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Local Examination Local Examination Of The ChestOf The Chest

Ashraf Madkour, Ashraf Madkour, MD, Dr.med., FCCPMD, Dr.med., FCCP

Chest department - Ain Shams UniversityChest department - Ain Shams University

ashraf_madkour@yahoo.comashraf_madkour@yahoo.com

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• InspectionInspection

• PalpationPalpation

• PercussionPercussion

• AuscultationAuscultation

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

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1-Shape of the chest.1-Shape of the chest.

2-Movement2-Movement

3-Symmetry3-Symmetry

5-Skin5-Skin

•PulsationsPulsations

•Scars, Dilated veins or PigmentationScars, Dilated veins or Pigmentation

7-Subcostal angel7-Subcostal angel

8-Special signs8-Special signs

InspectionInspection

::

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1- Shape of the Chest:1- Shape of the Chest:

• Normal ShapeNormal Shape• Elliptical/bilaterally symmetrical /freely mobile/oblique ribs /subcostal angle Elliptical/bilaterally symmetrical /freely mobile/oblique ribs /subcostal angle

70-110 º70-110 º

• Barrel shaped chestBarrel shaped chest• APAP T diameter/ bilaterally symmetrical / diminished expansion/ prominent T diameter/ bilaterally symmetrical / diminished expansion/ prominent

sternum /transverse ribs /subcostal angle obtuseºsternum /transverse ribs /subcostal angle obtuseº

• Pigeon chestPigeon chest

• Rachitic chestRachitic chest

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

Inspection:Inspection: Local Examination of the Local Examination of the ChestChest

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Barrel Chest

AP Diameter = Transverse Diameter

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Shape: Pectus ExcavatumShape: Pectus Excavatum

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Shape: Pigeon ChestShape: Pigeon Chest

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Movement:

Equality: Equality:

Compare clavicles, nipples, costal margins, spine of scapulae Compare clavicles, nipples, costal margins, spine of scapulae

(post.)(post.)

The less mobile side or site is the diseased one

e.g. Equal movement on both sides or

Decreased movement on (site- {e.g. right inframammary})

Movement is decreased in all diseases of chest

Unilateral ………. Or bilateral………………….

Expansion:Expansion:

N → N → 4-64-6cm max insp. & max exp. cm max insp. & max exp. 2 cm→ 2 cm→ pathological pathological

e.g. Normal expansion or decreased expansion

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Movement:

Rate: Rate: e.g. 16 breath per minute.

Pattern of breathing:Pattern of breathing:

e.g. thoracoabdominal or Abdominothoracic

Rhythm:Rhythm:

e.g. normal regular rhythm or irregular rhythm.

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• Normal chest: symmetrical on both Normal chest: symmetrical on both

sides sides • The diseased side or site got

limited movement.

• Bulge: chest wall…., Pleura…., Bulge: chest wall…., Pleura….,

lung….., mediastinum….lung….., mediastinum….• Retraction: Retraction: Pulmonary collapse , Pulm.

Fibrosis, Pleural fibrosis, ……..

Symmetry :

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e.g. Symmetrical on both sides

or Asymmetrical type: Bulge or Retraction Site: e.g. left

inframammary

Symmetry :

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• Scars, Dilated veins or PigmentationScars, Dilated veins or Pigmentation

• e.g. no scars, dilated veins or pigmentation

Skin:Skin:

SVC ObstructionSVC Obstruction

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ApicalApical

EpigastricEpigastric

Other pulsationsOther pulsationse.g.

Apex: Apical pulsation is visible in (site)

or invisible.

Epigastric: Epigastric pulsation is visible

or invisible.

Other pulsations

Pulsations:Pulsations:

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Palpation: Palpation:

•Tenderness:

•Movement

•Tactile vocal fremitus (TVF)

•Palpable adventitious sounds

•Pulsations

•Trachea:

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Palpation: Palpation:

Movement:Front: Front: infraclavicular, mammary, inframammary. infraclavicular, mammary, inframammary. Back:Back: scapular, infrascapular scapular, infrascapular

e.g. Equal movement on both sides or Decreased movement on (site- {e.g. right inframammary})

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Movement:

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Movement:

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Causes of decrease of chest wall movements Causes of decrease of chest wall movements ::

Unilateral Unilateral ↓↓ of chest wall movements: of chest wall movements:•Pleural effusionPleural effusion•EmpyemaEmpyema•PneumothoraxPneumothorax•Pulmonary consolidationPulmonary consolidation•Pulmonary collapsePulmonary collapse•pulmonary fibrosispulmonary fibrosis

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

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TVF

TVF: Palpable vibration of sound.

