Physical Examination of the Chest RC 275 Chest Topography: Anterior Chest.
4-History Taking & Chest Examination
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Transcript of 4-History Taking & Chest Examination
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History Taking & Chest
Examination
Dr. Waseem HAJJAR, MD. FRCS.
Assistant professor &Consultant Thoracic Surgeon
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A good history should be both:
Concise.
Coer the important points.
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Rules:
!. "atient shoul# $e allo%e# to tell his histor
in his o%n %or#s.
'. (ea#ing )uestions must $e aoi#e# unlessthe information can*t $e o$taine# $ other
means
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Questions:
!. Complete the imme#iate #escription.
'. +luci#ate the ague points.
. Fill in the gaps the histor not mentione# $
patient.
-. +mphasie the important points.
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Types of questions:
!. /eutral )uestions.
'. Simple #irect )uestions 0es1/o2.
. (ea#ing )uestions.
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WHAT SH34(D W+ 5/3W A634T
TH+ +7AM8/AT83/ 3F TH+ CH+ST9
HISTORY
SYMPTOMS
(A/DMAR5S
"+RT8/+/T :3CA64(AR;
S8
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Personal data:
/ame.
Age.
Se=.
3ccupation. Resi#ence.
The patients complaint>
A simple statement in the patients o%n %or#s an# its
#uration.
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HISTORY
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Present History:
This means #etaile# histor of the patients present
illness %hich must proi#e ans%er for the follo%ing
)uestions>
!. Duration
'. Mo#e of onset 0acute, su$ acute, chronic2.
. Se)uence of eents>
8. Course 0progressie, regressie or recurrent2.
88. Appearance of ne% a##itional smptoms or
#isappearance of others.
888. Treatment receie# #uring the course & response.
-. Analsis of each particular smptom.
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History
Acute1chronic #isor#er
"rece#ing sstemic #istur$ance
"ast me#ical histor
Drug histor
Social histor
Famil histor
3ccupational histor
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Past History:
Chil#hoo# #iseases.
Trauma.
Resi#ences or trael a$roa#.
Drug therap.
3perations.
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THE HIT!R"
FAM8(; H8ST3R; EMPHYSEMA AT AN EARLY AGE ? C3/S8D+R
A("HA @ ! A/T8TR;"S8/
RECURRENT RESPIRATORY INECTIONS AN!STERILITY IN A YOUNG A!ULT MALE@
C3/S8D+R C;ST8C F86R3S8S, 8MM3T8(+ C8(8A
3R ;34/
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#amily History:
Here#itar factor.
+=posure to same etiological circumstances.
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THE HIT!R"
OCCUPATIONAL # CHR3/3(3
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Ha$its:
SmoBing.
"hsical efforts.
A##iction.
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SYMPTOMS
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History
Dspnoea
Wheee Cough
Sputum
Haemoptsis
Chest pain
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MAIN SYMPTOMS OF
PULMONARY DISEASE
C34
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LUNG
58D/+;
S"(++/(8:+R
S58/
6RA8/
H+ART
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%ECRIE THE C!'(H
"R3D4CT8:+ @ /3/"R3D4CT8:+
AC4T+ @ CHR3/8C
T8M+ 3F DA;
"R+C8"8TA/TS @ R+(8+F
6(33D; @ /3/ 6(33D;
6AR58/< @ HAC5;
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C!'(H
SYMPTOM
M3R/8/AC4T+ @ 0"4(M3/AR; +M63(8SM, "/T7, ASTHMA2
CHR3/8C @ 0C3"D, CHF, 8(D2 TACH;"/+A @ RR'E 6R1M8/ 6RAD;"/+A ? RR G 6R1M8/ 0DR4
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%"P)E*
M; CH+ST F++(S T8
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THE NUMEROUS ETIOLOGIES
OF CHEST PAIN
"(+4R8T8C @ "AR8+TA( "(+4RA @ SHAR"
STA668/< @ 8/S"8RAT83/
+S3"HA
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SPUTUM - WHAT ARE ITS
CHARACTERISTICS ?
