Examination of the chest

References: Physical Exam by Barbara Bates University of Liverpool, UK De Gowins Physical Examination

Dr. J. T. Cordero

General examination

General demeanour Distress Breathlessness Sweating Pain or discomfort Cachexia

Nails Clubbing Koilonychia Tar staining of fingers Colour Cyanosis Pallor Tremors

Dr. J. T. Cordero

Inspection

Chest wall
Shape Deformities Scars Rashes Local

Breathing pattern
Rate Depth Regularity Symmetry Expansion Distress

lesions

Noise
Inspiratory
Expiratory

stridor wheeze

Talk Accessory

muscles of

Hoarseness

respiration

Upper respiratory Dr. J. T. Cordero tract

Palpation
Expansion can be assessed by placing thumbs together and laying outstretched hands across chest wall. On inspiration the thumbs will move apart.

Any local abnormality seen on inspection Trachea and mediastinum

Tracheal position Apex beat

Chest wall

Tenderness Expansion

Vocal fremitus Lymph nodes

Cervical Supraclavicular fossa Axillae

Dr. J. T. Cordero

Percussion

Compare positions right and left Percuss anterior, lateral and posterior aspects Cover all lung lobes

Assess areas of altered resonance by percussing from areas of normal resonance around the abnormality to detect extent

Dr. J. T. Cordero

Intercostal spaces (lay finger along intercostal space) - lung tissue Clavicles - lung apices Liver - dull Heart - dull

Auscultation

Patient breathes with open mouth Use the bell of the stethoscope Compare right and left Auscultate a large number of sites

Auscultate

anterior, lateral and posterior Listen for

Breath sounds (vesicular or

bronchial) Vocal resonance Added sounds e.g. wheezes, crackles and pleural rub

Dr. J. T. Cordero

Vesicular breath sounds

quiet, low pitched, rustling no gap between the phases of inspiration and expiration expiratory phase shorter than inspiratory phase

Dr. J. T. Cordero

Bronchial breathing
usually louder transmitted through airless tissue similar to sound heard over trachea gap between inspiration and expiration expiration phase prolonged Dr. J. T. Cordero

Wheezes
Prolonged musical sounds Usually in expiration Localised narrowing within the bronchial tree Usually arise from multiple sites during expiratory phase of respiration A single fixed wheeze (in position and time) suggests a single fixed narrowing (e.g. tumor)

Dr. J. T. Cordero

Stridor
A sign of large airway narrowing A harsh sound Usually high pitched Occurs in both inspiration and expiration, but is usually more marked in the former

Dr. J. T. Cordero

Coarse crackles
Fluid or secretions in the large bronchi Bubbling noise Can usually be cleared or altered by coughing

Dr. J. T. Cordero

Fine crackles

Inspiratory, high pitched, explosive Involve forceful popping open of closed small airways (can be mimicked by rubbing hair between finger and thumb over ear) Early inspiratory chronic bronchitis bronchiectasis Late inspiratory left ventricular failure fibrosis pneumonia
Dr. J. T. Cordero

Pleural rub
Inflamed surfaces rubbing together Creaking noise (can be reproduced by rubbing on the dorsum of a cupped hand placed over the ear) Usually heard in both inspiration and expiration

Dr. J. T. Cordero

Consolidation (solid)

May be reduced movement on affected side Trachea central Percussion note - dull Auscultation - bronchial breathing Vocal resonance increased Tactile fremitus increased

Dr. J. T. Cordero

Pleural effusion (fluid)

May be reduced movement on affected side Trachea deviated away from affected side (if large) Percussion note - dull Auscultation - reduced breath sounds Vocal resonance reduced Dr. J. T. Cordero Tactile fremitus - reduced

Pneumothorax (air)
May be reduced movement on affected Free air in side pleural cavity Trachea deviated away from affected side (if large) Percussion note - hyperresonant Auscultation - reduced breath sounds Vocal resonance Dr. J. T. Cordero reduced

Vocal resonance
On identifying an abnormality on auscultation or percussion Listen with stethoscope over the affected area and ask the person to say 99 Repeat over same area on the opposite side (or a known normal area if comparable area also abnormal) Increased over solid tissue, reduced over air and fluid

Dr. J. T. Cordero

Tactile (vocal) fremitus

On identifying an abnormality on auscultation or percussion Place hands over abnormal and equivalent area on the opposite side (or a known normal area if comparable area also abnormal) Ask the person to say 99 Vibration increased over solid tissue, reduced over air and fluid

Dr. J. T. Cordero

Surface markings of the lung

Dr. J. T. Cordero

Lobes of the Lung

Upper lobe Middle Lobe (on right) Lower lobe
4th Costal cartilage
Heart

6th Rib

Dr. J. T. Cordero

Anterior
The lower border of the lung (at rest) extends down to the 6th rib 4th Costal cartilage The oblique fissure is marked anteriorly by the point at which the midclavicular line crosses the sixth rib 6th rib The horizontal fissure on the right is marked by the position of the 4th costal cartilage Dr. J. T. Cordero

Lateral

T3

T10/T11

8th rib

The oblique fissure curls upwards towards the 3rd thoracic vertebrae The horizontal fissure extends as far as the oblique fissure in the mid-axillary position The lower border of the lung extends to the eight rib in the mid-axillary line

Dr. J. T. Cordero

Posterior

T3

T10/T11

Posteriorly the oblique fissure reaches up to the level of the 3rd thoracic vertebra The lower most border of the lung is marked by the 10th or 11th rib

Dr. J. T. Cordero

Anatomical landmarks
Suprasternal notch Clavicle Sternomanubrial joint (angle of Louis) 2nd intercostal space Midclavicular line Cardiac apex Anterior axillary line Mid-axillary line Posterior axillary line Dr. J. T. Cordero Xiphisternum

Match the items opposite to the diagram above drawing lines to the appropriate structures