2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
1
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
2
Personal History: As before, but put stress on the following points
Occupation: e.g.
– Silicosis which may be complicated by pulmonary T.B.
– Asbestosis which may be complicated by mesothelioma
In this respect it is important to ask about the following:
1-Duration of exposure: several years are needed for
pneumoconiosis to develop.
2- Adherence to safety measures as wearing special masks during
work to prevent inhalation of the dust.
Special Habits of medical importance especially smoking
cigarettes, shesha and goza.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
3
The six cardinal symptoms of chest diseases are:
1- Cough
2- Expectoration (sputum)
3- Hemoptysis
4- Chest pain
5- Dyspnea
6- Wheezes
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
4
Other symptoms of importance in chest diseases or may
point to the possibility of the presence of a chest disease include:
1- Symptoms suggestive of mediastinal syndrome as dysphagia
and hoarseness of voice.
2- Symptoms suggestive of toxemia as night fever, night sweats,
loss of appetite and weight as in T.B.
3- Symptoms suggestive of RVF as LLs edema and pain in the
RUQ of the abdomen ( due to congested tender liver).
4- Fever as in upper and lower resp. tract infections.
Finally any other symptoms related to other systems.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Attack or disease similar to the present one:
e.g. - Asthma.
- Recurrent pneumonia
Allergic disorders: like eczema, urticaria,
angioedema and hay fever.
Acute abdominal conditions.
Admission in any hospital before and why?
Bilharziasis: bilharzial cor pulmonale.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Chest injuries and operations.
Other Surgical Procedures.
Coma , convulsions….may predispose toaspiration lung abscess
Cardiac diseases and history of rheumaticfever.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Diabetes mellitus
Hypertension and history of intake ofantihypertensive drugs. Cough may result from ACE
inhibitors
T.B and history of admission to a chesthospital for treatment of T.B. Name of the medicines,
duration of the treatment and the adherence to it should beenquired about.
Previous radiological examination: comparison
with the current radiograph may be valuable in diagnosis.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Similar condition in the family.
History of T.B.
History of allergy as eczema and hay fever.
History of DM
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Clinical Examination of the Chest !!
Manish Prabhakar
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Ask about the following:
The frequency
The severity
Dry or productive
Time of occurrence
Relation to posture
Character of cough (better observed by the physician)
Cough
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Sputum
Amount
Color
Character (seous, mucoid,purulent and mucopurulent)
Odor
Relation to posture
What increases or decreases it
Associated conditions
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Hemoptysis1:The most important causes of hemoptysis are
•Mitral stenosis
•Pulm tuberculosis
•Pulm infarction
•Brochiectasis
•Bronchogenic carcinoma
•Bronchial adenoma
•Bleeding tendency
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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1st differentiate between hemoptysis and hematemesis
2nd ask about :
•Type and Degree
•Frequency and Duration
3rd ask about the preceding events e.g. DVT or
chest infection
Hemoptysis2:
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Type and Degree
Hemoptysis3:
•Frank hemoptysis
•Blood-stained sputum
•Blood streaked sputum
•Rusty sputum
Frequency and duration
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Chest pain: as elsewhere ask about
The onset..
Site.
Character.
Radiation.
What brings or increases the pain and conversely what
relieves or decreases it.
The associated symptoms.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Wheeze
What dose the patient mean by wheezing?
You should be able to differentiate between
wheeze and stridor.
Wheezing may be intermittent as in asthma or
persistent as in chronic bronchitis.
Wheezing may be diffuse as in asthma and
chronic bronchitis or localized as in
bronchogenic carcinoma.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Inspection
Palpation
Percussion
Auscultation
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Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the chest
1-Shape of the chest.
2-Spine Deformity
3-Symmetry and Mobility
4-Respiratory movements
5-Skin
6-Pulsations
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Clinical Examination of the Chest !!
Manish Prabhakar
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1- Shape of the chest
Normal Shape
Barrel shaped chest
Pigeon chest
Rachitic chest
Funnel-shaped chest (Pectus Excavatum)
Local examination of the chest
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Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the Chest
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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2-
Local examination of the Chest
Inspection
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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2-
Local examination of the Chest
Inspection
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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3-
Both sides of normal chest are
symmetrical in shape and mobility.
The diseased side or part is less
mobile than the healthy one.
Local examination of the Chest
Inspection
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Clinical Examination of the Chest !!
Manish Prabhakar
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3-
Local examination of the Chest
Inspection
Bulgiong Retraction
•Pleural effusion
•Pneumothorax
•Hydropneumothorax
•Empyema
•Precordial bulge
•Chest wall causes
•Pulmonary collapse
•Pulm. Fibrosis
•Pleural fibrosis
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the Chest
Inspection
4-
Respiratory rate
Mode of Breathing
Respiratory Depth
Maximum Chest Expansion ( use a tape measure)
Abnormal Respiratory Movements
- Abnormal Inspiratory Movements
- Abnormal Expiratory Movements
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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5-
Local examination of the Chest
Inspection & Palpation
Skin eruption e.g HZ
Nodules (inflammatory,metastatic,lipoma, neurofibroma…)
Subcutaneous emphysema
Purpuric spots,Vascular spiders, Bruises
Prominent bl vessels (arterial in coarctation of aorta and venous in SVC obstruction)
Scars (previous operation,trauma, intercostal tube…)
Discharging sinuses
Lesions of the breasts and enlargement of axillary LNs
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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6-
Local examination of the Chest
Inspection & Palpation
Apical
Parasternal
Epigastric
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the Chest
To confirm Respiratory Movements
Pulsations (see before)
Palpable Adventitious Sounds
Tactile Vocal Fremitus (TVF)
Position of the Trachea
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Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the Chest
1. Respiratory movements in the
infraclavicular regions
2. Respiratory movements at the costal
margins
3. Respiratory movements of the lower ribs
posteriorly
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Clinical Examination of the Chest !!
