Local chest examination

Local Examination Local Examination Of The ChestOf The Chest

Iman GalalIman GalalAssistant Professor Pulmonary MedicineAssistant Professor Pulmonary Medicine

Ain Shams UniversityAin Shams UniversityE-mail: [email protected]: [email protected]

InspectionInspection

PalpationPalpation

PercussionPercussion

AuscultationAuscultation

Local Examination of the Local Examination of the Chest:Chest:

Local Examination of the Local Examination of the ChestChest

1- Shape of the chest & Spine Deformity1- Shape of the chest & Spine Deformity

2-MovementMovement

3-Symmetry3-Symmetry

4-Pulsations4-Pulsations

5-Respiratory movements5-Respiratory movements

6-Skin6-Skin

7-Subcostal angel7-Subcostal angel

8-Special signs8-Special signs

InspectionInspection

::

Normal ShapeNormal Shape

Barrel shaped chestBarrel shaped chest

Pigeon chestPigeon chest

Rachitic chestRachitic chest

Funnel-shaped chest (Pectus Excavatum)Funnel-shaped chest (Pectus Excavatum)

Shape of the Chest:Shape of the Chest: Local Examination of the Local Examination of the ChestChest

Shape: Shape: ↑ ↑ AP diameterAP diameterLocal Examination of the Local Examination of the ChestChest

Shape: Pectus ExcavatumShape: Pectus ExcavatumLocal Examination of the Local Examination of the ChestChest

Spine Deformity: KyphosisSpine Deformity: KyphosisLocal Examination of the Local Examination of the ChestChest

Spine Deformity: ScoliosisSpine Deformity: ScoliosisLocal Examination of the Local Examination of the ChestChest

Both sides of normal chest are Both sides of normal chest are

symmetrical in shape and mobility.symmetrical in shape and mobility.

The diseased side or part is less The diseased side or part is less

mobile than the healthy one.mobile than the healthy one.

Movement & Symmetry :


Shape: Pigeon ChestShape: Pigeon ChestLocal Examination of the Local Examination of the ChestChest

Significance of Significance of ↓↓ respiratory movements: respiratory movements:

Unilateral Unilateral ↓↓ of chest wall of chest wall movements:movements:•Pleural effusionPleural effusion

•EmpyemaEmpyema•PneumothoraxPneumothorax•Pulmonary consolidationPulmonary consolidation•Pulmonary collapsePulmonary collapse•Pleural or parenchymatous pulmonary Pleural or parenchymatous pulmonary fibrosisfibrosis

Bilateral Bilateral ↓↓ of chest wall movements: of chest wall movements:•Bronchial asthmaBronchial asthma•EmphysemaEmphysema•Diffuse pulmonary fibrosisDiffuse pulmonary fibrosis


BulgingBulging RetractionRetraction

Pleural effusionPleural effusion

PneumothoraxPneumothorax

HydropneumothoraxHydropneumothorax

EmpyemaEmpyema

Precordial bulgePrecordial bulge

Chest wall causesChest wall causes

Pulmonary collapsePulmonary collapse

Pulm. FibrosisPulm. Fibrosis

Pleural fibrosisPleural fibrosis

Local Examination of the Local Examination of the ChestChestMovement &

Symmetry :

Respiratory rate

Type of respiration

Regularity of respiration

Pulse Rate: Respiratory Rate Ratio

Respiratory Movements:Respiratory Movements:Local Examination of the Local Examination of the ChestChest

Skin eruptionSkin eruption e.g HZe.g HZ

NodulesNodules (inflammatory,metastatic,lipoma, neurofibroma…)(inflammatory,metastatic,lipoma, neurofibroma…)

Subcutaneous emphysemaSubcutaneous emphysema

Purpuric spots,Vascular spiders, BruisesPurpuric spots,Vascular spiders, Bruises

Dilated prominent blood vesselsDilated prominent blood vessels (SVC obstruction)(SVC obstruction)

ScarsScars (previous operation,trauma, intercostal tube…)(previous operation,trauma, intercostal tube…)

Discharging sinusesDischarging sinuses

Lesions of the breastsLesions of the breasts

Skin:Skin: Local Examination of the Local Examination of the ChestChest

Skin: Skin: SVC ObstructionSVC ObstructionLocal Examination of the Local Examination of the ChestChest

ApicalApical

ParasternalParasternal

EpigastricEpigastric

Pulsations:Pulsations:Local Examination of the Local Examination of the ChestChest

Palpation: Palpation:

To confirm Respiratory Movements +/- To confirm Respiratory Movements +/- Expansion Expansion

Pulsations (see before)Pulsations (see before)

Palpable Adventitious SoundsPalpable Adventitious Sounds

TTactile actile VVocal ocal FFremitus (TVF)remitus (TVF)

Position of the TracheaPosition of the Trachea


Palpation of Respiratory MovementsPalpation of Respiratory Movements

1.1.Respiratory movements in the infraclavicular Respiratory movements in the infraclavicular

regionsregions

2.2.Respiratory movements at the costal marginsRespiratory movements at the costal margins

