Scribd Logo
Upload

Welcome to Scribd!

  • 86 views

    Physical Exam - Chest 2006

    Uploaded by

    api-19916399
    This document provides information on examining the chest, including landmarks, reference lines, regions, and examination techniques. It discusses inspection of the chest wall, breasts, and lungs. It covers palpation of the chest wall and breasts. It also details percussion and auscultation of the lungs, including normal and abnormal breath sounds. The document is intended as a guide for physical examination of the chest.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd

    Physical Exam - Chest 2006

    Uploaded by

    api-19916399
    86 views84 pages
    This document provides information on examining the chest, including landmarks, reference lines, regions, and examination techniques. It discusses inspection of the chest wall, breasts, and lungs. It covers palpation of the chest wall and breasts. It also details percussion and auscultation of the lungs, including normal and abnormal breath sounds. The document is intended as a guide for physical examination of the chest.

    Original Title

    physical exam.chest 2006

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PPT, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides information on examining the chest, including landmarks, reference lines, regions, and examination techniques. It discusses inspection of the chest wall, breasts, and lungs. It covers palpation of the chest wall and breasts. It also details percussion and auscultation of the lungs, including normal and abnormal breath sounds. The document is intended as a guide for physical examination of the chest.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    86 views84 pages

    Physical Exam - Chest 2006

    Uploaded by

    api-19916399
    This document provides information on examining the chest, including landmarks, reference lines, regions, and examination techniques. It discusses inspection of the chest wall, breasts, and lungs. It covers palpation of the chest wall and breasts. It also details percussion and auscultation of the lungs, including normal and abnormal breath sounds. The document is intended as a guide for physical examination of the chest.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 84

    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
    Clinical Examination
    Inspection of the Breasts
    Clinical Examination
    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
     Percussion: dullness or flatness
     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
     Percussion: dullness or flatness
     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
     
    THANK YOU !

                                           

                                                                                
                          

    You might also like