after pulse before letting go, so patient is unaware you’re counting their breaths)

Fine and course tremor

Fine tremor of Beta Agonist overuse Course tremor of CO2 retention

Inspection/palpation

From the hand upwards:

NECK

JVP (jugular venous pressure)

Lymph nodes

JVP

Lymph nodes

Inspection/palpation

FACE

Conjunctiva for anaemia

Central cyanosis

TRACHEA

Changes in the face, eyes and mouthYellowing of the skin and sclera

Corneal arcus XanthelasmaPaleness in the

conjunctiva

Angular stomatitisGlossitis

Blue lips –central cyanosis

Dry tongue

Tracheal alignment abnormalities

• Tension pneumothorax - shifts away from affected side

• Pleural effusion - shifts away from affected side

• Fibrosis or atelectasis - shifts towards affected side

• Pulmonary consolidation - no shift

Palpation: chest expansion

Palpation: tactile vocal fremitus

• Bilateral comparison of vocal vibrations

• Increased with alveolar consolidation

• Decreased with increased distance between lung and chest wall

– pneumothorax, pleural effusion

Tactile fremitus

Percussion

• Assess density of underlying tissue by resonance of sound

• Presence of fluid will produce a dull sound

• Air between the lungs and the chest wall (pneumothorax) produces a hollow note

Percussion

Percussion notes

Resonance – normal

Dullness – increased density

• Atelectasis, alveolar filling/consolidation, pleural effusion, fibrosis

Hyperresonance – decreased density

• Hyperinflation (COPD), pneumothorax

Auscultation – areas

Video

Feel calves fortenderness/warmth/swelling

Deep vein thrombosis

Sacral and pitting oedema

Any questions?