PHYSICAL DIAGNOSIS
THE CHEST
DR SHAM A. CADER
THE ORGANS
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ANATOMY
• One should have a clear understanding of
anatomy of the respiratory system to
perform a proper physical exam. Some of
the important anatomical details are
outlined below.
TRACHEA
1. Starts from cricoid cartilage to sternal angle
anteriorly and T4 spinous process posteriorly, where
it divides into left and right main stem bronchi. This
information is important in understanding D'spine
sign seen in patients with large Mediastinal mass.
2. Trachea is slightly slanted to right.
Bronchovesicular breathing heard in right
infraclavicular region is due to this phenomenon.
3. Trachea has intra and extra thoracic components.
This has important bearing in the understanding of
physiology of variable obstruction.
MANUBRIUM ANGLE
• The angle between the body and Manubrium.
Many important land marks occur at this level.
It is called Louis Angle.
• 2nd rib articulates to Manubrium at this site.
The ribs are counted anteriorly starting from
this point.
• Carina of trachea is at this level.
• Mediastinum is divided into superior and
inferior at this level.
RIBS
• Anteriorly ribs are counted down starting from
2nd rib. There are 12 ribs and 11 interspaces.
You can also count up from 12th rib. Inferior
angle of scapula sits on 7th rib posteriorly.
SPACES
• Anteriorly there are supra clavicular,
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infraclavicular, precardiac and Traube's space.
Posteriorly we have interscapular, supra, and infra
scapular spaces.
Infraclavicular: Space below clavicle
Supraclavicular: Space above clavicle
Precardiac: Space in front of heart
Traube's: Space overlying stomach
Interscapular: Space between scapula
Suprascapular: Space above scapula
Infrascapular: Space below the scapula
LINES
• Midsternal Line: A vertical line down the middle of
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sternum
Parasternal Line: A vertical line along lateral edge
of sternum
Mid-Clavicular Line: A vertical line from middle of
clavicle
Anterior Axillary Line: A vertical line along anterior
axillary fold
Mid-Axillary Line: A vertical line at mid point
between anterior and posterior axillary line.
Posterior Axillary Line: Along post axillary fold
Scapular Line: Inferior angle of scapula
Vertebral line: Over spinous processes in the midline
Right Lung:
• With a marking pen start 3 centimeters above
clavicle in midclavicular line, come down along
right parasternal line , join to 6th rib in
midclavicular line, to 8th rib in mid-axillary
line, to 10th rib posteriorly, to vertebral line
posteriorly.
Left Lung:
• At angle of Louis, follow the outer margin of
heart to 6th rib in mid-clavicular line.
• Appreciate that apex of lung is just under the
skin easily palpable in the supraclavicular
space.
• Pancoast tumor and TB occur at this site.
Hence, the apex of lungs should be routinely
examined.
Surface Anatomy of Lobes
• Draw oblique fissure by drawing a line strait
from 6th rib in MCN. to 5th rib in mid axillary
line and along the medial margin of scapula
(with the patients hands on head) to 3rd spinous
process
• Transverse fissure can be drawn by
drawing a line from 5th rib in midaxillary line to 4th rib anteriorly
Once the fissures are drawn over the outline of lungs, one
can easily recognize the surface anatomy of lobes of lungs.
One can then appreciate the importance of examining the
patient all around the chest to cover the lobes. Most of
lower lobe is in back, upper lobe is in front and all of
middle lobe is in front. In the axilla all of the three lobes
can be seen.
DIAPHRAGM
• Pleura: Once the diaphragm has been outlined
you can appreciate that the pleural gutter is deep
posteriorly. Fluid thus tends to accumulate
posteriorly
• Mediastinum is the space between lungs from inlet to
outlet of thorax. Anteriorly it is between parasternal
lines. Posteriorly it is at vertebral line. Mediastinum is
narrow posteriorly and widens anteriorly. Inferiorly it
extends to xiphisternum. Superiorly it starts at
suprasternal notch. Since the inlet of thorax is slanted,
only posterior Mediastinum extends to neck.