Intensity depends on: Intensity depends on:

– Nature of conducting media( √ consolidation)

– Nº of media (no of media→ TVF due to reflection & deflection of vibration)

– Diameter of conducting tube.

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TVFTVF

TVFTVF TVFTVF Consolidation (nature of

media)

Cavitation (Nº of media)

Collapse with patent main bronchus (Nº of media)

Pleural effusion (Nº of media)

Pneumothorax (nature of media)

Emphysema (nature of media)

Collapse (Diameter of conducting tube)

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Palpable Adventitious SoundsPalpable Adventitious Sounds

Palpable adventitious soundse.g. Palpable adventitious sounds or No palpable adventitious sounds.

Palpable Pleural Rub

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PulsationsPulsations

PulsationsApex: (site)Others:

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Position of the Trachea:Position of the Trachea:

e.g. Central or shifted to (right or left)

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Causes of deviation of the tracheaIpsilateralIpsilateral

(To pull)(To pull)

ContralateralContralateral

( To push)( To push)

CollapseCollapse

FibrosisFibrosis

Apical massApical mass

Pleural effusionPleural effusion

PneumothoraxPneumothorax

Position of the Trachea:Position of the Trachea:

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Percussion:TechniquePercussion:Technique

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Percussion - technique

Hyperextend middle finger and place IP joint firmly against Hyperextend middle finger and place IP joint firmly against patients chest (pleximeter)patients chest (pleximeter)

Finger // to border percussedFinger // to border percussed

Tap with Rt middle finger (plexor)Tap with Rt middle finger (plexor)

Movement Movement from wrist from wrist

2-3 taps & do not damp2-3 taps & do not damp

Same: plexor, pleximeter, force & space on either sidesSame: plexor, pleximeter, force & space on either sides

Start from healthy sideStart from healthy side

Percussion notes: Percussion notes: normal resonance/impaired note/ dull / normal resonance/impaired note/ dull / stony dullness/hyper-resonant (stony dullness/hyper-resonant (resonance)/ tympanitic resonanceresonance)/ tympanitic resonance

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Percussion: Anterior ChestPercussion: Anterior Chest

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Percussion: Posterior ChestPercussion: Posterior Chest

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Percussion:Percussion:

Upper border of liver is in the (e.g. 5th ) intercostal space in Midcalvicular line (MCL).

Bare area of heart is (dull or resonant)

Kronig`s isthmus is (dull or resonant)

Traub`s area is (tympanatic or resonant or dull)

Comparative percussion of the lungs

– Front MCL, Midaxillary line (MAL) (Rt & Lt)

– Back Paravertebral then scapular line(SL)over suprascapular, scapular, upper & lower interscapular areas and infrascapular areas

e.g. By comparative percussion there is Normal resonant note on both side in MCL, MAL& SL.

Diffuse area of stony dullness over (Site/e.g. Rt lower axillary & infrascapular areas)

Impaired note over (Site /Lt infraclavicular area)

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Percussion:Percussion:

Tidal percussion (Rt & LT)

e.g. Positive tidal percussion (mobile diaphragm)

immobile diaphragm (Rt or Lt)

Direct percussion over bony prominences

– Clavicle , sternum, spines of scapula, spines

for tenderness or percussion note changes

e.g. no tenderness or percussion note changes.

Shifting dullness

Done in presence of diffuse dullness only

e.g. positive or negative test.

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Auscultation:Auscultation:

Intensity of breath soundsIntensity of breath sounds

Character of breath soundsCharacter of breath sounds

Adventitious soundsAdventitious sounds

Vocal resonance Vocal resonance (Confirmatory signs of bronchial breathing)(Confirmatory signs of bronchial breathing)

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Auscultation:Auscultation:

•Breath soundsIntensity of breath sounds

e.g. equal intensity of breath sounds orGeneralized decrease of intensity of breath sounds.

or

Decrease of intensity of breath sounds over (Site/e.g. Rt lower axillary area). Or

Absence of intensity of breath sounds over (Site/e.g. Lt lower axillary area).

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Auscultation:Auscultation:

Character of respiratory soundse.g. Vesicular breathing Harsh Vesicular breathing Bronchial breathing

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Auscultation:Auscultation:

Vocal resonance (Confirmatory signs of bronchial breathing):

•Bronchophony (present or absent)

•Whispering pectoroliquy (present or absent)

•Aegophony E→A (present or absent)

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Auscultation:Auscultation:

Adventitious sounds Site: Generalized or localized (e.g. Rt upper axillary area). Timing: Inspiratory or expiratory or both Type:

e.g. Sibilant or sonorous ronchi or both

Fine or coarse crepitations Pleural rub

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