Chest Examination

By : Dr Abdulbagi
MBBS OIU
BLS certificate NHCPS
First Aid certificate NHCPS
.PSO member
.Founder of medical educational platform (about 3k students)
You can be a fine doctor without
.being able to elicit every sign

However, finding signs and putting

together the clues they give us to find a
diagnosis is one of the best parts of being
.a doctor
as you starting the examination, be a
good WIPER
.Wash your hands
.Introduce yourself to the patient
Permission. Explain that you wish to examine their
heart. Ask the patient if they are in any pain and to tell
.you if the experience any during the examination
Expose the necessary parts of the patient. Ideally the
.patient should be undressed from the waist up
Reposition the patient. In this examination the patient
.should be supine and reclined at 45 degrees
: General
:Ds 5
Diseased? Look ill/unwell/ well
”Dysmetria “average weight/cachexic
?Distressed? Or cyanosed
Dysmorphic
.Dependencies (IV line, nebulizer, O Mask, sputum pot, etc...)
2
 Keys To Performing a Respectful & Effective Exam
Explain what you’re doing (& why) before doing it•
acknowledge
Expose minimum amount of skin necessary•
:Examining heart & lungs of female patients•
Ask pt to remove bra prior (can’t hear well thru fabric)–
Expose side of chest to extent needed–
Don’t rush•
 :Hand
.Clubbing
Cyanosis (acrocyanosis)
Tobacco staining
,

Asterixis (‘carbon dioxide flap’)

yellow nail
syndrome’:

lymphoede
ma

exudative
pleural
effusion
Asterixis
Tobacco
‘tar’-stained
fingers
Face
Pallor of the conjunctiva (anaemia) •
Central cyanosis •
Features of Horner’s •
Central
cyanosis of
the tongue
Distend
ed neck
veins
chest
Inspection
Symmetry “bulging/depression”/ Deformity •
”Chest movement “side moving less •
”inward on inspiration“
:Pattern of breathing •
”abdomino-thoracic/thoraco-abdomonal“
Respiratory rate •
.scar, viens +
Hyperinflat
ed chest

Intercostal
indrawing
Kyphoscoliosi
s
Kyphosis:
exaggerated
anterior curvature
of the spine

Scoliosis is lateral
curvature
Pectus .1
carinatum
“pigeon chest”

2. Harrison’s
sulcus
Pectus
excavatum
”“funnel chest
Dilated
superfici
al veins
 .Normally: e.g •
Chest of normal contour moving equally with
respiration, thoraco-abdominal breathing
Respiratory rate 15 breaths/minutes
.no scars or prominent viens
Palpation
 Palpation
Trachea
”Apex beat “site
Chest expansion
”TVF “tactile vocal fremitus
 : Normally
..…Trachea is central, apex at
Normal, equal chest movement with
intact tactile vocal fremitus
Percussio
n
Auscultati
on
Air entry
Breath sounds
”“vesicular/bronchial
Added sounds
Vocal resonance/ whispering
‘

’ pectoriloquy
:Normally

Normal, equal Air entry

vesicular Breathing no Added
sounds intact Vocal resonance
Back of chest
• Expansion
• Tactile vocal fremitus
• Percussion
• Auscultation
• Vocal resonance
Discussion
Clinical DDx

PE
Lung fibrosis
Consildation
Pnemothorax
 DDx of PE
.Infection TB
.Malignancy
Inflammatory: SLE, RA

