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Chest exam

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Physical examination

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									Examination of the Chest



2002/2003   Clinical Examination of the Chest   1
                                                                  Personal History

Personal History: As before, but put stress on the following points
 Occupation: e.g.
   – Silicosis which may be complicated by pulmonary T.B.
   – Asbestosis which may be complicated by mesothelioma
In this respect it is important to ask about the following:
1-Duration of exposure: several                     years   are   needed      for
pneumoconiosis to develop.
2- Adherence to safety measures as wearing special masks during
work to prevent inhalation of the dust.

 Special Habits of medical importance especially smoking
cigarettes, shesha and goza.
 2002/2003              Clinical Examination of the Chest                      2
        History of the present illness
   The six cardinal symptoms of chest diseases are:
     1- Cough
     2- Expectoration (sputum)
     3- Hemoptysis
     4- Chest pain
     5- Dyspnea
     6- Wheezes

2002/2003            Clinical Examination of the Chest   3
           History of the present illness2
 Other symptoms of importance in chest diseases or may
point to the possibility of the presence of a chest disease include:
1- Symptoms suggestive of mediastinal syndrome as dysphagia
and hoarseness of voice.
2- Symptoms suggestive of toxemia as night fever, night sweats,
loss of appetite and weight as in T.B.
3- Symptoms suggestive of RVF as LLs edema and pain in the
RUQ of the abdomen ( due to congested tender liver).
4- Fever as in upper and lower resp. tract infections.
     Finally any other symptoms related to other systems.

    2002/2003           Clinical Examination of the Chest       4
               Past History1
Attack or disease similar to the present one:
e.g.   - Asthma.
       - Recurrent pneumonia
Allergic disorders: like eczema, urticaria,
angioedema and hay fever.
Acute abdominal conditions.
Admission in any hospital before and why?
Bilharziasis: bilharzial cor pulmonale.

 2002/2003     Clinical Examination of the Chest   5
               Past History2
Chest injuries and operations.
Other Surgical Procedures.
Coma , convulsions….may predispose to
aspiration lung abscess
Cardiac diseases and history of rheumatic
fever.




 2002/2003     Clinical Examination of the Chest   6
                    Past History3
Diabetes mellitus
Hypertension and history of intake of
antihypertensive drugs. Cough may result from ACE
inhibitors

T.B and history of admission to a chest
hospital for treatment of T.B. Name of the medicines,
duration of the treatment and the adherence to it should be
enquired about.

Previous radiological examination:                 comparison
with the current radiograph may be valuable in diagnosis.

 2002/2003           Clinical Examination of the Chest     7
            Family and Social History

 Similar condition in the family.
 History of T.B.
 History of allergy as eczema and hay fever.
 History of DM




2002/2003         Clinical Examination of the Chest   8
                                                        1
            Analysis of Chest Symptoms

  Cough
 Ask about the following:
  The frequency
  The severity
  Dry or productive
  Time of occurrence
  Relation to posture
 Character of cough (better observed by the physician)


2002/2003           Clinical Examination of the Chest       9
                                                      2
            Analysis of Chest Symptoms

Sputum
   Amount
   Color
   Character (seous, mucoid,purulent and mucopurulent)
   Odor
   Relation to posture
   What increases or decreases it
   Associated conditions
2002/2003         Clinical Examination of the Chest       10
                                                         3
            Analysis of Chest Symptoms
Hemoptysis1: most important causes of hemoptysis are
           The
        •Mitral stenosis
        •Pulm tuberculosis
        •Pulm infarction
        •Brochiectasis
        •Bronchogenic carcinoma
        •Bronchial adenoma
        •Bleeding tendency

2002/2003            Clinical Examination of the Chest       11
                                                         4
              Analysis of Chest Symptoms
 Hemoptysis2:
1st differentiate between hemoptysis and hematemesis
2nd ask about :
                   •Type and Degree
                   •Frequency and Duration

3rd ask about the preceding events e.g. DVT or
chest infection



  2002/2003          Clinical Examination of the Chest       12
                                                       5
            Analysis of Chest Symptoms

Hemoptysis3:
Type and Degree
        •Frank hemoptysis
        •Blood-stained sputum
        •Blood streaked sputum
        •Rusty sputum

Frequency and duration

2002/2003          Clinical Examination of the Chest       13
            Analysis of Chest Symptoms6

  Chest pain: as elsewhere ask about
 The onset..
 Site.
Character.
 Radiation.
What brings or increases the pain and conversely what
relieves or decreases it.
 The associated symptoms.