• Sternal angle separates superior from inferior
Mediastinum. The inferior Mediastinum is
divided into anterior, middle and posterior
compartments. The space in front of heart is
anterior Mediastinum and behind is posterior
Mediastinum. Heart itself defines the middle
Mediastinum. The posterior Mediastinum is
divided into paravertebral and prevertebral
space. Superior Mediastinum extends into the
neck and is called cervico-Mediastinal space
It is important to know the structures in
each compartment. In the differential of
masses in the Mediastinum one uses this
knowledge
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COSTAL ANGLE
• Costal angle is formed by the 10 rib with Costal
cartilage on either side and xiphisternum in the
middle. The normal angle is . Both sides are
symmetrical. Volume changes in each
hemithorax will alter this relationship.
Hyperinflated lungs will increase the Costal
angle. Diaphragmatic paralysis also alters the
symmetry of Costal angle.
• Spinous Process
• The most prominent spinous process is 7th
cervical vertebra. You can count down the
thoracic vertebra and the ribs using this
landmark.
Respiratory Rate and Pattern of
Breathing
• The patient should not be aware that you are
counting his respiratory rate. Count the
respiratory rate while pretending to take the
patient's pulse.
• Note the rate, pattern and comfort of
respiration.
Normal
• Resting rate is between 10-14 per minute,
regular with no apparent discomfort..
• Chest wall and abdomen expand during inspiration
and is symmetrical.
• Abdominal component of expansion is dominant
in men and thoracic component in women.
• Periodic deep breathing (Sighs) less tha 5 per
minute.
Abnormal Finding
• Minor changes in rate and rhythm of respiration
occur due to anxiety and while it may represent an
abnormality, it may not be significant
• Rate
• Rate below 10/min: Bradypnea: (Narcotics,
raised intracranial tension, myxedema)
• Rate above 20/min: Tachypnea: (Interstitial,
vascular and multitude of diseases, anxiety
Pattern
• Periodic breathing. Cyclical increase and decrease
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in depth of respiration: Cheyne-stokes breathing:
(CHF, Cerebrovascular insufficiency)
Slow deep breathing: Kussmaul: (Ketoacidosis)
Totally irregular with no pattern:Biot's breathing:
(CNS injury)
Periodic deep breathing: Sighs: (Anxiety state)
Instead of simultaneous chest and abdominal
expansion with inspiration abdomen retracts while
chest expands: Abdominal paradox:
(Diaphragmatic paralysis)
• On the side of unstable chest wall hemithorax
retracts while the normal side expands with
inspiration: Thoracic paradox: (Flail chest)
• With lips pursed patient controls expiration
slowly: Pursed lip breathing: (Obstructive lung
disease)
• No abdominal component : ( Acute abdomen)
• No thoracic component: (Pleurisy, Chest wall
pain, Ankylosing spondylitis)
Discomfort
• Labored breathing: (Heart and Lung diseases)
• Unable to assume supine position because of
worsening shortness of breath: Orthopnea: (CHF,
Diaphragmatic paralysis, SVC syndrome, Anterior
mediastinal mass)
• Unable to erect position because of worsening
shortness of breath, more comfortable in supine
position : Platypnea: (Pulmonary spiders in
cirrhotic)
Size of Thorax
• The size of thorax is determined by the balance
between elastic recoil of lungs and chest wall
compliance. In normal, the FRC position is
usually at 60% of the TLC. At this position
muscle length tension curve is optimal for
muscle contraction. If the elastic recoil of lung
decreases the resting position of thorax will be
larger, it maybe 80% of the TLC position. This
position is very inefficient to generate force by
muscles and leads to shortness of breath.
Symmetry of Hemithorax
• Both sides are equal in size and asymmetry is
abnormal. Unilateral lung or pleural disease
alters negative pressure in pleura, affecting the
resting size of hemithorax. e.g. In
pneumothorax the negative pressure in pleura is
lost and there is nothing to hold chest wall
down. Hemithorax on that side will assume
TLC position. In patients with atelectasis the
negative pressure in pleura increases and the
size of hemithorax will become smaller
• It is best to assess symmetry of hemithorax
with patient laying flat in bed without pillows.
