CHEST EXAMINATION GENERAL EXAMINATION • Introduce yourself & take permission while pt. 45 degree. • Observe important stuff in patient background, as tissues & if possible color of the phlegm, Oxygen supply. • Hands: cyanosis, clubbing ( suppurative lung disease, SCC,idipathic pulmonary fibrosis), tight skin (SS), joint swelling (RA), tar stain, steroid SE ( purpura/paper skin), palmar erythema (RA), tremors (fine: B+,coarse:RF). Pulse for pounding (hypercapnia), pulsus paradoxicus ( severe asthma), distract pt while counting for RR (No:12-20). • Face: uveitis (SS,RA), pallor (anemia of chronic disease),jaundice (alpha1 antitrypsin,cancer,MAC), puffy eyes (amyloidosis, lymphoma,GP$).tongue (cyanosis), pursed lip breathing (CO2 retension), parotid enlargement (sarcoidosis, lymphoma). • Neck: raised JVP (corpulmonale), LNDs (TB/cancer/atypical pneumonia). • LL: edema (amyloidosis/corpulmonale), DVT. LOCAL (FRONT INSPECTION) • Proper exposure from face to umblicus while pt.lie flat. • Start inspection from foot of bed by asking the patient to take deep breath then from side of the bed while asking the pt. to put his hands on his head ( type of breathing/limited expansion/scar/depression/axilla &axillary lines). • Chest wall abnormalities are also examined, and may include: • Kyphosis, abnormal anterior-posterior curvature of the spine • Scoliosis, abnormal lateral curvature of the spine • Barrel chest, - chest wall increased anterior-posterior; normal in children; typical of hyperinflation seen in COPD • Pectus excavatum - sternum sunken into the chest • Pectus carinatum - sternum protruding from the chest BREATHING PATTERN 1. Cheyne-Stokes respirations (cycles of 30 seconds-2minutes) caused by strokes, traumatic brain injuries, brain tumors, carbon monoxide poisoning, and metabolic encephalopathy or first-time high altitude sickness, normal side-effect of morphine administration. 2. Biot’s breathing (cluster respiration) Caused by damage to the medulla oblongata by stroke (CVA) or trauma, pressure on the medulla due to uncal or tentorial herniation or prolonged opioid abuse. 3. Kussmaul’s respirations Caused by ketoacidosis, uremia, salicylate, metabolic acidosis. 4. Apneustic respirations caused by damage to the upper part of the pons “respiratory center”. 5. Ataxia respirations caused by damage to the medulla oblongata secondary to trauma or stroke. This respiratory pattern usually indicates a very poor prognosis. BREATHING PATTERN (FRONT PALPATION) • CHEST EXPANSION.. ask patient to take deep breath in & out with your hands comparing both lungs: • Longitudinal over the first 3intercostal spaces in the parasternal line. • Vertical over the nipple line with your thumbs perpendicular on your hands with a flap of skin between both thumbs. • Vertical over infra mammary line with a flap of skin… • TACTILE VOCAL FREMITUS: With the ulnar border of your hands placed in same intercostal space in the right then compare it with the left side while the patient is asked to say 99 or 44 in arabic. • Palpation of the apex & palpable P2 might be appropriate in certain cases. FRONT PERCUSSION • Put middle finger of your indominant hands on the area to be percussed& percuss twice with middle finger of dominant hands. • First clavicle percussion.. Either indirect or take permission of the patient to do it direct ( painful secondry to osteoprosis secondry to long term steroid intake). • Second MCL in 2 supra mammary intercostal spaces, mammary space & 2 infra mammary spaces with the left line deviated alittle from the heart outline. FRONT AUSCULTATION • Same sites of percussion while patient taking breath from his mouth while it is opened. • Comment on: breath sounds, type of breath ( vesicular, vesicular with prolonged expiration, bronchial), additional sounds: Wheezes, describing a continuous musical sound on expiration or inspiration. A wheeze is the result of narrowed airways. Common causes include asthma and emphysema, Crackles or rales. Intermittent, non-musical and brief sounds. Comment on timming, intensity as fine (soft, high-pitched) or coarse (louder, low-pitched) and relation to cough. Pleural rub ( stitchy continous sound). • Vocal resonance while the patient is saying 99 or 44 in arabic. AXIALLARY LINE EXAMINATION • Ask the patient to put his hands over his head & do percussion & auscultation in 3 intercostal spaces. NECK EXAMINATION (while patient sitting dawn) • TRACHEA: inspection for prominent clavicular head of sternomastoid. • Palpation for shift by putting index & ring finger over clavicular heads of sternomastoid & touch gently the space between trachea & both heads with index to check if there is deeper space .. Shift, For tracheal tug by putting ring & index on the trachea & if it is moving antero posterior .. Tracheal tug positive, For crico sternal notch by counting fingers that could be applied between cricoid & sternum.. More than three positive. • APEX OF LUNGS: percussion with index perpendicular on clavicle and Auscultate with cone. • LYMPH NODE EXAMINATION BACK EXAMINATION • INSPECTION: while patients hands by his sides. • PALPATION: hands longitudinal inter scapular then vertical infra scapular while patient hands by his sides. • PERCUSSION: with patient hands hugged from front, 1 space supra scapular, 2 spaces inter scapular, 2 spaces infra scapular. IMPORTANT DIFFERENTIAL DIAGNOSIS SIGNS OF HYPERINFLATION • Inspection: pursed lips, indrawing of supraclavicular, intercostal spaces (accessory muscles), increased antero-posterior diameter, flat ribs, increased subcostal angle, limited expansion. • Palpation: limited expansion, absent apex, tracheal tug, reduced cricosternal notch. • Percussion: hyperresonance, encoarchement of cardiac, liver dullness. • Auscultation: reduced breath sounds, vesicular with prolonged expiration. POSITIVE END EXPIRATORY PRESSURE maintain pressure in lung & inhibit collapse • Pursed lips. • Prolonged expiration. • Forced expiratory timing: stethoscope over trachea & ask patient to take deep breath and hold then expirate all (if it take more than 6seconds.. Positive). CO2 RETENSION SIGNS • • • • Bounding pulse. Warm hands. Flappy tremors. Papilledema. DIFFERENTIAL DIAGNOSIS OF BASAL DULLNESS • Consolidation: rare to be bilateral, shows increased breath sounds,vocal resonance. • Collapse: midline shift & dullness is not stony with absent breath sounds. • Pleural thickness: not higher in back, normal vocal resonance. • Diaphragm paralysis: changed level between inspiration &expiration. DIFFERENTIAL DIAGNOSIS OF LATERAL THORACOTOMY • PNEUMONECTOMY: unilateral depressed/ deformed chest with extensive tracheal shift, need more than 1 drain(scar). • LOBECTOMY: upper shows reduced breath sounds in front with extensive tracheal shift/ lower shows back changes with no or minimal shift.