Physical Exam - Chest 2006

The Chest
 Department of Physical Diagnostics

 1st Teaching Hospital
 Medical college of zhengzhou university(MC
ZU)
Landmarks on the Chest Wall
Landmarks on the Chest Wall
Reference Lines
Reference Lines
Reference Lines
Fossas and Regions
 Suprasternal fossa,
 Supraclavicular fossa,
 Infraclavicular fossa,
 Axillary fossa
 Scapular region,
 supra-
 infra-
 Interscapular region
Chest Wall
 Visible veins-collateral circulation
 Pay attention to the direction of blood
flow
 Regional enlargement:
 Rib fracture
 Tumor on the chest wall
 Cardiac enlargement
 Local Tenderness : Local Tenderness
: Inflamation, Rib fracture ,
 “Gripping snow” sensation subcutane
ous- emphysema
 Sternum tenderness and percussion p
ain- leukemia
Chest Wall
 Local tenderness: inflammation, rib fracture

Abnormal Intercostal Space
Recessed or narrowed
Depressed when inspirating air way
Obstruction
One –side depression: atelectasis, pleural
adhesion
Wide or swelling
General—emphysema, bronchial asthma
One-side—pleural effusion , pneumothora
x
Chest
 Normal: Ap: T=1:1.5
 Abnormal:
 Flat chest,
 Barrel chest
 Rachitic chest
 Pigeon chest,
 Funnel chest
 Harrison groove
 Regional transfiguration
 Thorax-vertebrae-malformation-induced
Funnel Chest Deformity
Pigeon Chest Deformity
Breasts
Inspection of Breast
۞Contour:
 Normal: symmetric hemisphere
 Asymmetric:
 Enlarged—inflammation, tumor
 Under—sized: hypogenesis
Breast Examination
۞ Skin
 Redness—inflammati
on
 Peau d’orange (oran
ge peel)
 --malignancy
 Retraction:--scar, tu
mor
Breast Examination
 Nipple
 Nipple retraction
 Bilateral and lifelong: hypogenesis
 Unliateral and recent: inflammation and malig
nancy
 Dischange:--benign or malignant
Indrawing of the Nipple
Palpation
۞Position
 Sitting
 Supine
۞Technique:
 Examine with the flat of the hand and tips of
the fingers
 Bimanual palpation
Breast Palpation
Examination area
Examination pattern
American Cancer Society
breast cancer screening guidelines 1997
(for asymptomatic women)
Age 20 – 39 Age 40 and

elder
Breast self Monthly Monthly
examination
Clinical breast Every 3 Annually

examination years
Mammography None Annually
Clinical Examination
Inspection of the Breasts
Inspection of the Breasts
Palpation of the Breasts
Pathological Findings
 Increased consistency, diminished el

asticity, tenderness
 Masses
• Location
• Size
• Contour, margin, rigidity, mobility
 Lymphadenovarix
• Axiliary, suprasternal fossa
Common Diseases
۞Acutemastadenitis
۞Tumor
 Cystic hyperplasia
 Fibroma
 Cancer
۞Gynecomastia in the male
Gynecomastia
pulmonary examination
The Lung
۞ Inspection
 Respiratory movement
 Normal: symmetric
 Enhanced or decreased (unilateral or bilateral)
 Dyspnea
 Inspiratory –:three depressions sign”
 Expiratory –protraction of intercostal space
 Respiratory frequency (16~18/min or 12-18/min)
 Tachypnea— >24/min or 25/min
 Bradypnea— <12/min or 8/min
Respiratory Rate
 Bradypnea: rate less than 8 per minute

