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.