3.3.Respiratory movements of the lower ribs Respiratory movements of the lower ribs

posteriorlyposteriorly


Symmetry & Movement:Local Examination of the Local Examination of the ChestChest

Palpation: Chest ExcursionPalpation: Chest ExcursionLocal Examination of the Local Examination of the ChestChest

TVFTVF

Increased TVFIncreased TVF Decreased TVFDecreased TVF

Consolidation

Cavitation

Collapse with patent main bronchus

Thick chest wall

Pleural effusion

Pleural fibrosis

Pneumothorax

Emphysema

Collapse


Palpable Adventitious SoundsPalpable Adventitious Sounds

Palpable RhonchiPalpable Rhonchi

•Diffuse

•Localized and Persistent

Palpable Pleural Rub


Position of the Trachea:Position of the Trachea:

How to test for the position of the trachea?How to test for the position of the trachea?

Trill’s sign:Bulging of the sternomastoid Trill’s sign:Bulging of the sternomastoid

muscle in front of the deviated trachea.muscle in front of the deviated trachea.

To evaluate the position of the To evaluate the position of the

Upper Mediastinum.Upper Mediastinum.


Position of the Trachea:Position of the Trachea:Local Examination of the Local Examination of the ChestChest

Causes of deviation of the tracheaIpsilateralIpsilateral

(To pull)(To pull)

ContralateralContralateral

( To push)( To push)

CollapseCollapse

FibrosisFibrosis

Apical massApical mass

Pleural effusionPleural effusion

PneumothoraxPneumothorax

Local Examination of the Local Examination of the ChestChestPosition of the Trachea:Position of the Trachea:

Percussion:TechniquePercussion:TechniqueLocal Examination of the Local Examination of the ChestChest

Percussion

Cut your nails

Percussion: Anterior ChestPercussion: Anterior Chest

1.1. Percuss from side to side Percuss from side to side and top to bottom using and top to bottom using the pattern shown in the the pattern shown in the illustration. illustration.

2.2. Compare one side to the Compare one side to the other looking for other looking for asymmetry. asymmetry.

3.3. Note the location and Note the location and quality of the percussion quality of the percussion sounds you hear. sounds you hear.

Percussion: Posterior ChestPercussion: Posterior Chest

1.1. Percuss from side to side and Percuss from side to side and top to bottom using this top to bottom using this pattern. Omit the areas pattern. Omit the areas covered by the scapulae. covered by the scapulae.

2.2. Compare one side to the other Compare one side to the other looking for asymmetry. looking for asymmetry.

3.3. Note the location and quality Note the location and quality of the percussion sounds you of the percussion sounds you hear. hear.

4.4. Find the level of the Find the level of the diaphragmatic dullness on diaphragmatic dullness on both sides. both sides.

Traube’s area:Traube’s area:

4 points:4 points:

Left 6Left 6thth rib in the MCL to 8 rib in the MCL to 8thth costal cartilage in the costal cartilage in the

parasternal line ,then along the left costal margin parasternal line ,then along the left costal margin

to the 11to the 11thth rib in the MAL, then the 9 rib in the MAL, then the 9thth rib in the rib in the

MAL.MAL.

Kronig’s Isthmus :Kronig’s Isthmus :

It is a band of resonance representing lung apex.It is a band of resonance representing lung apex.

LaterallyLaterally it is marked by a line joining 2 points:it is marked by a line joining 2 points:

1.1. The junction of the medial 2/3 of the clavicle with The junction of the medial 2/3 of the clavicle with

the lateral 1/3.the lateral 1/3.

2.2. The junction of the medial 1/3 of the scapular The junction of the medial 1/3 of the scapular

spine with the lateral 2/3.spine with the lateral 2/3.

MediallyMedially marked by a line between the sternal marked by a line between the sternal

end of clavicle and the 7end of clavicle and the 7thth cervical spine. cervical spine.

Bare area of the heart :Bare area of the heart :

Medial border: left lateral border of the sternumMedial border: left lateral border of the sternum

Lateral border: left parasternal lineLateral border: left parasternal line

Superior border: lower border of Lt 4Superior border: lower border of Lt 4thth rib. rib.

Inferior border: upper border of Lt 6Inferior border: upper border of Lt 6thth rib rib

Surface anatomy of liver:Surface anatomy of liver:

Upper border:Upper border:

It starts from the left 6It starts from the left 6thth rib rib just inside the MCL, just inside the MCL,

passing to the Rt and slightly upwards to the 5passing to the Rt and slightly upwards to the 5thth rib rib

in the MCL, then the 7in the MCL, then the 7thth rib in anterior axillary line, rib in anterior axillary line,

to the 9to the 9thth rib in mid-axillary line. rib in mid-axillary line.

1.1. Find the level of the diaphragmatic dullness on both Find the level of the diaphragmatic dullness on both

sides. sides.