Stand either at head or foot end and look
tangentially at the thorax level to assess
asymmetry
Accessory Inspiratory Muscles
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Accessory Expiratory Muscles
• Normal tidal expiration is passive and there is
no muscle contraction. Expiratory muscle
contraction is always accessory. When you
force expiration, expiration muscles come into
play. Abdominal muscles and intercostals are
expiratory muscles. If a patient is contracting
abdominal muscles for quiet respiration it is
abnormal and he is attempting to force
expiration.
Forced Expiration
• Only peak flows can be increased by forced
expiration. The flow rates cannot be increased
for most of expiratory phase by forcing
expiration. The increasing positive pressure in
pleura compresses airway and further decreases
airway size thus countering the increased force
to expire.
• In patients with increased airway resistance
patients attempt to increase airflow. They have
two options either to adopt a rapid shallow
breathing or to use pursed lip breathing to
counter auto-peep and enhance emptying of
lung. When airways are severely narrowed, air
trapping occurs and patient may breath with a
very high FRC and the only way he can breath
is to adopt a rapid shallow breathing.
Negative Pleural Pressure
Assessment
• Only peak flows can be increased by forced
expiration. The flow rates cannot be increased
for most of expiratory phase by forcing
expiration. The increasing positive pressure in
pleura compresses airway and further decreases
airway size thus countering the increased force
to expire.
• In patients with increased airway resistance
patients attempt to increase airflow. They have
two options either to adopt a rapid shallow
breathing or to use pursed lip breathing to
counter auto-peep and enhance emptying of
lung. When airways are severely narrowed, air
trapping occurs and patient may breath with a
very high FRC and the only way he can breath
is to adopt a rapid shallow breathing.
Method Of Exam
1. Position yourself in front of the patient and note
the position of the thyroid cartilage.
2. Inspect for the symmetry of clavicular insertion
of both sternomastoids.
3. Tracheal Position: Gently bend the head to relax
the sternomastoids. By inserting your finger
between the trachea and sternomastoid, assess
and compare the space on either side
Trachea: Position
To evaluate the position of the upper
mediastinum
• Normal: Trachea is slightly tilted to right.
As a result, the clavicular insertion of right
Sternomastoid is slightly more prominent
and the space between trachea and
sternomastoid is smaller compared to left.
Abnormal Finding
• Tracheal deviation could be either due to
Lung, pleural, Mediastinal or Chest wall
disease. The mediastinum can be either
pulled or pushed away from the lesion
• Lung
Pull: ( Loss of lung volume)
• Atelectasis
• Fibrosis
• Agenesis
• Surgical resection
Push: (Space occupying lesions)
• Large mass lesions
Pleura
1. Push:
• Pneumothorax
• Pleural effusion
2. Pull:
• Pleural fibrosis
Mediastinal masses and thyroid tumors
Kypho-scoliosis
Atelectasis
Resorptive atelectasis
• When airways are obstructed there is no further
ventilation to the lungs and beyond. In the early
stages blood flow continues and gradually the
oxygen and Nitrogen get absorbed, resulting in
atelectasis.
• The following in an example of right lung
resorptive atelectasis. In this instance, atelectasis
followed bronchial obstruction due to cancer.
Chest: Observation
Chest asymmetry
• Kyphoscoliosis
• Larger hemithorax : (Pneumothorax,
Pleural effusion)
• Smaller hemithorax: (Atelectasis, Pleural
fibrosis, Agenesis of Lung)
Increased pleural negative
pressure
• Unilateral (airway obstruction) or bilateral
(COPD, DIF, Asthma)
• Intercostal and supraclavicular fossa
retraction
• Downward movement of trachea with
quiet inspiration
Skin and soft tissue
• Puncture sites and Scars (Thoracentesis,
FNAB, Chest tube, Surgical scars)
Prominent collateral veins (SVC
syndrome)
Swelling (Recent thoracentesis, Empyema,
Mesothelioma, Empyema necessitatis, Cystic
hygroma
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• Erythema (Empyema)
• Warmth (Empyema)
• Tenderness ( Empyema, Rib and chest wall
lesions )
• Subcutaneous nodules (Metastasis)
Voice transmission
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Patient to say "99" "1, 2, 3" or "E"
Each time you lay your hands or listen
All around the chest and compare
Dorsal surface of your fingers or ulnar surface of
your hand (tactile fremitus)
Listen with diaphragm (vocal resonance)
If increased have patient whisper
Note the intensity
Quality of pitch
Compare
Tactile Fremitus
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Abnormal Finding
• Decreased: (Pleural effusion,
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Pneumothorax, Atelectasis, Mass)
Increased: (conditions giving bronchial
breathing)
Bronchophony: (Normal)
Whispering pectoroliquy ( Normal )
Qualitative: Egophony
Lungs: Percussion
• Percuss the lung fields, alternating, from
top to bottom and comparing sides.