Manish Prabhakar
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2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the Chest
Palpation:Resp Movements
Unilateral reduction of chest wall movements•Pleural effusion
•Empyema
•Pneumothorax
•Pulmonary consolidation
•Pulmonary collapse
•Pleural or parenchymatous pulmonary fibrosis
Bilateral reduction of chest wall movements•Bronchial asthma
•Emphysema
•Diffuse pulmonary fibrosis
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the Chest
Palpation
How to test for TVF?
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the Chest: Palpation
Increased TVF Decreased TVF
•Consolidation
•Cavitation
•Collapse with patent main
bronchus
•Thick chest wall
•Pleural effusion
•Pleural fibrosis
•Pneumothorax
•Emphysema
•Collapse
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the Chest: Palpation
Palpable Rhonchi
•Diffuse
•Localized and Persistent
Palpable Pleural Rub
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the Chest: Palpation
How to test for the position of the
trachea?
Trill’s sign:Bulging of the sternomastoid
muscle in front of the deviated trachea.
To evaluate the position of the upper mediastinum.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the Chest: Palpation
Causes of deviation of the trachea
Ipsilateral
(To pull)
Contralateral
( To push)
•Collapse
•Fibrosis
•Apical mass
•Pleural effusion
•Pneumothorax
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Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the chest
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Cut your nails
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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1. Percuss from side to side
and top to bottom using
the pattern shown in the
illustration.
2. Compare one side to the
other looking for
asymmetry.
3. Note the location and
quality of the percussion
sounds you hear.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
40
1. Percuss from side to side and
top to bottom using this
pattern. Omit the areas covered
by the scapulae.
2. Compare one side to the other
looking for asymmetry.
3. Note the location and quality of the
percussion sounds you hear.
4. Find the level of the diaphragmatic
dullness on both sides.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Clinical Examination of the Chest !!
Manish Prabhakar
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1. Find the level of the diaphragmatic dullness on
both sides.
2. Ask the patient to inspire deeply.
3. The level of dullness (diaphragmatic excursion)
should go down 3-5cm symmetrically.
4. Decreased or asymmetric diaphragmatic
excursion may indicate paralysis or emphysema.
Local examination of the chest: percussion
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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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.
Local examination of the chest: percussion
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the chest
Intensity of breath sounds
Type of breath sounds
Adventitious sounds
Voice sounds (vocal resonance)
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
45
Local examination of the chest
•While the patient relaxed and breathes normally with
mouth open, auscultate the lungs, making sure to auscultate
the apices and middle and lower lung fields posteriorly,
laterally and anteriorly.
•Alternate and compare both sides at each site.
•Listen to at least one complete respiratory cycle at each site.
•First listen with quiet respiration. If breath sounds are
inaudible, then have him take deep breaths.
•First describe the breath sounds and then the adventitious
sounds.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the chest
•Note the intensity of breath sounds and make a
comparison with the opposite side.
•Assess length of inspiration and expiration. Listen for a
pause between inspiration, expiration and the quality of
pitch of the sound
•Also compare the intensity of breath sounds between
upper and lower chest in upright position. Compare the
intensity of breath sounds from dependent to top lung in
the decubitus position.
•Note the presence or absence of adventitious sounds.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the chest
The normal breath sounds heard over the lung
tissue are called vesicular breathing.
The vesicular breathing is heard over the lungs,
lower pitched and softer than bronchial breathing.
Expiration is shorter (I > E) and there is no pause
between inspiration and expiration.
The breath sounds are symmetrical and louder in
intensity in bases compared to apices in erect
position and dependent lung areas in decubitus
position.
No adventitious sounds are heard.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the chest
The breath sounds heard over the tracheobronchial
tree are called bronchial breathing.
The only place where tracheobronchial trees are
close to chest wall without surrounding lung tissue
are trachea, right sternoclavicular joints and posterior
right interscapular space. These are the sites where
bronchial breathing can be normally heard. In all
other places there is lung tissue and vesicular
breathing is heard.
The bronchial breath sounds have a higher pitch,
louder, inspiration and expiration are equal and there
is a pause between inspiration and expiration.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
49
A prolonged expiratory phase (E > I)
indicates airway narrowing, as in:
Local examination of the chest
Bronchial asthma.
Chronic bronchitis
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the chest
Bronchial breathing may be heard in
pathological conditions as:
Consolidation
Collapse with patent large airways
Compressed lung by a large pl effusion or a
tension pneumothorax
Pulmonary fibrosis
Cavitation
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the chest
Crepitations: types
Rhonchi: sibilant and sonorous
Pleural rub
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Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the chest
Voice Transmission Tests: are only used in special
situations. All these tests become abnormal in
consolidation. They include:
Bronchophony
Whispered Pectoriloquy
Egophony
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Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the chest
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.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the chest
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.
2009/2010
Clinical Examination of the Chest !!
Manish Prabhakar
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Local examination of the chest
1. Ask the patient to say "ee" continuously.
2. Auscultate several symmetrical areas over
each lung.
3. You should hear a muffled "ee" sound. If you
hear an "ay" sound this is referred to as
"E -> A" or egophony.
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