Download LOCAL EXAMINATION OF THE CHEST

LOCAL EXAMINATION OF THE CHEST
It is necessary for the patient to be stripped to the waist. Usually, the patient lies in a recumbent or
semi-recumbent position with arms abducted, when the anterior and lateral aspects of the chest are
being examined, and sit upright with arms folded across the chest, when the posterior aspect of the
chest is being examined. When the patient cannot sit, the posterior chest may be examined by turning
the patient on his lateral sides. Always compare between identical points or areas on both sides of the
chest.
Anatomoical consedearations
The right lung is composed of three lobes (the upper, middle and lower lobes) separated from each other by the minor
and major interlobar fissures, while the left lung is composed of two lobes only (the upper and lower lobes) separated
by the major interlobar fissure only. The right lung is composed of 10 bronchopulmonary segments: the upper lobe has
three segments (anterior, apical and posterior), the middle lobe has two segments (medial and lateral) and the lower
lobe has five segments (apical, anterior, posterior, medial and lateral), while the left lung is composed of 8
bronchopulmonary segments only: the upper lobe has two segments (anterior and apicoposterior), the lingula has two
segments (superior and inferior) and the lower lobe has four segments (apical, anterior, posterior, and lateral).
Surface anatomy of various organs:
1- Lungs: The apices of the lungs rise 2-3 cm above the medial thirds of the clavicles. From this point the inner
margins of the lungs and their covering pleurae slant towards the sternum, meeting each other in midline at the
sternal angle, then on the right side: The lung margin continues down as far as the 6 th costal cartilage, where it
turns laterally to meet the midclavicular line at the 6th rib, the midaxillary line at the 8th rib and the scapular line at
10th thoracic vertebra and then a line ascends along the paravertebral line to join the apex. On the left side: The
landmarks are the same with the exception that the lung border turns away from sternum at 4 th till the 6th costal
cartilage (to the parasternal line) where it turns laterally, due to the heart, which lies in contact with chest wall in
this area.
2- Pleurae: The pleura lies so close to the lungs at the apices and along the inner margins, so following the same
surface markings, but the at the lower borders of the lungs the pleura extends farther (reaching the level of 8 th rib
in the midclavicular line, level of the 10th rib in the midaxillary line and level of 12th thoracic vertebra in
Anterior
paravertebral line).
3- Kronig’s isthmus:
a- Anterior: Medial 2/3 of the clavicle.
b- Posterior: Medial 1/3 of spine of scapula.
Posterior
c- Medial: A line
joining
sternoclavicular
joint
withpleurae
the 7 th cervical
spine posteriorly.
Surface anatomy of the lungs and
from anterior
and posterior
d- Lateral: A line joining point A (junction of medial 2/3 of clavicle with outer 1/3) and point B (junction of
medial 1/3 of spine of scapula with lateral 2/3).
4- Lung fissures:
a- The oblique fissure (both lungs): a line drawn from the 3rd thoracic spine posteriorly slanting downwards and
Surface anatomy of the lung fissures from anterior
laterally to cut the 5th rib in the midaxillary line and ends at the 6 th costal cartilage anteriorly 3 inches from
middle line. It also divides the axilla into upper and lower axillary areas.
b- The transverse fissure (right lung only): a line drawn laterally from the costal cartilage of the 4 th rib to meet
the oblique fissure at the 5th rib in midaxillary line.
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Surface anatomy of lung fissures from lateral positions
5- Traube’s area: It is an area of tympanitic resonance overlying the fundus of the stomach:
a- Upper border: Base of the Left Lung.
b- Lower border: Left Costal Margin
c- Left border: Anterior border of spleen
d- Right border: Lower border of left lobe of liver.
6- Bare area of Heart: An area over the anterior chest wall extending from the 4 th to the 6th costal cartilages and from the left sternal
border to the left parasternal line.
7- Heart:
a- Left 5th intercostal space, 3.5 inches from median plane.
b- Left 2nd costal cartilage, 1.5 inches from median plane.
c- Right 3rd costal cartilage, 1.0 inches from median plane.
d- Right 6th costal cartilage, 0.5 inches from median plane.