 Tachypnea: rate greater than 25 per min
ute
Effort of Ventilation
 Person appears uncomfortable.
 Breathing seems voluntary.
 Accessory muscles are in use,
 expiratory muscles are active and
 expiration is not passive any more.
 The degree of negative pleural pressure is
high.
 The respiratory rate is increased.
Resting Size and Shape of Thorax
 Barrel chest
 Kyphosis
 Scoliosis
 Pectus excavatum
 Gibbus
Barrel Chest
 AP Diameter =
Transverse
 Diameter
Depth and Rhythm
Pattern of Breathing
 Kussmals
 Sleep apnea
 Cheyne strokes
 Pursed lip breathing
 Orthopnoea: Short of breath in supine positio
n, gets some relief by sitting or standing up.
Breathing Patterns
Palpation
۞Chest expansion (dynamic event

s of respiration)
 One—side recession ----pleural diseases, ate
lectasis
۞Pleural friction fremitus
 A sign of acute pleuritis
Chest Expansion
 Asymmetrical chest expansion is abnormal

 The abnormal side expands less and lags
 behind the normal side
 Any form of unilateral lung or pleural disease
can cause asymmetry of chest
expansion
 Global expansion decrease
Tracheal Position:
Mediastinum
 Any deviation of the mediastinum is abnormal

 Lateral shift: The mediastinum can be either pull
ed or pushed away from the lesion
 Pull: Loss of lung volume (Atelectasis, fibrosis,
agenesis, surgical resection, pleural fibrosis)
 Push: Space occupying lesions (pleural effusion,
 pneumothorax, large mass lesions)
 Mediastinal masses and thyroid tumors
Vocal (Tactile) Fremitus
۞ Principle
۞ technique
Vocal (Tactile) Fremitus: Pathological Con
dition
۞Weaken or disappear:
 Obstructive atelectasis, emphysema
 Pleural effusion, pneumothorax, subcutaneous emphy
sema
۞Enhanced
 Consolidation of lung tissue: lobar pneumonia, pulmon
ary infarction
 Large cavity in the lung, esp. near the pleura: lung abs
cess, cavernous pulmonary tuberculosis
Percussion
۞Techniques
 Mediate percussion
 Immediate percussion
۞Content
 Percussion note
 Lung border
 Diaphragmatic excursion
Percussion Notes of the Lung
۞Characters:
 Normal chest: resonance
 Inferior > superior, left>right, anterior>posterior
 Duliness if the lung overlaps with neighboring organ (liv
er)
۞Influencing factors
 Chest wall thickness
 Air in the pleural space and the lung
Lung Border
۞ Kronig’s isthmus
Lines IC
: 5~6cm
spaces
۞ Anterior border:
۞ Inferior border: Midclavicular 6th
۞ Diaphragmatic
excursion: 6~8cm Midaxillary 8th
Scapular 10th
Pathological Percussion Notes
۞ Dullness, flatnes
s:
 Volume reduction: pneu
monia, TB, atelectasis, l
ung edema.
 Airless tissue: lung tum
or, lung abcess, pleural
effusion.
Pathological Percussion Notes
۞ Hyperresonance
:
 Emphysema
۞ Tympany:
 Cavernous tuberculosis
 Lung abscess
 Pneumothorax
Percussion: Decreased or Increased
Resonance is Abnormal
 Dullness
 􀂄 Decreased resonance is noted with pleural
 effusion and all other lung diseases
 􀂄 The dullness is flat and the finger is painful to
 percussion with pleural effusion
 Hyper resonance: Increased resonance can b
e noted either due to lung distention as seen
in asthma, emphysema, bullous disease or d
ue to Pneumothorax
 Traube's space
Abnormal Lung Border
۞Kronig’isthmus:
 Widening: --emphysema
 Narrowing (unilateral):--tuberculosis, tumor
۞Inferior border:
 Lowered:--emphysema
 Rised :--atelectasis, increased intra-abdominal pressure
 Undetecteable:--pleural effusion, pneumothorax
Abnormal Diaphragmatic Excursion
۞ Decreased: < 4cm

 Unilateral : atalectasis, pleural adhension
 Bilateral : emphysema, lung fibrosis
Contents of Auscultation
 Breath sounds
– Bronchial breath sounds
– Vesicular breath sounds
– Bronchovesicular sounds
 Adventitious sounds
– Crackles
– Wheezes
 Vocal resonance
 Pleural friction rub
Principles of Sound Transmission
 Distance
 Number of interfaces
 The nature of the transmitting medium