2.2. Ask the patient to inspire deeply. Ask the patient to inspire deeply.

3.3. The level of dullness (diaphragmatic excursion) The level of dullness (diaphragmatic excursion)

should go down 3-5cm should go down 3-5cm symmetricallysymmetrically. .

4.4. Decreased or asymmetric diaphragmatic excursion Decreased or asymmetric diaphragmatic excursion

may indicate paralysis or emphysema.may indicate paralysis or emphysema.

Diaphragmatic ExcursionDiaphragmatic ExcursionLocal Examination of the Local Examination of the ChestChest

1. It is used to differentiate supra-diaphragmatic from

infra-diaphragmatic dullness.

2. While the patient seated find the upper level of

dullness

3. Ask the patient to take deep inspiration and to hold

it then percuss again.

4. If the note becomes resonant infra-diaphragmatic

cause.

5. If there is no change of the note supra-

diaphragmatic cause as pleural effusion.

Tidal percussion:Tidal percussion: Local Examination of the Local Examination of the ChestChest

Auscultation:Auscultation:

Intensity of breath soundsIntensity of breath sounds

Type of breath soundsType of breath sounds

Adventitious soundsAdventitious sounds

Voice sounds (vocal resonance)Voice sounds (vocal resonance)


Technique of Auscultation

• While the patient relaxed and breathes normally While the patient relaxed and breathes normally with mouth open, auscultate the lungs, making sure with mouth open, auscultate the lungs, making sure to auscultate the apices and middle and lower lung to auscultate the apices and middle and lower lung fields posteriorly, laterally and anteriorly. fields posteriorly, laterally and anteriorly.

• Alternate and compare both sides at each site. Alternate and compare both sides at each site.

• Listen to at least one complete respiratory cycle at Listen to at least one complete respiratory cycle at each site. each site.

• First listen with quiet respiration. If breath sounds First listen with quiet respiration. If breath sounds are inaudible, then have him take deep breaths. are inaudible, then have him take deep breaths.

• First describe the breath sounds and then the First describe the breath sounds and then the adventitious sounds. adventitious sounds.


Technique of AuscultationTechnique of Auscultation

•Note the intensity of breath sounds and make a Note the intensity of breath sounds and make a

comparison with the opposite side. comparison with the opposite side.

•Assess length of inspiration and expiration. Listen for Assess length of inspiration and expiration. Listen for

a pause between inspiration, expiration and the a pause between inspiration, expiration and the

quality of pitch of the sound quality of pitch of the sound

•Also compare the intensity of breath sounds between Also compare the intensity of breath sounds between

upper and lower chest in upright position. Compare upper and lower chest in upright position. Compare

the intensity of breath sounds from dependent to top the intensity of breath sounds from dependent to top

lung in the decubitus position. lung in the decubitus position.

•Note the presence or absence of adventitious sounds.Note the presence or absence of adventitious sounds.


Bronchial breathing may be heard in:Bronchial breathing may be heard in:

ConsolidationConsolidation

Collapse with patent large airwaysCollapse with patent large airways

Compressed lung by a large pl effusion or a Compressed lung by a large pl effusion or a tension pneumothorax tension pneumothorax

Pulmonary fibrosisPulmonary fibrosis

CavitationCavitation

Local Examination of the Local Examination of the ChestChestAuscultation: Auscultation: Bronchial BreathingBronchial Breathing

Auscultation:Adventitious soundsAuscultation:Adventitious sounds

Crepitations: typesCrepitations: types

Rhonchi: sibilant and sonorousRhonchi: sibilant and sonorous

Pleural rubPleural rub


Auscultation: Voice soundsAuscultation: Voice sounds

Voice Transmission Tests: are only used in special situations. All these tests become abnormal in consolidation. They include:

Bronchophony

Whispered Pectoriloquy

Egophony


Auscultation: Voice sounds- BronchophonyAuscultation: Voice sounds- Bronchophony

1. Ask the patient to say "ninety-nine“ or 44 in arabic

several times in a normal voice.

2. Auscultate several symmetrical areas over each

lung.

3. The sounds you hear should be muffled and

indistinct. Louder, clearer sounds are called

bronchophony. bronchophony.


Voice sounds: Whispered PectoriloquyVoice sounds: Whispered Pectoriloquy

1. Ask the patient to whisper "ninety-nine“ or 44 in

arabic several times.

2. Auscultate several symmetrical areas over each

lung.

3. You should hear only faint sounds or nothing at all.

If you hear the sounds clearly this is referred to as

whispered pectoriloquy. whispered pectoriloquy.


Voice sounds: EgophonyVoice sounds: Egophony

1.1. Ask the patient to say "ee" continuously. Ask the patient to say "ee" continuously.

2.2. Auscultate several symmetrical areas over each Auscultate several symmetrical areas over each

lung. lung.

3.3. You should hear a muffled "ee" sound. If you hear You should hear a muffled "ee" sound. If you hear

an "ay" sound this is referred to as an "ay" sound this is referred to as "E -> A" or "E -> A" or

egophony.egophony.


Local chest examination

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