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					PHYSICAL DIAGNOSIS


    THE CHEST

  DR SHAM A. CADER
    THE ORGANS
•
              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,
    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
    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
            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 mid-
     axillary 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 .
        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
    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

•
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

•
• Erythema (Empyema)
• Warmth (Empyema)
• Tenderness ( Empyema, Rib and chest wall
  lesions )
• Subcutaneous nodules (Metastasis)
          Voice transmission

•   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
•
          Abnormal Finding

• Decreased: (Pleural effusion,
    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).
    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
    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
• 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

•   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
•   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

				
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