• Percuss over the intercostal space and
note the resonance and the feel of
percussion.
• Keep the middle finger firmly over the
chest wall along intercostal space and tap
chest over distal interphalangeal joint with
middle finger of the opposite hand.
• The movement of tapping should come from the
wrist.
• Tap 2-3 times in a row.
• Do not leave the percussing finger on chest ,
otherwise you will dampen the sound.
• Stand on one side and with your flat of hand, tap
the chest from top to bottom and from side to side
to compare. I use this method as a screening step
to identify the area of abnormality
• The movement of tapping should come from the
wrist.
• Tap 2-3 times in a row.
• Do not leave the percussing finger on chest ,
otherwise you will dampen the sound.
• Stand on one side and with your flat of hand, tap
the chest from top to bottom and from side to side
to compare. I use this method as a screening step
to identify the area of abnormality
Movement of Diaphragm:
• Identify the lower limit of resonance during
deep inspiration and deep expiration.
• This determines the range of movement of
the diaphragm.
Normal
• The lung is filled with air (99% of lung is air).
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Hence, percussion of it gives a resonance. This
step helps identify areas of lung devoid of air.
Appreciate the dullness of the left anterior chest
due to heart and right lower chest due to liver.
Note the hyper-resonance of the left lower anterior
chest due to air filled stomach.
Normally, the rest of the lung fields are resonant.
Normal diaphragmatic excursion is 5-6 cm.
Abnormal Finding
Lungs fields
Dullness: (Mass, Atelectasis, Consolidation,
Pleural effusion)
Hyper-resonance: (Emphysema, Asthma,
Pneumothorax, Blebs)
• Decreased or increased resonance is abnormal.
Increased resonances can be noted either due to
lung distention as seen in asthma, emphysema,
bullous disease or due to Pneumothorax.
Decreased resonance is noted with pleural
effusion and all other lung diseases.
Experienced physicians are able to discriminate
between dullness of pleural effusion from a
consolidation or a mass lesion of lung. The
dullness is flat and the finger is painful to
percussion with pleural effusion.
• Diaphragmatic motion
Diaphragmatic motion
• Decreased diaphragmatic excursion:
(Emphysema, paralysed diaphragm)
Auscultation of Lungs
• While the patient breathes normally with mouth
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open, auscultate the lungs, making sure to
auscultate the apices and middle and lower lung
fields posteriorly, laterally and anteriorly.
Alternate and compare sides.
Use the diaphragm of the stethoscope. Listen to at
least one complete respiratory cycle at each site.
First listen with quiet respiration. If breath sounds
are inaudible, then have him take deep breaths.
First describe the breath sounds and then the
adventitious sounds.
• Note the intensity of breath sounds and make a
comparison with the opposite side.
• Assess length of inspiration and expiration.
Listen for the pause between inspiration,
expiration and the quality of pitch of the sound
• Also compare the intensity of breath sounds
between upper and lower chest in upright
position. Compare the intensity of breath sounds
from dependent to top lung in the decubitus
position.
• Note the presence or absence of adventitious
sounds
Normal
• There are two normal breath sounds. Bronchial
and vesicular. Breath sounds heard over the
tracheobronchial tree are called bronchial
breathing and breath sounds heard over the lung
tissue are called vesicular breathing. The only
place where tracheobronchial trees are close to
chest wall without surrounding lung tissue are
trachea, right sternoclavicular joints and posterior
right interscapular space. These are the sites where
bronchial breathing can be normally heard. In all
other places there is lung tissue and vesicular
breathing is heard
• The bronchial breath sounds over the
trachea has a higher pitch, louder,
inspiration and expiration are equal and
there is a pause between inspiration and
expiration.