– The more dense the medium, the better the
transmission
Breath Sounds
 Ascending branch– inspiratory p

hase
 Descending branch– expiratory
phase
 Length of the line– duration
 Thickness of the line– loudness
 Angle-- pitch
Vesicular Breath Sounds
 Low pitched, fine, and hear

d well at the periphery of th
e lung. It is an inspiratory s
ound. In inspiration phase, i
t’s relatively louder, higher
pitched and lasts longer
Bronchial Breath Sounds
 They are harsher and of high

er pitch than vesicular sound
s. It is an expiratory sound.In
expiration phase, it’s relativel
y louder, higher pitched and l
asts longer.
 Best heard at laryngeal, supr
asternal fossa, C 6-7, and T
1-2
Bronchovesicular Breath Sounds
 A mixture of the two elements

 The two phases are quite similar in i
ntensity, duration, and pitch.
 Best heard anteriorly over the upper
end of the sternum and just beside it
at the level of Louis’s angle, and pos
teriorly over the interscapular space
s at the level of the third and fourth t
horacic vertebrae, either or both api
ces.
Abnormal Breath Sounds
 Abnormalities in vesicular breath sound a

rea, including:
– Exaggerated vesicular breathing and diminis
hed vesicular breathing
– Abnormal bronchial breath sounds
– Abnormal bronchovesicular sounds
Abnormal Vesicular Breath Sounds
 Diminished vesicular breath sounds
– Reduced air inflow into the alveoli
– Decreased velocity of air flow into the lung
– Obstruction of breath sound conduction
 Exaggerated vesicular breath sounds
– Unilateral: compensatory breath sounds
– Bilateral: enhanced respiratory movement and ventilatory function
 Prolonged breath sounds
– Partial obstruction, spasm, or narrowing of the lower respiratory tra
ct
– Diminished elasticity of the lung tissue
Abnormal Bronchial Breath Sounds
 Causes:
– Consolidation of the lung
 Bronchial breathing heard in areas normall
y yielding only vesicular breathing always
means consolidation
– Large cavity inside the lung
– Compressive atelectasis
Abnormal Bronchovesicular Breath S
ounds
 Bronchovesicular breath sounds appears in th

e area where the vesicular breath sounds do
minate
 Seen in lobular pneumonia, lobar pneumonia,
tuberculosis of the lung
Crackles and Wheezes
 Wheezes
 Crackles
Crackles
Characters of the Crackles
 Dominate during inspiration phase or at the
end of inspiration
 Fixed site of auscultation
 Transient
 Stable quality
 Medium and fine crackles may coexist
 May diminish or disappear after cough.
Classification of Crackles
 Coarse crackles: exudate in trachea, bronchia o

r cavity.
 Medium crackles: exudate in bronchia (mediu
m size).
 Fine crackles: exudate in bronchiole.
 Crepitus: exudate in bronchiole or alveoli.
Clinical Significance
 Localized crackles: regional diseases

 Crackles in bilateral bases of the lungs:
pulmonary congestion caused by heart
failure or bronchopneumonia
 Generalized crackles in bilateral lung
fields: acute pulmonary edema or severe
bronchopneumonia
Wheezes
 Pathogenosis: airway narrowing
 Pathology:
– Inflammation-induced mucosal congestion an
d edema together with exudate
– Spasmodic contraction of bronchial smooth
muscle
– Intralumenal tumor or foreign body obstructi
on
– Narrowing of lumen caused by compression
Characters of Wheezes
 High-pitched
 Lasting long
 Biphasic but typical in inspiration phase
 Inconstant sites, intensity, and quality

Clinical Significance of Wheezes
 Changeable and fugitive, varying tones: e

xudate in respiratory tract, bronchitis
 Diffuse wheeze ( narrowing of small airw
ays) :– asthma
 Localized fixed wheezes: air way narrowi
ng –endobronchial tuberculosis or tumor
 Inspiratory wheeze: air way obstruction –
laryngeal spasm, foreign body, tumor
Classification of Wheezes
 Sibilant wheezes: wheezes in the finer
tubes piping, squeaking and whistling
 Sonorous wheezes: in the larger tubes
deep-toned and groaning.