INSPECTION
Chest is inspected from the head or from the foot. If the patient is too ill to sit up, the back is
examined by rolling the patient on each side in turn.include the following :
-
Shape
Symmetry
Movement of the chest
Respiration
Pulsations
Subcostal angel
The skin overlying the chest wall
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1- Shape of the chest:
The healthy chest is an ellipse in cross section (the anteroposterior to transverse diameters in the
ratio of 5:7), bilaterally symmetrical with smooth contours, the ribs are oblique and the subcostal
angle is about 70-110o. Chest diameters are measured by the pelvimeter.
Abnormal shapes of chest that may be present are:
a- Barrel chest: The anteroposterior diameter is increased, ribs are horizontally placed with wide
intercostals spaces, spine becomes concave forwards, sternum is much more arched and the
subcostal angle is obtuse. This deformity is present in emphysema.
b- Funnel chest: An exaggeration of normal depression seen at end of the sternum, often congenital
but may be acquired in shoemakers (pectus excavatum). It is due to fibrous replacement of the
anterior portion of the diaphragm. It is usually asymptomatic, but when there is marked degree of
depression of the sternum, the heart may be compressed and apex shifted to left with reduction in
the lungs ventilatory capacity.
c- Rachitic chest: A groove in the region of costochondral junctions during inspiration (Harrison’s
sulcus) with swellings of costochondral junctions (Rachitic rosary).
d- Pigeon’s chest: The sternum becomes prominent and the chest acquires a triangular form (pectus
carinatum). The congenital form is due to malinsertion of anterior portion of the diaphragm, being
inserted in posterior rectus sheath rather than the sternum while the acquired form occurs in
rickets.
e- Spinal deformities: kyphoscoliosis and lateral scoliosis.
f- Unilateral enlargement: pleural effusion, pneumothorax, lung or chest wall tumors, compensatory
emphysema and precordial prominence secondary to pericardial effusion or valvular heart
disease.
Unilateral
2- gMovement
of retraction:
the chest: fibrothorax and lung collapse.
a- Inspection is the best way of assessing any limitations of movements of the chest.
b- The degree of chest expansion is measured by placing a tape measure below the nipples and
instructs the patient to breathe deeply in and out. Normal chest expansion is about 4-6 cm.
Generalized decrease of movement means expansion less than 2cm.
c- Compare movement of the two sides while the patient is breathing quietly. A delay in
movement on one area means that there is an element of bronchial obstruction in the
corresponding bronchus e.g. adenoma or early bronchial carcinoma. This will not be evident if
the patient breathes deeply because it tends to overcome the obstruction.
d- Note abnormal inspiratory movements produced by contraction of the accessory muscles of
inspiration (sternomastoids, scaleni and trapezii).
e- Paradoxical movement of the chest wall (indrawing of chest wall during inspiration) is seen in
patients with double fractures of a series of ribs or of the sternum (flail chest).
a- Unilateral reduction of chest wall movement occurs in pleural effusion, empyema,
pneumothorax, lung consolidation or collapse and lung or pleural fibrosis. The affected
side, whatever the type of pathology, always moves less than the sound side.
b- Generalized decrease of chest expansion occurs in asthma, pulmonary fibrosis, and
emphysema and in conditions, which restrict chest movement as ankylosing spondylitis,
systemic sclerosis and obesity.
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3- Symmetry of the chest:
a. Healthy chest is bilaterally symmetrical with smooth contours.
b. If asymmetry is present define its area
a. Causes of asymmetry: pleural effusion or fibrosis and lung collapse or fibrosis.
4- Rate, rhythm and type of respiration or any abnormal respiratory movement:
a- Rate of breathing should be observed without the patient’s knowledge. Respiratory rate
varies in normal individuals between 14 and 18 per minute. Respiratory rate is increased in
pyrexia, acute pulmonary infections, bronchial asthma and acute pulmonary edema and it is
decreased during sleep and with use of narcotics.
b- In men respiration is usually abdominothoracic (diaphragmatic) while in women it is
thoracoabdominal (costal). A change in type of breathing may be significant of disease.
Respiration is mainly thoracic in peritonitis, ascites, large ovarian cyst or pregnancy and
mainly abdominal in ankylosing spondylitis, intercostal paralysis, fracture ribs or pleurisy.
c- Abnormal breathing patterns
Abnormal breathing patterns are:
1) Purse lip breathing: in COPD to decrease collapse of bronchi in expiration.
2) Bitot’s breathing: sudden deep breathing with apnea in tuberculous meningitis.