;+((3W @
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HEMOPTYSIS - REQUIRES
CAREFUL QUESTIONING
TH8S S;M"T3M 4S4A((; D+/3T+S A
S+R834S 8((/+SS. T6, T4M3R,
6R3/CH8+CSTAS8S, "+, CARD8AC
D8S+AS+ TH+ "AT8+/T SH34(D 6+ 4+ST83/+D
CAR+F4((; R+
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CLUES TO DIFFERENTIATING
HEMOPTYSIS FROM HEMATEMESIS
HEMOPTYSIS
C34
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THE PULMONARY
E"AMINATIONSIGNS
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,H*T H!'-% ,E .)!, *!'T THE
E/*0I)*TI!) !# THE CHET1
H8ST3R;
S;M"T3MS
LAN!MAR&S
PERTINENT $OCA%ULARY
SIGNS
HO' TO PERORM AN E"AM
HO' TO ORMULATE A !IERENTIAL !IAGNOSIS
H3W T3 "R+S+/T TH+ 8/F3RMAT83/
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T3"3
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T3"3
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The Chest
8nspection
"alpation
"ercussion
Auscultation
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Inspection o t!e c!est
I()ort*+t:
# SHAPE
# MO$EMENT
# $ISI%LE PULSATIONS,
SHAPE o- the .hest:!e-or(ities: # /y)hosis
# s.oliosis
# de)ressed ster+u( 0)e.tus e1.*2*tu(3
# bulges i+ le-t )*r*ster+*l *re*0.o+ge+it*l (*l-or(*tio+3
e4g4 $S!
o- the thor*1
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Chest 2all
"ectus carinatum "ectus e=caatum
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Pe3tus Ex3a4atum
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Inspe3tion
Shape Scars (esions Resp rate Resp #epth Mo#e of $reathing A$normal inspirator moements A$normal e=pirator moements
Asmmetr of moement
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Ni.oti+e st*i+i+g
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5 liters o-O5
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6ARR+( CH+ST
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arrel Chest
AP Di"#ete$ % T$"ns&e$se
Di"#ete$
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P*-P*TI!)
F++(8/< W8TH TH+ HA/D @ F8/
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Palpation
Chest e=pansion
Tactile ocal fremitus
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Chest Expansion
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Chest Expansion
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Chest Expansion
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Tr*.he* e1*(
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Per3ussion
8llustrate resonance
Compare $oth si#es
Map out a$normal area
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0ETH!% !# PERC'I!)
D8R+CT 8/D8R+CT
D8S+AS+ A M3/TH -!I-?I'>!K
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0ETH!% !# PERC'I!)
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0ETH!% !# PERC'I!)
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Per3ussion
8mpaire#0dull2resonance o$taine# @
Aerate# lung tissue is separate# from the
chest %all e.g. flui#, pleural thicBening
(ung tissue is airless e.g. consoli#ation,collapse, fi$rosis
Lsto+y dull+ess? pleural effusion
Hperresonance ? pneumothora=
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Per3ussion te3hnique
"lace left han# on chest %all, palm
#o%n%ar#s %ith fingers separate#
'n#phalan= oer area of intercostal space
Right mi##le finger striBes the 'n# phalan=pro#ucing hammer effect
+ntire moement comes from %rist
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PERC'I!) !')%
T;M"A/; @ H+ARD 3:+R TH+ A6D3M+/
R+S3/A/C+ @ H+ARD 3:+R /3RMA(
(4/ "rimar orsecon#ar 0lung, pleural, me#iastinal2
Suppuratie lung #isease> 0lung a$scess,
$ronchiectasis, empema2 Diffuse interstitial fi$rosis> Aleolar capillar
$locB sn#rome
8n association %ith other sstemic #isor#ers
C-'I)(
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C-'I)(
"A8/(+SS @ F8/
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LO$I%ON!6S ANGLE@ TH+ A/'GO?'G,!GO
