THE CHEST EXAMINATION Szymon Wcisło Medical University of Lodz General Surgery and Thoracosurgery Clinic Military Teaching Hospital No. 2 Lodz, Zeromskiego Street No. 113

The regions of the chest ► The surface of chest consists of some smaller regions which we can name similiar to the nearest points of the chest. ► We can describe these regions on the front and back of chest.

The regions of the chest

Lines of the body ► These lines are usefulness to describe localisation of some disorders and physiological symptoms which we can investigate in the chest.

Lines of the body

Respiratory system ► Trachea ► Main bronchi  Right – wider, shorter and descendens more verticaly than left (foreign body most often run in right lung bronchial tree)  Left ► LUNGS  Right – three lobes ► Upper ► Middle ► Lower  Left – two lobes ► Upper ► Lower

Respiratory system

Circulatory system ► Heart  Four cavities ► Right and left ventricles ► Right and left atriums  Four valves ► Bicuspid or mitral valve ► Aortic or semilunar valve ► Tricuspid valve ► Pulmonary valve

Circulatory system - heart ► Apex – is the lowest part of the heart on the left side ► This part of heart adheres to front wall of chest ► We can see sometimes the apex beat – asthenic people

Circulatory system - heart

Clinical examination ► Conduct an investigation  Always speek with patient – after and during physical examination ► Conduct a physical examination  Inspection  Palpation  Percusion  Auscultation

Inspection ► Age  Child  Adolescent  Young  Middle-aged  Elderly  Geriatric ► Some diseases are conjugated with age

Inspection ► Size  Short  Medium  Tall ► Physical appearance  Thin / slim  Normal  Overweight / obese

Inspection ► Body constitution = Size + Physical appearance  Pyknic (short + obese)  Normostenic (medium + normal)  Asthenic (tall + thin)

Inspection ► Changes in skin colour  Normal  Bluishes / cyanosis – couse by some disorders of respiratory or circulatory system  Jundice – icterus  Pallor – shortness of breath  Redness – some skin inflammations, high fever

Inspection ► Temperature  Normal 36,6°C  Subnormal  Elevated  High ► Consciousness or unconsciousness ► Perspiration – profuse or not ► Swelling ► Scars of previous operations

Inspection ► Respiration  Abdominal – men  Thoracical – women  Asthmatic – status asthmaticus (bronchospasm – contraction of bronchi)  Laboured - dyspnoea  Shallow - hyperventilation  Tachypnoe – over 20 breaths per minute  Bradypnoe – below 14 breaths per minute

Inspection ► Constitution of thorax  Barell chest – emphysematous chest  Rachitic chest  Chicken chest – sternum to front like birds  Funnel chest – shoe maker`s chest

Inspection ► Skin lesions  Abscess  Cyst  Erythema  Macula  Nodule  Scar  Ulcer  Tumours – angioma, lipoma, papilloma, adenoma, cancer

Inspection ► Erythema ► Cyst ► Ulcer ► Tumour neoplasmaticus

Inspection ► Sometimes we observe apex beat ► Always we must observe typical localisation of:  Axillary lymph nodes  Lymph nodes over clavicle  Lymph nodes above clavicle ► Breast – another exercises

Palpation ► In this kind of examination we use our palm ► All lesions detected in observation must be checked with palpation ► Skin lessions always must be described with its diameters (cm)

Palpation ► Tenderness  Rib fracture  Some skin lessions ► Swelling ► Pathological pulses on chest surface ► Lymph nodes  Single or not  Enlarged or not  Sliding relative to tissues

Palpation Apex beat  This beat can be found in point localized in crossing: the fifth intercostal space and vertical line 2 cm medial to left midclavicle line  Norm: when the pulp of the forefinger covers this beat  If the apex beat is larger then forefinger pulp that can mean – fluid in pericardial cavity – heart tamponade

Palpation Size of forefinger pulp

Palpation

Palpation Pectoral fremitus – the sensation felt by palpation ► In summary of this examination we describe vocal fremitus like:  Symmetric  Unsymmetric ► Some disorders of lungs can couse the unsymmetric pectoral fremitus for example  Pneumothorax (the presence of air or gas in a cavity of pleura)  Hydrothorax – fluid in the pleural cavity  Lung inflammation

