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]
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InspectionInspection
PalpationPalpation
PercussionPercussion
AuscultationAuscultation
Local Examination of the Local Examination of the Chest:Chest:
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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
::
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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
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Shape: Shape: ↑ ↑ AP diameterAP diameterLocal Examination of the Local Examination of the ChestChest
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Shape: Pectus ExcavatumShape: Pectus ExcavatumLocal Examination of the Local Examination of the ChestChest
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Spine Deformity: KyphosisSpine Deformity: KyphosisLocal Examination of the Local Examination of the ChestChest
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Spine Deformity: ScoliosisSpine Deformity: ScoliosisLocal Examination of the Local Examination of the ChestChest
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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 :
Local Examination of the Local Examination of the ChestChest
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Shape: Pigeon ChestShape: Pigeon ChestLocal Examination of the Local Examination of the ChestChest
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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
Local Examination of the Local Examination of the ChestChest
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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 :
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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
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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
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Skin: Skin: SVC ObstructionSVC ObstructionLocal Examination of the Local Examination of the ChestChest
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ApicalApical
ParasternalParasternal
EpigastricEpigastric
Pulsations:Pulsations:Local Examination of the Local Examination of the ChestChest
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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
Local Examination of the Local Examination of the ChestChest
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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
Local Examination of the Local Examination of the ChestChest
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Symmetry & Movement:Local Examination of the Local Examination of the ChestChest
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Palpation: Chest ExcursionPalpation: Chest ExcursionLocal Examination of the Local Examination of the ChestChest
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TVFTVF
Increased TVFIncreased TVF Decreased TVFDecreased TVF
Consolidation
Cavitation
Collapse with patent main bronchus
Thick chest wall
Pleural effusion
Pleural fibrosis
Pneumothorax
Emphysema
Collapse
Local Examination of the Local Examination of the ChestChest
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Palpable Adventitious SoundsPalpable Adventitious Sounds
Palpable RhonchiPalpable Rhonchi
•Diffuse
•Localized and Persistent
Palpable Pleural Rub
Local Examination of the Local Examination of the ChestChest
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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.
Local Examination of the Local Examination of the ChestChest
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Position of the Trachea:Position of the Trachea:Local Examination of the Local Examination of the ChestChest
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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
Local Examination of the Local Examination of the ChestChestPosition of the Trachea:Position of the Trachea:
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Percussion:TechniquePercussion:TechniqueLocal Examination of the Local Examination of the ChestChest
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Percussion
Cut your nails
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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.
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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.
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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.
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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.
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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
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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.
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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
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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.
Tidal percussion:Tidal percussion: Local Examination of the Local Examination of the ChestChest
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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)
Local Examination of the Local Examination of the ChestChest
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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.
Local Examination of the Local Examination of the ChestChest
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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.
Local Examination of the Local Examination of the ChestChest
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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
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Auscultation:Adventitious soundsAuscultation:Adventitious sounds
Crepitations: typesCrepitations: types
Rhonchi: sibilant and sonorousRhonchi: sibilant and sonorous
Pleural rubPleural rub
Local Examination of the Local Examination of the ChestChest
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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
Local Examination of the Local Examination of the ChestChest
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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.
Local Examination of the Local Examination of the ChestChest
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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.
Local Examination of the Local Examination of the ChestChest
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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 Examination of the Local Examination of the ChestChest
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