CLU%%ING
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DO NOT FORGET THE TRACHEA
TRACH+A( D+:8AT83/
A4SC4(TAT+ ? STR8D3R
TRACH+A( T4< 03(8:+RS S8
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A%NORMAL %REATHING PATTERNS
A"/+A ? CARD8AC ARR+ST
683TS @ 8/CR+AS+D 8/TRACRA/8A( "R+SS4R+ @ DR4
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6
RE*THI)(7
TH8S /38S+ CA/ 6+ H+ARD AT TH+ 6+DS8D+W8TH34T TH+ ST+TH3SC3"+
(AC5S A M4S8CA( "8TCH
A8R T4R64(+/C+ CA4S+D 6; /ARR3W+D
A8RWA;S CHR3/8C 6R3/CH8T8S
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LUNG SOUNDS
BREATH SOUNDS ADVENTITIOUS
TRACHEAL
BRONCHIAL
VESICULAR
WHEEZE
RHONCHI
CRACKLEPLEURAL RUB
STRIDOR
SQUEAK
RE*TH !')%
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RE*TH !')%
:+S8C4(AR @ /3RMA( 6R+ATH S34/DS ? S8T+ 3F "R3D4CT83/ TH+A(:+3(8
TRACH+A( @ T464(AR @ (85+ 6(3W8/< A8R THR34
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%REATH SOUN!S
TIMING
CHARACTERISTIC
TRACHEAL %RONCHIAL %$ $ESICULAR
INTENSITY $ERY LOU! LOU! MO!ERATE LO'
I:E RATIO 7:7 7:8 7:7 8:7
th d
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reath sounds
5 i l $ th d
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5esi3ular $reath sounds
:i$rations of the ocal cor#s cause# $tur$ulent flo% through the larn=
Transmitte# along trachea, $ronchi to chest
%all Rustling )ualit
8nspiration continuous %ith e=piration
8ntensit increases #uring inspiration & fa#es
#uring first !1r#e=piration
%iminished $reath so nds
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%iminished $reath sounds
Con#uction limite# $Airflo% limitation
e.g. #iffusel @ asthma, emphsema
localise# @ tumour, collapse
Something separating chest %all from lung
e.g. effusion, fi$rosis
ron3hial $reathing
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ron3hial $reathing
L$lo%ing inspirator & e=pirator soun#s +=pirator phase as long as inspiration
Distinct pause $et%een phases
High?pitche# e.g. consoli#ation (o%?pitche# e.g. fi$rosis
*dded sounds
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*dded sounds
Rhonchi 0%heee2 Crepitations 0cracBles2
"leural soun#s
Rhon3hi
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Rhon3hi
Due to passage of air through narro%e#$ronchus e.g. $ronchospasm, mucosal
oe#ema
Musical )ualit High or lo% pitche#
4suall e=pirator
+=piration prolonge#
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*%5E)TITI!' !')%
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*%5E)TITI!' !')%
TH+S+ AR+ S34/DS H+ARD D4R8/
Rhythm or for3e = palpitation
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Rhythm> or for3e = palpitation
0 time, mo#e of onset & offset, relation to
e=ertion, #uration, irregularit2.
A ymptoms due to pressure on
surrounding stru3tures
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surrounding stru3tures
0 esophagus, $ronchi , neres, spine2
(eneral Examination
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!.
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-o3al Examination
9 Com$ined Inspe3tion and palpation:
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!. Shape.'. Car#iac impulses 0ape= $eat, parasternal
pulsations, epigastric, to the right of
sternum, suprasternal notch, 'n#left space2
. Thrills.-. "alpa$le heart soun#s.K. "osition of the me#iastinum
I. Tactile ocal fremitusO. Chest moementsG. (ocal ten#erness,pulsations,%heees.
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*pex $eat
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; Per3ussion
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Tpes of percussion notesApices of the lungs
Anterior chest %all
(ateral chest %all "osterior chest %all
Car#iac an# hepatic #ullness
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6reath soun#s.A#entitious soun#s.
:ocal resonance .
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