Physical examinatio+cxr

Respiratory system 1In The name of God

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Physical Examination of the Chest

معاینھ فیزیکی سیستم تنفس

Diagram of Thoracic Area

Chest Topography: Anterior Chest

Chest Topography:Lateral Chest

Chest Topography:Posterior Chest

Respiratory tract anatomy

fig 13-1

Lung Anatomy• Right Lung

– Superior lobe– Middle lobe– Inferior lobe

• Left Lung– Superior lobe– Inferior lobe

Fissures:

Location of Lobes

Lung Anterior

Lung Posterior

Lung Left Side

Lung Right Side

Physical Exam Techniques

• Observation• Palpation• Percussion• Auscultation

Observation:Breathing Patterns

• Apnea• Tachypnea/Bradypnea• Biot’s• Cheynes-Stokes• Kussmaul

Observation:Thoracic Contour

Observation: Thoracic Contour(cont.)

• Pectus Excavatum• Pectus Carinatum• Kyphosis• Scoliosis• Kyphoscoliosis• Symmetry of chest movement

Barrel Chest

Scoliosis

Kyphosis

Observation: Clubbing

Palpation: Tracheal Alignment

Tracheal Alignment Abnormalities

• Pneumothorax – shifts to unaffected side• Pleural Effusion – shifts to unaffected side• Fibrosis or Atelectasis – shifts towards

affected side• Pulmonary consolidation – no shift

Palpation : Chest Excursion

Palpation: Vocal Fremitus

• BILATERAL comparison of vocal vibrations

• Increased with alveolar consolidation

• Decreased with increased distance between lung and chest wall– Pneumothorax, Pleural

effusion

Percussion

• Assess density of underlying tissue

Percussion Notes

• Resonance – normal• Dullness – increased density

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

• Hyperresonance – decreased density– Hyperinflation (COPD), Pneumothorax

Lets all listen in

Auscultation: Listening to breath sounds with a stethoscope

Normal Breath Sounds and Their Locations

Abnormal Breath Sounds: Diminished or Absent

• Increased distance between aerated lung and chest wall:– Pneumothorax, Pleural effusion, Atelectasis,

Obesity around thorax• Decreased or absent airflow

– Airflow obstruction (eg asthma), Hyperinflation (COPD), Malpositioned ET Tube

Abnormal Breath Sounds: Bronchial or Bronchovesicular

in abnormal part of the lung

• Lung has become more solid and less aerated in these areas

• Consolidation, eg, pneumonia, or Atelectasis

Abnormal Breath Sounds: Adventitious Sounds

• Wheeze – continuous musical sounds heard mostly during expiration – May be also heard on inspiration

• Caused by a sudden change in airway caliber– Edema, spasm, secretions, foreign body

Abnormal Breath Sounds: Adventitious Sounds

• Crackles – discontinuous sound heard mostly on inspiration

• Caused by small airways and alveoli popping open or from secretions in very large airways

Condition Chest Excursion

Fremitus Percussion BreathSounds

Atelectasis

Pneumothorax

Pleural Effusion

Pulmonary Consolidation

Fibrosis

Pulmonary Edema

Techniques - Projection

•P-A (relation of x-ray beam to patient)

Techniques - Projection (continued)•Lateral

Techniques - Projection (continued)

•Lateral Decubitus

Techniques - Projection (continued)

•Oblique

The Normal Chest X-ray• PA View:

1. Aortic arch2. Pulmonary trunk3. Left atrial appendage4. Left ventricle5. Right ventricle6. Superior vena cava7. Right hemidiaphragm8. Left hemidiaphragm9. Horizontal fissure

Lung Anatomy• Trachea• Carina• Right and Left Pulmonary

Bronchi• Secondary Bronchi• Tertiary Bronchi• Bronchioles• Alveolar Duct• Alveoli

Anatomy

Rotation

Rotation (continued)

Penetration

Inspiration/Expiration

Technical Details

•Type•Rotation •Inspiration/expiration•Penetration

Summary of Density • Air• Water• Bone• Tissue

Tissue

DensitiesThe big two densities are:

(1) WHITE - Bone(2) BLACK - Air

The others are:

(3) DARK GREY- Fat (4) GREY- Soft tissue/water

And if anything Man-made is on the film, it is:

(5) BRIGHT WHITE - Man-made

Pitfalls to Chest X-ray Interpretation

• Poor inspiration• Over or under penetration• Rotation• Forgetting the path of the x-ray beam

Systematic Approach• Soft Tissues

– Breast shadows– Supraclavicular areas– Axillae– Tissues along side of

breasts

Systematic Approach• Diaphragm and

Pleural Surfaces– Diaphragm

• Dome-shaped• Costophrenic angles

– Normal pleural is not visible

– Interlobar fissures

Mediastinum

Made of:

1. Pulmonary Art.+Veins2. The Bronchi

Left Hilus higher (max 1-2,5 cm)

Identical: size, shape, density

Lung Anatomy on Chest X-ray• The right upper lobe

(RUL) occupies the upper 1/3 of the right lung.

• Posteriorly, the RUL is adjacent to the first three to five ribs.

• Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib

Lung Anatomy on Chest X-ray• The right middle lobe

is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum

Lung Anatomy on Chest X-ray• The right lower lobe is the

largest of all three lobes, separated from the others by the major fissure.

• Posteriorly, the RLL extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm.

• Review of the lateral plain film surprisingly shows the superior extent of the RLL.

Lung Anatomy on Chest X-ray• These lobes can be separated

from one another by two fissures.

• The minor fissure separates the RUL from the RML, and thus represents the visceral pleural surfaces of both of these lobes.

• Oriented obliquely, the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body.

Lung Anatomy on Chest X-ray• The lobar architecture

of the left lung is slightly different than the right.

• Because there is no defined left minor fissure, there are only two lobes on the left; the left upper

Lung Anatomy on Chest X-ray• These two lobes are

separated by a major fissure, identical to that seen on the right side, although often slightly more inferior in location.

• The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe.

The Silhouette Sign• An intra-thoracic radio-

opacity, if in anatomic contact with a border of heart or aorta, will obscure that border. An intra-thoracic lesion not anatomically contiguous with a border or a normal structure will not obliterate that border.

Pathology

RUL pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

RML pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

RLL pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

LUL pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

LLL pneumoniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

Consolidation on CTCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

Hilar m lCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

The Enlarged Hila

Causes:

1. Adenopathies (neoplasia, infection)

2. Primary Tumor

3. Vascular

4. Sarcoidosis

Multiple MassesCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

Hilar Lymphadenopathy - BLCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

Pleural EffusionCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

Pulmonary FibrosisCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

Heart failureCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

PneumothoraxCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

RUL collapseCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

EmphysemaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

Cervical RibCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

Cavitating lesionCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

Hiatus herniaCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

Chest Tube, NG Tube, Pulm. artery cathCreate PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)

Physical examinatio+cxr

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