Palpation ► Symmetricaly in:  Regio pectoralis  Regio mammaria  Regio inframammaria

Palpation ► Respiratory expansion  Inspected on back  Two hands examination  Symmetric or unsymmetric  Linea mediana posterior is the reference point

Palpation

Percussion Finger percussion ► Right middle finger tapping the left middle finger ► In chest over the lungs we can hear:  Vesicular resonance – healthy lungs  Tympanic resonance – pneumothorax, pulmonary emphysema  Dull percussion sound – fluid in pleural cavity, inflammation, cancer, lung tissue without air

Percussion

► We percuss symetricaly following points:  Front of the chest: ► Second intercostal space near the sternum ► Fourth intercostal space in midclavicle line ► Sixth intercostal space in anterior axillary line ► Over the clavicle  Back of the chest: ► Over the scapula ► Medialy to the scapula ► Under the scapula

Percussion

Respiratory movement ► We check on back – scapular line ► First patient inhales and stops the air in lungs and then we percuss the lung in vertical direction from up to down and stop when the percussion sound change from vesicular to dull – this is down inhaling border of examined lung ► Secondary patient exhale and stops breathing then we percuss lung like when the patient inhale – exhaling border of examined lung ► Norm: 2-6 cm

Percussion Respiratory movement Exhalation Inhalation

Percussion Lower border of lung ► Vertical direction of percussion (up to down) ► Vesicular resonance change to dull resonance sound ► Patient in sitting positon ► Patients always breath spontaneously

Percussion ANATOMICAL LINE RIGHT SIDE (intercostal space) LEFT SIDE (intercostal space) SternalisVIV Midclavicule VIVI MidaxillaryVIIVIII ScapularXIXI ParavertebralXX

Percussion Heart percussion ► Sometime we percuss the heart ► In this examination we percuss the borders of heart  Irrelative (part of heart adhering to front wall of chest)  Relative (all shape of heart which we can percuss)

Percussion Relative borders of heart

Percussion Irrelative borders of heart

Percussion ► Relative borders:  Upper border – third intercostal space or thirth rib  Left border – apex line (vertical line 2 cm medialy to left midclavicle line)  Right border – right sternal line  Down border – we don`t examine because of stomach fundus ► Irrelative borders:  Upper border – fourth intercostal space or forth rib  Left border – apex line  Right border – left sternal line  Down border – fifth intercostal space

Auscultation ► In this kind of examination we use stethoscope ► We examine the lungs and heart ► Over the lungs we can hear some kinds of murmurs or rales ► Over the heart we can hear some murmurs

Auscultation Lungs auscultate ► Symetrical examination ► Norm over the lungs is vesicular murmur ► Some inflammations or neoplasms can cause the more intensive and louder vesicular murmur ► We auscultate the lungs in typical points of front and back chest wall ► No murmurs sound sugests pneumothorax or fluid in the pleural cavity (hydrothorax)

Auscultation IV intercostal space in midclavicle line IV intercostal space in midclavicle line II intercostal space near the sternum

Auscultation VI intercostal space in front axillary or midaxillary line VI intercostal space in front axillary or midaxillary line Over the clavicle we check the murmur from lung apex

Auscultation Above the scapula In the middle of scapulas Over the scapula

Auscultation ► Pathological lung murmurs which we can sometimes hear:  Moist rales ► Coarse rales ► Bubbling rales ► Fine rales  Dry rales – like snoring  Crepitant rales – like walking on snow  Whistling rales – like whistle sound Like water gurgitation

Auscultation Heart auscultation ► We auscultate four valves in this order:  Mitral = bicuspid  Aortic  Pulmonary  Tricuspid ► Always we try to hear two tones over the valves ► First tone occurs in the same time when we palpate the artery pulse

Auscultation

Auscultation ► Mitral valve – point of apex beat ► Pulmonary valve – second left intercostal space near the sternum ► Aortic valve – second right intercostal space near the sternum ► Tricuspid valve – forth right intercostal space near the sternum

Auscultation ► Pathological murmurs could be heard at patients with:  Stenosis of valve  Insufficiency of valve ► These murmurs occur  After first tone  After second tone  Between first and second tone