.HF

Nephrotic, liver failure, GIT

Investigations
.CBC
.Chest x ray
.US
.Aspiration for lab analysis
Management of PE
....Supportive :O2, blood
.Aspiration
.Treatment the underlying cause
 DDx lung fibrosis
TB
Sarcoidosis
Aspestosis, ILP
.Drug induced ; Bleomycin, Busulfan, Amyodaron
Investigations
. CBC
Chest X ray: reticuonoduler pattern, Bilateral hyler lymphadenopathy.
.Cavitatory lesions
.PFT: restrictive pattern
 Management
....Supportive : O2, fluids, Blood
Treat the underlying cause: Anti TB, Steroid Sarcoidosis,lung
.....transplant
 DDx Consildation
Pneumonia
: Manigment*
According to severity : CURB_65
Supportive
Analgesics
Antibiotics
Case1
child is evaluated for high fevers, dyspnea, and pleuritic chest pain.
Chest x-ray shows a lobar infiltrate. What is the most likely causative
?organism
Case2
A child is evaluated for dry cough, sore throat, and a macular rash.
Chest x-ray shows interstitial infiltrates. What is the most likely
?causative organism
Explanation
Community-acquired pneumonia in school-aged
children
Lobar pneumonia Bilateral
Etiology Etiology
Streptococcus pneumoniae Mycoplasma pneumoniae Chlamydia
.pneumoniae Viruses
Clinical features
Clinical features
Abrupt onset of fever, cough, chest pain
Fever, malaise, headache, sore throat
Increased work of breathing
Prolonged, gradually worsening cough
Focal crackles
Patient can often continue normal activities
Treatment
.Bilateral crackles, wheezing
Oral amoxicillin (outpatient) or intravenous Treatment
ampicillin or ceftriaxone (if hospitalized)
Macrolide (eg, azithromycin)
Note
Mycoplasma pneumoniae is the most common cause of community-
acquired (atypical) pneumonia. Onset is generally (progressive), and
.symptoms are typically (mild). It is treated with (macrolides)
Streptococcus pneumoniae is the most common cause of community-
acquired (typical) pneumonia. Onset is generally (abrupt), and
.symptoms are typically (severe). It is treated with (amoxicillin)
Quiz
?Which are most likely to be community-acquired vs hospital-acquired
Streptococcus pneumoniae -
Klebsiella pneumoniae -
MRSA -
Respiratory viruses -
Gram-negative bacilli -
Case3
year-old woman comes to the emergency department because of a 1-month -48
history of chest pain, mild shortness of breath, and a dry cough. The chest pain is
exacerbated by coughing and deep breathing. She is homeless and has not seen a
physician in more than 20 years. She has smoked one pack of cigarettes daily for
the past 33 years and drinks 3–4 beers daily. Her temperature is 37.3°C (99.1°F),
pulse is 115/min, respirations are 23/min, and blood pressure is 113/65 mm Hg.
Pulse oximetry on room air shows an oxygen saturation of 97%. Physical
examination shows scleral jaundice, diffuse telangiectasias on the chest, and
bilateral pedal edema. Pulmonary examination shows decreased breath sounds
and dullness to percussion on the right side. Cardiac examination shows normal
heart sounds with no murmurs, rubs, or gallops. The abdomen is mildly distended
and there is shifting dullness to percussion. The spleen is palpated 3 cm below
.the left costal margin
 Explanation
Unilateral pleural effusion
requires diagnostic thoracocentesis to obtain a pleural fluid specimen for diagnosis of
the underlying etiology. The aspirated pleural fluid is analyzed (e.g., cytochemistry, cell
count, pH, albumin, lactate dehydrogenase, glucose) and further categorized as a
transudative effusion or an exudative effusion. Given this patient's smoking history and
underlying cirrhosis, it is important to differentiate between hepatic hydrothorax
(transudate) and malignant pleural effusion secondary to lung or liver cancer (exudate).
In patients with large symptomatic pleural effusions, diagnostic thoracocentesis can be
.combined with therapeutic thoracocentesis to provide symptomatic relief
Bilateral pleural effusions
Pleural fluid drainage is not required. if the patient is asymptomatic, and it's suspected
to be due to transudation ( cirrhosis, cardiac failure, or nephrotic syndrome), and
responsive to medical therapy
Case4
A 55-year-old woman comes to the physician because of an 8-month
history of persistent dry cough and shortness of breath with mild exertion.
She reports feeling too weak to leave the house on most days. She has
rheumatoid arthritis and hypertension. She used to work as a hotel
receptionist but quit her job a year ago because of worsening joint pain.
She smoked a pack of cigarettes daily for 27 years but quit 2 years ago. Her
medications include methotrexate, folic acid, and enalapril. Her
temperature is 36.1°C (97°F), pulse is 98/min, respirations are 18/min, and
blood pressure is 148/82 mm Hg. Pulse oximetry on room air shows an
oxygen saturation of 96%. Physical examination shows an enlargement of
the fingertips with increased curving of the nails and bilaterally enlarged
metacarpophalangeal joints. Inspiratory crackles are heard over both lung
bases. A high-resolution CT scan of the chest is shown. The diffusing
?capacity of the lung (DLCO) is decreased. What is the most likely diagnosis
 Explanation
This patient's chest CT scan findings are consistent with interstitial lung
disease (ILD), which can manifest with persistent dry cough, exertional
dyspnea, digital clubbing due to chronic hypoxia, and bibasilar
inspiratory crackles on auscultation. ILD is caused by excess collagen
deposition in the extracellular matrix of the lung that leads to diffuse
thickening of the alveolar walls and progressive fibrosis of the lung
parenchyma, resulting in restrictive lung disease and decreased DLCO.
While most cases of ILD are idiopathic (i.e., idiopathic pulmonary
fibrosis), this patient's ILD is most likely secondary to rheumatoid
arthritis and/or methotrexate use. Smoking is also a risk factor for
.pulmonary fibrosis
 Pneumothorax
Primary

Secondery

:Investigations

: Manigment