3) Cheyne-stokes breathing: periods of apnea alternating with periods of hyperventilation that begins
gradually. It is observed in respiratory or heart failure and is probably due to delay in circulation time
between the central and the peripheral chemoreceptors
4) Kussmaul’s breathing: rapid deep breathing in renal and hepatic failure.
5) Hyperventilation: in meningitis, encephalitis, cerebral hemorrhage, fevers, hyperthyroidism, anxiety and
salicylate overdose. Hyperventilation causes respiratory alkalosis (due to CO2 wash) with tetany and
drowsiness.
d-
Any Lower Intercostal Spaces (Litten’s sign):
Indrawing of the lower 6 intercostal spaces is normally present in deep inspiration and in
thin persons but when it is present during quite breathing, it indicates a low flat diaphragm.
Contraction of a low flat diaphragm causes pull on the lower intercostal spaces.
5- Pulsations over the Chest Wall:
a- The apical pulsations ,epigastric pulsations ,parasternal pulsations ,pulsations over
pulmonary or aortic area and any visible pulsations over the chest wall should be examined.
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6- Skin and Chest wall:
a- Inspect the skin for scars of pleural tapping (in midaxillary or scapular lines), scars of
intercostal intubations (in 5th space in midaxillary line) or thoracotomy scar.
b- Inspect the chest wall for dilated veins, which indicate superior vena cava obstruction. If
obstruction is proximal to the azygos vein, dilated veins will be seen all over the chest wall
and if obstruction is distal to the azygos vein, dilated veins is seen mainly around the
shoulder.
c- Cutaneous lesions such as skin eruptions, sarcoid nodules (especially in scar areas),
malignant nodules, purpuric spots, bruises or discharging sinuses should be noticed.
7- Position of the Trachea: (Trill’s sign):
a- Trachea is central in its cervical part & it is an indicator of the mediastinal position.
b- Tracheal displacement is suspected if prominence of the sternomastoid muscle on one side
is present.
c- The trachea may be displaced to opposite side by pneumothorax or pleural effusion or
drawn to the same side by pulmonary fibrosis or collapse or pleural fibrosis.
8- Subcostal angle:
a- Normally, the subcostal angle is from 70– 110o.
b- Increased obtuseness indicates gradual increase in intrathoracic or intra-abdominal pressures
and increased acuteness indicates abnormal protrusion of the sternum as in pectus
excavatum or emphysema.
PALPATION
It includes the following:
-
Movement of the chest
Mediastinum position
Tenderness
TVF
Pulsations
Palpaple rhonchi
1- Movements of the chest wall:
a- Respiratory movements are compared on infraclavicular, mammary areas, inframammary
and infrascapular areas.
b- Hands are put (with fingers directed towards clavicles) to compare movements of the
infraclavicular areas.
c- Grasping the sides of the chest with the outstretched thumbs near the middle line and asking
the patient to take a deep breath examine movements of the mammary, inframammary and
infrascapular areas.
Unilateral reduction of chest wall movement occurs in pleural effusion, pneumothorax, empyema and in
pulmonary consolidation and collapse. In bronchial asthma, emphysema and diffuse pulmonary fibrosis
movements of the chest wall are symmetrically reduced (in the first two cases due to over inflation of the
lungs and in the last case the movement is restricted by the less distensible lungs).
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(1)
(2)
(3)
(4)
Infraclavicular
Mammary
Inframammary
Estimation of chest movement anteriorly
(1)
(2)
Suprascapular areas
Subscapular areas
Estimation of chest movement posteriorly
2- Position of the mediastinum
-Determinded by both the position of the trachea and the cardiac apex
- Trachea:
a- Position of the trachea is determined by thrusting the tip of the index finger gently into the
suprasternal notch and noticing the resistance on each side of the trachea, the side with least
resistance indicates that the trachea is shifted to the other side.
b- Normally, trachea is central in its cervical part and slightly shifted to the right in its
intrathoracic part, this shift is not felt clinically.
c- A downward movement of the trachea and larynx during inspiration, detected by thumb and
index fingers on the sides of the thyroid cartilage, is felt in COPD patients due to contractions
of the low flat diaphragm.
d- Tracheal tug (downward pull on the trachea and larynx during systole) is felt in cases of
aortic aneurysm.
3-Local tenderness:

Search for local tenderness by superficial palpation of the chest while looking at the
patient’s face to see if there is pain at special areas.