2002/2003          Clinical Examination of the Chest   14
            Analysis of Chest Symptoms7\

Wheeze
 What dose the patient mean by wheezing?
 You should be able to differentiate between
 wheeze and stridor.
 Wheezing may be intermittent as in asthma or
 persistent as in chronic bronchitis.
 Wheezing may be diffuse as in asthma and
 chronic bronchitis or     localized as in
 bronchogenic carcinoma.
2002/2003          Clinical Examination of the Chest   15
            Local Examination
                   Of
                The Chest


2002/2003       Clinical Examination of the Chest   16
   Local Examination of the Chest

   Inspection
   Palpation
   Percussion
   Auscultation



2002/2003   Clinical Examination of the Chest   17
                                                   Local examination of the chest

  Inspection
 1-Shape of the chest.
 2-Spine Deformity
 3-Symmetry and Mobility
 4-Respiratory movements
 5-Skin
 6-Pulsations
2002/2003      Clinical Examination of the Chest                          18
                                                 Local examination of the chest

 Inspection2
1- Shape of the chest
Normal Shape
Barrel shaped chest
Pigeon chest
Rachitic chest
Funnel-shaped chest (Pectus Excavatum)

 2002/2003   Clinical Examination of the Chest                          19
                                            Local examination of the Chest

            Shape: increased AP diameter




2002/2003           Clinical Examination of the Chest                 20
                                            Local examination of the Chest
                                            Inspection
            2- Spine Deformity: Kyphosis




2002/2003           Clinical Examination of the Chest                 21
                                         Local examination of the Chest
                                         Inspection
        2- Spine Deformity: Scoliosis




2002/2003        Clinical Examination of the Chest                 22
                                       Local examination of the Chest
                                       Inspection
        3- Symmetry and Mobility

Both sides of normal chest are
symmetrical in shape and mobility.
The diseased side or part is less
mobile than the healthy one.



2002/2003      Clinical Examination of the Chest                 23
                                           Local examination of the Chest
                                           Inspection
       3-Symmetry and Mobility2

              Bulgiong                          Retraction

        •Pleural effusion             •Pulmonary collapse
        •Pneumothorax                 •Pulm. Fibrosis
        •Hydropneumothorax            •Pleural fibrosis
        •Empyema
        •Precordial bulge
        •Chest wall causes


2002/2003          Clinical Examination of the Chest                 24
                                           Local examination of the Chest
                                           Inspection
      4- Respiratory Movements
   Respiratory rate
   Mode of Breathing
   Respiratory Depth
   Maximum Chest Expansion ( use a tape measure)
   Abnormal Respiratory Movements
            - Abnormal Inspiratory Movements
            - Abnormal Expiratory Movements

2002/2003          Clinical Examination of the Chest                 25
                                                          Local examination of the Chest
                                                          Inspection & Palpation
                              5- Skin
Skin eruption e.g HZ
Nodules (inflammatory,metastatic,lipoma, neurofibroma…)
Subcutaneous emphysema
Purpuric spots,Vascular spiders, Bruises
Prominent bl vessels (arterial in coarctation of aorta and venous in SVC obstruction)
Scars (previous operation,trauma, intercostal tube…)
Discharging sinuses
Lesions of the breasts and enlargement of axillary LNs
   2002/2003                  Clinical Examination of the Chest                     26
                                        Local examination of the Chest
                                        Inspection & Palpation

               6- Pulsations

Apical
Parasternal
Epigastric




2002/2003       Clinical Examination of the Chest                 27
                                        Local examination of the Chest

                   Palpation
To confirm Respiratory Movements
Pulsations (see before)
Palpable Adventitious Sounds
Tactile Vocal Fremitus (TVF)
Position of the Trachea

2002/2003       Clinical Examination of the Chest                 28
                                       Local examination of the Chest

