Chest Exam / Lung Topography

Physical examination employs the use of inspection, palpation, percussion, and auscultation to determine patients’ clinical status and their response to therapy

Each examination is modified according to the purpose of the examination

Physical examination skills develop over time with practice

Examination of the Head and Neck

Identify the patient’s facial expression, looking for evidence of pain or acute distress

Look for evidence of cyanosis around the lips and oral mucosa

Patients may use pursed-lip breathing when COPD is present

Eyes

The eyes are inspected for pupillary response to light when neurologic defects are suspected

Dilated and fixed pupils suggest brain death in some patients

The eyelids may droop (ptosis), indicating damage to the third cranial nerve

Neck

The trachea should be midline If it is deviated to one side, a unilateral lung

problem is probably present Atelectasis pneumothorax

The status of the jugular veins in the neck is important Patients with cor pulmonale have JVD

Use of accessory muscles in the neck suggests obstructive lung disease

Lung Topography

Anterior chest is defined by the midsternal and midclavicular lines

Lung Topography

Lateral chest is defined by midaxillary, anterior axillary and posterior axillary lines

Lung Topography

Posterior chest is defined by the midspinal and midscapular lines

Thoracic Cage Landmarks

Thoracic Cage Landmarks

On the posterior chest, C7 is seen as the most prominent spinous process at the base of the neck

Thoracic Cage Landmarks

The angle of Louis, or sternal angle, is located on the anterior chest. Formed by the

ridge between the manubrium and the gladiolus

Lung Fissures The oblique fissure

starts at rib six on the anterior chest at the midclavicular line

It runs up and laterally crosses the midaxillary line at fifth rib and across the posterior chest, ending at T3

horizontal fissure passes from the fourth rib at

the midsternal line laterally to the fifth rib in the midaxillary line

Tracheal Bifurcation

At T4 on posterior chest

At sternal angle on anterior chest

Tracheal Bifurcation

Diaphragm

The diaphragm is a dome-shaped muscle

The top of the dome rests at about the fifth rib anteriorly and at T9 on the posterior chest normally

Lung Borders

On the anterior chest the upper border of the lung extends 2 to 4 cm above the medial third of the clavicles. The inferior border of the lung is at rib six normally

Lung Borders

On the lateral chest the lower margin of the lung is at rib eight

Lung Borders

On the posterior chest the superior border of the lung extends to T1. The inferior border varies with breathing but is usually at about T10

Examination of the Thorax

Look Feel Listen

Look For A barrel chest or

evaluate the A-P diameter An in crease A-P

diameter is consistent with COPD

Look For

Kyphoscoliosis is present when the spine is bent laterally and from front to back Can causea

restrictive lung problem

Look For

Pectus carinatum is seen as an abnormal sternal protrusion

Look For

Pectus excavatum is seen as depression of the sternum

Look For

Breathing pattern is important to identify when lung disease is present

Rapid and shallow breathing is consistent with restrictive disease

A prolonged expiratory time is consistent with obstructive lung disease

Retractions are seen as inward depression of the skin around the rib cage with inspiration This suggests a high work of breathing (WOB)

Abdominal paradox is seen as inward movement of the abdomen with inspiration This suggests diaphragm paralysis or fatigue

Hoover’s sign is seen as inward movement of the lateral chest with inspiration. It is a sign of severe COPD.

Feel For (Palpation)

Vocal fremitus is assessed to identify pathologic changes in the lung.

Increased vocal fremitus is consistent with pneumonia and atelectasis.

Decreased vocal fremitus is consistent with lung hyperinflation, pleural disorders, and obesity.

Palpation

Palpation

Use palpation to assess for uniform chest excursion

Percussion

Percussion is done to determine the condition of the underlying lung.

Increased resonance is heard with pneumothorax and lung hyperinflation.

Decreased resonance is heard with pneumonia and atelectasis.