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
Subcutaneous emphysema is recognized by the crackling sensation.
4- Tactile vocal fremitus (TVF):
a- This sign detects vibrations transmitted to the hand from the larynx. While putting palm of
the same hand on the chest in identical areas on the both sides in turn, the patient is asked to
say 44 in Arabic and follow the direction of the main bronchus and be away from the midline
b- Pathologically, vocal fremitus is diminished when a bronchus is blocked as in tumors and in
pleural effusion or pneumothorax, which damps down vibrations.
Increased vocal fremitus occurs when vibrations are better conducted as in cases of:
iLung consolidation as in pneumonia.
iiConsolidation collapse with a patent bronchus.
iiiA large cavity or cavity surrounded by consolidation.
ivAt upper level of a pleural effusion posteriorly because the collapsed lung floats on
fluid and becomes in close contact with trachea and chest wall.
vIn tension pneumothorax because the lung is collapsed totally and transmission of
vibrations is directly from the trachea.
(1)
(2)
(3)
Infraclavicular area
Mammary area
Inframammary area
Steps in estimation of TVF anteriorly, note do each step on both sides in turn
(1)
(2)
(3)
(4)
Suprascapular
Upper interscapular Lower interscapular
Subscapular
Steps in estimation of TVF posteriorly, note do each step on both sides in turn
6- Palpable adventitious sounds:
a- Palpable pleural rub may be present in the lower axillary or infrascapular areas.
b- Palpable rhonchi may be present in asthmatic patients.
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7- Pulsations:
a- The hand should be placed on each side of chest to avoid overlooking dextrocardia. The
apex, left parasternal 3rd and 4th spaces, pulmonary, aortic and epigastric areas should be
palpated for pulsations.
b- Pulsations in pulmonary area indicate pulmonary hypertension or pulmonary artery
aneurysm. A palpable pulmonary component of the 2nd heart sound “diastolic shock” is
present in pulmonary hypertension.
Form of the chest: Diameters of the chest are measured by the pelvimeter. The sternum and ribs
should be palpated for any masses. It is important to examine the vertebral column by passing
your fingers (the thumb and index fingers) along the lateral borders of the spine from above
downwards to see if there is kyphosis, scoliosis or kyphoscoliosis. Scoliosis may be acquired
(secondary to lung or pleural diseases where the curve of spine is towards the diseased side) or
congenital (curve of spine is towards the healthy side).
PERCUSSION
1- Percussion is setting up artificial vibrations in a tissue by means of a sharp tap with the fingers.
The middle finger of the left hand is placed in close contact with the chest wall and a blow is
made on the second phalanx with the middle finger of the right hand. The striking finger must be
kept at right angle to the other finger and wrist movement makes striking and the finger must be
lifted immediately to avoid damping vibrations.
2- Usually percussion of the chest is light percussion except at the back (a large mass of tissue) or on
determination of the upper border of the liver anteriorly.
3- Percussion proceeds from resonant to dullness and parallel to the percussed border (except in
Kronig’s isthmus where it proceeds from dullness to resonance).
4- Normal resonance is found over lung tissue, hyperresonance is found in emphysema and
pneumothorax and tympany is found over the stomach. Normal dullness is found over solid
viscera such as the liver and the heart, impaired note is found over consolidated or collapsed lung
and stony dullness is found in cases of pleural effusion.
5- Percussion note should be done on both sides of chest as follows:
a- Anteriorly:
iClavicles.
iiRight border of the heart
iiiUpper border of the liver
ivBare area of the heart
vTraubs area
viComparative percussion for both lungs
- From 1st intercostals space to upper border of liver on right and to the
6th intercostal space on the left side in midclavicular line.
- Percussion may be done also in the anterior axillary line.
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-
Axillae: From 4th to 7th intercostals spaces in the midaxillary line.
b- Posteriorly:
iKronig’s isthmus.
iiSuprascapular area.
iiiInterscapular areas.
ivScapular areas.
vInfrascapular areas down to the 11th rib or 12th thoracic spine.
6- During percussion of back, on reaching level of the diaphragm, we do tidal percussion to detect
diaphragmatic mobility on each side. Tidal percussion differentiates between supra and
infradiaphragmatic dullness and detects diaphragmatic paralysis.