    Palpation of Respiratory Movements

1. Respiratory movements in the
   infraclavicular regions
2. Respiratory movements at the costal
   margins
3. Respiratory movements of the lower ribs
   posteriorly

  2002/2003    Clinical Examination of the Chest                 29
            Palpation: Chest Excursion




2002/2003          Clinical Examination of the Chest   30
                                        Local examination of the Chest
                                        Palpation:Resp Movements
Signifacance of reduced respiratory movements
Unilateral reduction of chest wall movements
       •Pleural effusion
       •Empyema
       •Pneumothorax
       •Pulmonary consolidation
       •Pulmonary collapse
       •Pleural or parenchymatous pulmonary fibrosis
Bilateral reduction of chest wall movements
       •Bronchial asthma
       •Emphysema
       •Diffuse pulmonary fibrosis
 2002/2003            Clinical Examination of the Chest                  31
                                  Local examination of the Chest
                                  Palpation

                       TVF
            How to test for TVF?




2002/2003       Clinical Examination of the Chest                  32
                                 Local examination of the Chest: Palpation


                         TVF2

        Increased TVF                            Decreased TVF

•Consolidation                       •Thick chest wall
•Cavitation                          •Pleural effusion
•Collapse with patent main           •Pleural fibrosis
bronchus                             •Pneumothorax
                                     •Emphysema
                                     •Collapse

  2002/2003        Clinical Examination of the Chest                 33
                               Local examination of the Chest: Palpation


  Palpable Adventitious Sounds
Palpable Rhonchi
      •Diffuse
      •Localized and Persistent

Palpable Pleural Rub


2002/2003        Clinical Examination of the Chest                 34
                                    Local examination of the Chest: Palpation


             Position of the Trachea
       To evaluate the position of the upper mediastinum.

How to test for the position of the
trachea?
Trill’s sign:Bulging of the sternomastoid
muscle in front of the deviated trachea.



 2002/2003            Clinical Examination of the Chest                 35
                                      Local examination of the Chest: Palpation



            Position of the                      Trachea 2


       Causes of deviation of the trachea
                Ipsilateral                     Contralateral
                (To pull)                          ( To push)
            •Collapse                     •Apical mass
            •Fibrosis                     •Pleural effusion
                                          •Pneumothorax

2002/2003               Clinical Examination of the Chest                 36
                                                Local examination of the chest

            Percussion:Technique




2002/2003        Clinical Examination of the Chest                       37
                             Cut your nails




              Percussion2
2002/2003   Clinical Examination of the Chest   38
         Percussion:Anterior Chest
1. Percuss from side to side
   and top to bottom using
   the pattern shown in the
   illustration.
2. Compare one side to the
   other looking for
   asymmetry.
3. Note the location and
   quality of the percussion
   sounds you hear.

  2002/2003        Clinical Examination of the Chest   39
          Percussion:Posterior Chest
1. Percuss from side to side and
   top to bottom using this
   pattern. Omit the areas covered
   by the scapulae.
2. Compare one side to the other
   looking for asymmetry.
3. Note the location and quality of the
   percussion sounds you hear.
4. Find the level of the diaphragmatic
   dullness on both sides.

    2002/2003          Clinical Examination of the Chest   40
                                                Percussion
2002/2003   Clinical Examination of the Chest        41
                                  Local examination of the chest: percussion

              Diaphragmatic Excursion

1. Find the level of the diaphragmatic dullness on
   both sides.
2. Ask the patient to inspire deeply.
3. The level of dullness (diaphragmatic excursion)
   should go down 3-5cm symmetrically.
4. Decreased or asymmetric diaphragmatic
   excursion may indicate paralysis or emphysema.