• The vesicular breathing is heard over the
thorax, lower pitched and softer than
bronchial breathing. Expiration is shorter
and there is no pause between inspiration
and expiration. The intensity of breath
sound is higher in bases in erect position
and dependent lung in decubitus position
• The breath sounds are symmetrical and
louder in intensity in bases compared to
apices in erect position. No adventitious
sounds are heard.
Abnormal Finding
• Intensity of breath sounds, in general, is a
good index of ventilation of the underlying
lung. If the intensity increases there is more
ventilation and vice versa. Breath sounds
are markedly decreased in emphysema
• Symmetry: If there is asymmetry in
intensity, the side where there is decreased
intensity is abnormal.
• Bronchial breathing anywhere other than
over the trachea, right clavicle or right
interscapular space is abnormal. Presence of
bronchial breathing would suggest
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Consolidation
Cavitation
Complete alveolar atelectasis with patent airways
Mass interposed between chest wall and large
airways
• Tension Pneumothorax
• Massive pleural effusion with complete atelectasis
of lung
• Experienced physicians could discriminate
between consolidation and cavitation by noting the
quality of bronchial breathing. In consolidation,
the bronchial breathing is low pitched and sticky
and is termed tubular type of bronchial breathing.
In cavitary disease, it is high pitched and hollow
and is called cavernous breathing. You can
simulate this sound by blowing over an empty
coke bottle. In tension pneumothorax bronchial
breath sounds has a metallic quality and is called
amphoric breathing
Adventitious sounds
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Wheeze
Stridor (rhonchi)
Crackles
Pleural Rub 91
AUSCULTATION
• Tracheal Breath Sounds: Loud, harsh, high
pitched.
• Bronchial Breath Sounds: Loud, high-pitched
with air swishing past.
• Bronchovesicular Sounds: Heard near branching
of main bronchi, combination of bronchial and
vesicular sounds.
• Vesicular Sounds: Soft, low-pitched, airy,
swishing, heard below the level of the bronchi
• PLEURAL FRICTION RUB: Grating sound
heard during breathing that stops when the breath
is held. Caused by friction of visceral and parietal
pleura.
• PULMONARY CONSOLIDATION: Occurs
with late-stage lobar pneumonia.
• BRONCHOPHONY: Increased transmission of
sound to the lung periphery. Indicative of
pulmonary consolidation
• WHISPERED PECTORILOQUY: Words
being understood better when whispered.
Also indicative of pulmonary consolidation.
• EGOPHONY: "E" to "A" sound-changes.
Indicative of pulmonary consolidation or
pleural effusion.
• HAMMAN'S SIGN: Crunching, crackling
sound over chest heard synchronous with
the heart beat. Occurs with mediastinal
emphysema -- air in the mediastinum.
• CAUSES: Can follow thoracic surgery,
trauma.
• Boerhaave's Syndrome: Esophageal
rupture causing air in mediastinum. Rare
LUNG DISEASES
• Asthma
• Atelectasis: Bronchial plug ------>
decreased lung volume ------> higher lung
density ------> lung mass is pulled toward
chest wall by negative pressure
• Tracheal deviation toward affected side
• crackles, maybe
• no breath sounds
• Bronchiectasis: Chronic bronchial dilation.
• Caused by frequent pulmonary infections or
pneumonia.
• Large amounts of sputum will be expectorated
when patient lies prone hanging toward floor.
• Bronchitis: Acute (infectious) or chronic
(smoker's)
• Bronchiolitis: Common in infants and children
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Lung Cancer
Cor Pulmonale
Croup: Kids under 3 years old. Rapid, staccato coughs.
Differential Diagnosis is between inflammatory Croup or
Spasmodic Croup.
Cystic Fibrosis
Pleural Effusion: Dullness on percussion. Decreased
fremitus. Reduced breath sounds.
Emphysema
Epiglottitis: In kiddies, don't inspect the pharynx without a
chest tube nearby.
Pneumonia