7- If there is dullness at any line we do shifting dullness to detect any fluid level
(hydropneumothorax) and we repeat it in three planes to see if it is localized or not (while sitting
in midclavicular line and in the midaxillary line and while lying flat).
1-
Bare area of the heart, normally dull by light percussion, becomes resonant in emphysema and left
sided pneumothorax. When the heart is enlarged or in pericardial effusion the size of the dullness
increases.
2- Dullness in Traube’s area may be due to:
a- Left pleural effusion.
b- Left basal consolidation.
c- Enlarged left lobe of the liver.
d- Ascites.
e- Splenomegaly.
f- Full stomach and gastric carcinoma.
3- Increased resonance of Traube’s are may be due to:
a- Left basal collapse.
b- Pneumoperitoneum.
c- Cirrhotic shrunken liver.
d- Splenectomy.
e- Dilatation of the stomach.
Anterior
Posterior
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Areas of percussion
Anterior
Posterior
Tidal percussion
AUSCULTATION
1- Normal breath sounds are generated by turbulence of air in the large airways. They are composed
of two elements: the bronchial and the vesicular elements.
2- Normally, expiration is longer than inspiration, with inspiration/expiration ratio of 1:1.33, but
clinically inspiration is heard longer than expiration because flow of air is turbulent (active
process) while it is laminar in expiration (passive process).
3- Auscultation determines:
a- Equality of Breath Sounds.
b- Intensity of Breath Sounds: Decreased in emphysema and in bronchial obstruction.
c- Character of the Respiratory sounds:
1. Vesicular breathing: inspiration longer and expiration nearly inaudible.
2. Bronchial breathing: inspiration= expiration with a gap in-between.
iOrdinary bronchial: over trachea and in massive effusion.
iiCavernous: over large cavities.
iiiTubular: in pneumonic consolidation.
ivAmphoric: in tension pneumothorax.
3. Bronchovesicular: Normally occurs near lung roots behind & in upper lobes near middle
line anteriorly (inspiration=expiration without gap).
d- Vocal resonance:
a. Quantitative changes:
i. Increase: bronchophony and pectoriloquy. Vocal resonance is examined for by
asking the patient to say 44 in Arabic in loud voice and then to whisper it to
detect for whispering pectoriloquy. The presence of whispered pectoriloquy over
the spinous process of the 4th, 5th and 6th thoracic vertebrae in adults & over the
first 2 or 3 thoracic spines in infants is called D’Espin’s sign. Bronchophony and
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e-
whispering pectoriloquy are heard in the same instances with bronchial
breathing.
ii. Decrease: as in pleural effusion and pneumothorax.It is a confirmatory test which
is used mainly to confirm the presence of hollow breathing
b. Qualitative changes: Egophony: It is a peculiar form of vocal resonance which is heard at
the upper limit of pleural effusion posteriorly. It is detected by asking the patients to say
“A” which will be heard as “E”.
Adventitious sounds:
a. Rhonchi: Sibilant (high pitched) and sonorous (low pitched). They are caused by
vibrations of the walls of narrowed airways and are more evident during
expiration.comment on type,site and the time
b. Crepitations:
i. Coarse: They are mainly audible during inspiration and are usually due to
increased secretions resulting from chronic bronchitis or bronchiectasis. Coarse
bubbling crepitations occur in bronchopleural fistula. They may vary from breath
to breath and be modified or abolished by coughing.
ii. Fine: They represent the opening of a small airway previously closed (or opening
of collapsed alveoli). They are most numerous during the second half of
inspiration and are not influenced by cough. Such crackles are heard in
pulmonary fibrosis & edema, allergic alveolitis, cystic fibrosis, miliary
tuberculosis, pneumonic consolidation (especially as resolution begins) and over
infarcted lung. Post-tussive crepitations may also be heard in cases of pulmonary
tuberculosis.
iii. Comment on site,type and the timing whether inspiratory or expiratory
c. Pleural rub: It is a coarse leathery sound that tends occurs in the same part of the
respiratory cycle (during both inspiration and expiration). It is not altered by cough. The
intensity of pleural rub is often increased by deep breathing and by firm pressure of the
stethoscope. Pleural rub is distinguished from pericardial rub by its disappearance on
holding breath.
F – Auscultate the heart especially the pulmonary area
Anterior
Posterior
Areas of auscultation
‫الحمد هلل‬
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