  2002/2003        Clinical Examination of the Chest                  42
                                    Local examination of the chest: percussion

                  Tidal percussion
1. It is used to differentiate supra-diaphragmatic from
   infra-diaphragmatic dullness.
2. While the patient seated find the upper level of
   dullness
3. Ask the patient to take deep inspiration and to hold it
   then percuss again.
4. If the note becomes resonant  infra-diaphragmatic
   cause.
5. If there is no change of the note  supra-diaphragmatic
   cause as pleural effusion.
   2002/2003         Clinical Examination of the Chest                  43
                                                      Local examination of the chest



                Auscultation
    Intensity of breath sounds
    Type of breath sounds
    Adventitious sounds
    Voice sounds (vocal resonance)




2002/2003         Clinical Examination of the Chest                        44
                                                           Local examination of the chest

        Technique of Auscultation1
•While the patient relaxed and breathes normally with
mouth open, auscultate the lungs, making sure to auscultate
the apices and middle and lower lung fields posteriorly,
laterally and anteriorly.
•Alternate and compare both sides at each site.
•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.
  2002/2003            Clinical Examination of the Chest                        45
                                                        Local examination of the chest

         Technique of               Auscultation2

•Note the intensity of breath sounds and make a
comparison with the opposite side.
•Assess length of inspiration and expiration. Listen for a
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.
   2002/2003        Clinical Examination of the Chest                        46
                                                Local examination of the chest

   Auscultation: Normal Breath Sounds1
The normal breath sounds heard over the lung
tissue are called vesicular breathing.
The vesicular breathing is heard over the lungs,
lower pitched and softer than bronchial breathing.
Expiration is shorter (I > E) and there is no pause
between inspiration and expiration.
The breath sounds are symmetrical and louder in
intensity in bases compared to apices in erect
position and dependent lung areas in decubitus
position.
 No adventitious sounds are heard.
   2002/2003      Clinical Examination of the Chest                  47
                                          Local examination of the chest

Auscultation: Normal Breath Sounds2
The breath sounds heard over the tracheobronchial
tree are called bronchial 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 have a higher pitch,
louder, inspiration and expiration are equal and there
                     inspiration Chest
is a pause betweenClinical Examination of theand expiration.
   2002/2003                                                 48
                                                      Local examination of the chest


    Auscultation:Vesicular breathing
       with prolonged expiration
A prolonged expiratory phase (E > I)
  indicates airway narrowing, as in:
    Bronchial asthma.
        Chronic bronchitis




2002/2003         Clinical Examination of the Chest                        49
                                                         Local examination of the chest


  Auscultation:Bronchial breathing
Bronchial breathing may be heard in
pathological conditions as:
    Consolidation
    Collapse with patent large airways
    Compressed lung by a large pl effusion or a
    tension pneumothorax
    Pulmonary fibrosis
    Cavitation
 2002/2003           Clinical Examination of the Chest                        50
                                                    Local examination of the chest


  Auscultation:Adventitious sounds

Crepitations: types
Rhonchi: sibilant and sonorous
Pleural rub




 2002/2003      Clinical Examination of the Chest                        51
                                                         Local examination of the chest

              Auscultation: Voice sounds

Voice Transmission Tests: are only used in special
   situations. All these tests become abnormal in
   consolidation. They include:

  Bronchophony
  Whispered Pectoriloquy
  Egophony



  2002/2003          Clinical Examination of the Chest                       52
                                                     Local examination of the chest

  Auscultation: Voice sounds- Bronchophony

1. Ask the patient to say "ninety-nine“ or 44 in
   arabic several times in a normal voice.
2. Auscultate several symmetrical areas over
   each lung.
3. The sounds you hear should be muffled and
   indistinct. Louder, clearer sounds are
  called bronchophony.

  2002/2003      Clinical Examination of the Chest                       53
                                                       Local examination of the chest
           Auscultation: Voice sounds-
                Whispered Pectoriloquy

1. Ask the patient to whisper "ninety-nine“ or 44
   in arabic several times.
2. Auscultate several symmetrical areas over
   each lung.
3. You should hear only faint sounds or nothing
   at all. If you hear the sounds clearly this is
  referred to as whispered pectoriloquy.

   2002/2003       Clinical Examination of the Chest                       54
                                                      Local examination of the chest
          Auscultation: Voice sounds-
                       Egophony

1. Ask the patient to say "ee" continuously.
2. Auscultate several symmetrical areas over
   each lung.
3. You should hear a muffled "ee" sound. If you
  hear an "ay" sound this is referred to as
  "E -> A" or egophony.


  2002/2003       Clinical Examination of the Chest                       55

								
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