Vocal Resonance
 Mechanism: same as tactile fremitus

 Clinical significance:
– Decreased: emphysema, intrapleural air
or fluid, thickened pleura ,obstruction to fl
ow of air into the lung, edema of chest w
all, obesity
– Increased: fluid is present in the pleural c
avity
Vocal Resonance
 Bronchophony: spoken voice changes to be more

concentrated, nearer the listener’s ear, and the w
ords are more clearly heard. Seen in solidification
or compression of lung tissue
 Pectoriloquy: the intensity of the spoken voice is i
ncreased, seen in solidification of lung tissue
Pleural Friction Rub
 Mechanism: The raw surfaces of pleura grate

and may produce an audible sound resembling
creaking leather.
 Features:
– Best heard at the end of inspiration phase
– Disappear when stop breathing ( main difference to
pericardial friction sound)
 Clinical significance: inflammation of pleura
Common Diseases
 Emphysema
 Lung consolidation
(lobar pneumonia)
 Atelectasis
 Pleural effusion
 Pneumothorax
Emphysema
 Pathology: air trapping in the lun

g
 Inspection: barrel chest
 Palpation: decreased dynamic ev
ents of respiration and tactile fre
mitus
 Percussion: hyperresonce; Dow
n-shifting of the inferior border of
the lung
 Auscultation: decreased breath s
ounds and vocal resonance
Lobar Pneumonia
 Pathology: too much fluid in alveol
i
 Inspection: ?
 Palpation: decreased dynamic eve
nts of respiration, increased tactile
fremitus.
 Percussion: dullness or flatness
 Auscultation: tubular breath sound
, crackles, increased vocal resona
nce.
Atelectasis
 Pathology: the airway is obstruct

ed and the lung holds no air
 Inspection: the affected chest wa
ll is flattened
 Palpation: decreased dynamic e
vents of respiration and tactile fre
mitus;The trachea is shifted to th
e affected side
 Auscultation: breath sounds and
vocal resonance disappear.
Pleural Effusion
 Pathology: fluid is trapped in ple

ural cavity
 Inspection:
 Palpation: decreased dynamic e
vents of respiration and tactile fr
emitus;The trachea is shifted to t
he unaffected side
 Auscultation: breath sounds and
vocal resonance disappear
Pneumothorax
 Pathology: air is trapped in pleural c
avity
 Inspection: over-inflation of the affec
ted side
 Palpation: decreased dynamic event
s of respiration and tactile fremitus;T
he trachea is shifted to the unaffect
ed side
 Percussion: tympany
 Auscultation: breath sounds and voc
al resonance disappear

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The Chest

 Department of Physical Diagnostics

 Local tenderness: inflammation, rib fracture

Age 20 – 39 Age 40 and

Clinical breast Every 3 Annually

 Increased consistency, diminished el

 Bradypnea: rate less than 8 per minute

۞Chest expansion (dynamic event

 Asymmetrical chest expansion is abnormal

 Any deviation of the mediastinum is abnormal

excursion: 6~8cm Midaxillary 8th

۞ Decreased: < 4cm

 The nature of the transmitting medium

 Ascending branch– inspiratory p

 Low pitched, fine, and hear

 They are harsher and of high

 A mixture of the two elements

 Abnormalities in vesicular breath sound a

 Bronchovesicular breath sounds appears in th

 Coarse crackles: exudate in trachea, bronchia o

 Localized crackles: regional diseases

 Biphasic but typical in inspiration phase

 Inconstant sites, intensity, and quality

 Changeable and fugitive, varying tones: e

 Sibilant wheezes: wheezes in the finer

tubes piping, squeaking and whistling

 Sonorous wheezes: in the larger tubes

deep-toned and groaning.

 Mechanism: same as tactile fremitus

 Bronchophony: spoken voice changes to be more

 Mechanism: The raw surfaces of pleura grate

 Pathology: air trapping in the lun

 Pathology: the airway is obstruct

 Pathology: fluid is trapped in ple

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