‫بسم هللا الرحمن الرحيم‬
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.
 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 6th costal cartilage, where it turns laterally to meet the midclavicular
line at the 6th rib, the midaxillary line at the 8 th 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
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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 paravertebral line).
Anterior
Posterior
Surface anatomy of the lungs and pleurae from anterior and posterior
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3- Kronig’s isthmus:
a- Anterior: Medial 2/3 of the clavicle.
b- Posterior: Medial 1/3 of spine of scapula.
c- Medial: A line joining sternoclavicular joint with the 7 th cervical spine
posteriorly.
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 laterally to cut the 5 th 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 4th rib to meet the oblique fissure at the 5 th rib in
midaxillary line.
Surface anatomy of the lung fissures from anterior
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Surface anatomy of lung fissures from lateral positions
Surface anatomy of lung fissures from posterior
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.
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6- Bare area of Heart: An area over the anterior chest wall extending from
the 4th to the 6th costal cartilages and from the left sternal border to the left
parasternal line.
7- Heart:
abcd-
Left 5th intercostal space, 3.5 inches from median plane.
Left 2nd costal cartilage, 1.5 inches from median plane.
Right 3rd costal cartilage, 1.0 inches from median plane.
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.
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
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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.
g- Unilateral retraction: fibrothorax and lung collapse.
2- Movement of the chest:
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).
f- 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.
g- 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.
3- Symmetry of the chest:
a. Healthy chest is bilaterally symmetrical with smooth contours.
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b. Causes of asymmetry: pleural effusion or fibrosis and lung collapse or
fibrosis.
4- Rate and type of respiration:
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 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 or decreased sensitivity
of the respiratory center to CO2.
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 CO 2 wash) with
tetany and drowsiness.
5- Pulsations over the Chest Wall:
a- The cardiac pulsations should be examined. In emphysema, the
hyperinflated lungs may obscure all the precordial pulsations except
those on epigastrium.
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b-
The apex may be displaced to opposite side by pneumothorax or pleural
effusion, or drawn to same side by pulmonary collapse or fibrosis or
pleural fibrosis. It is a guide to the position of the mediastinum.
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- Lower Intercostal Spaces (Litten’s sign):
a- 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.
b- Contraction of a low flat diaphragm causes pull on the lower intercostal
spaces.
9- Subcostal angle:
a- Normally, the subcostal angle is from 70– 110o.
b- Increased obtuseness indicates gradual increase in intrathoracic or intraabdominal pressures and increased acuteness indicates abnormal
protrusion of the sternum as in pectus excavatum or emphysema.
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PALPATION
1- 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).
2- 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.
 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.
b- Pathologically, vocal fremitus is diminished when a bronchus is blocked
as in tumors and in pleural effusion or pneumothorax, which damps
down vibrations.
c- Increased vocal fremitus occurs when vibrations are better conducted as
in cases of:
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iiiiiiiv-
v-
Lung consolidation as in pneumonia.
Consolidation collapse with a patent bronchus.
A large cavity or cavity surrounded by consolidation.
At upper level of a pleural effusion posteriorly because the
collapsed lung floats on fluid and becomes in close contact
with trachea and chest wall.
In 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
5- Movements of the chest wall:
a- Respiratory movements are compared on infraclavicular, mammary
areas, inframammary, suprascapular, interscapular, scapular and
infrascapular areas.
b- Hands are put (with fingers directed towards clavicles) to compare
movements of the infraclavicular areas. For movements of the
suprascapular areas hands are put also with the fingers directed upwards.
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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.
d- 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).
(1)
(2)
(3)
Infraclavicular
Mammary
Estimation of chest movement anteriorly
(4)
Inframammary
(1)
(2)
Suprascapular areas
Subscapular areas
Estimation of chest movement posteriorly
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 2 nd
heart sound “diastolic shock” is present in pulmonary hypertension.
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 compared on both sides of chest as follows:
a- Anteriorly:
iClavicles.
iiFrom 1st intercostals space to upper border of liver on right and to
the 6th intercostal space on the left side in midclavicular line.
iiiPercussion may be done also in the anterior axillary line.
b- Axillae: From 4th to 7th intercostals spaces in the midaxillary line.
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c- Posteriorly:
iKronig’s isthmus.
iiSuprascapular area.
iiiInterscapular areas.
ivScapular areas.
vInfrascapular areas down to the 11th rib or 12th thoracic spine.
6- We start percussion by determining the upper border of the liver in the
midclavicular line then comparative percussion on both sides of chest (each
side in turn space by space) in midclavicular, midaxillary and scapular lines.
7- On reaching upper border of the liver, we fix the finger and ask the patient to
take a deep breath and then we repercuss again to see whether the diaphragm
is mobile or not (tidal percussion). After finishing tidal percussion, and the
finger is still in place, we percuss lightly to see lung encroachment on liver
dullness (hyperinflation or emphysema).
8- 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.
9- 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).
10- 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.
11abcdef-
Dullness in Traube’s area may be due to:
Left pleural effusion.
Left basal consolidation.
Enlarged left lobe of the liver.
Ascites.
Splenomegaly.
Full stomach and gastric carcinoma.
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12abcde-
Increased resonance of Traube’s are may be due to:
Left basal collapse.
Pneumoperitoneum.
Cirrhotic shrunken liver.
Splenectomy.
Dilatation of the stomach.
Anterior
Posterior
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
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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 whispering pectoriloquy are
heard in the same instances with bronchial breathing.
ii. Decrease: as in pleural effusion and pneumothorax.
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”.
e- Adventitious sounds:
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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.
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.
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.
Anterior
Posterior
Areas of auscultation
‫ استاذ اآلمراض الصدرية‬- ‫ شريف البوهى‬:‫د‬.‫الحمد هلل ا‬