1. History Taking & Chest Examination
Dr. Waseem HAJJAR, MD. FRCS.
Assistant professor &
Consultant Thoracic Surgeon

2. A good history should be both:
Concise.
Cover the important points.

3. Rules: Patient should be allowed to tell his history in his own words.
Leading questions must be avoided unless the information can’t be obtained by other means

4. Questions: Complete the immediate description.
Elucidate the vague points.
Fill in the gaps the history not mentioned by patient.
Emphasize the important points.

5. Types of questions: Neutral questions.
Simple direct questions (yes/No).
Leading questions.

6. WHAT SHOULD WE KNOW ABOUT THE EXAMINATION OF THE CHEST?
HISTORY
SYMPTOMS
LANDMARKS
PERTINENT VOCABULARY
SIGNS
HOW TO PERFORM AN EXAM
HOW TO PRESENT THE INFORMATION
HOW TO FORMULATE A DIFFERENTIAL DIAGNOSIS

7. Personal data: Name. Age. Sex. Occupation. Residence.
The patients complaint:
A simple statement in the patients own words and its duration.

8. HISTORY

9. Present History:
This means detailed history of the patients present illness which must provide answer for the following questions:
Duration
Mode of onset (acute, sub acute, chronic).
Sequence of events:
Course (progressive, regressive or recurrent).
Appearance of new additional symptoms or disappearance of others.
Treatment received during the course & response.
Analysis of each particular symptom.

10. History Acute/chronic disorder Preceding systemic disturbance
Past medical history
Drug history
Social history
Family history
Occupational history

11. Past History: Childhood diseases. Trauma. Residences or travel abroad.
Drug therapy.
Operations.

12. THE HISTORY FAMILY HISTORY
EMPHYSEMA AT AN EARLY AGE - CONSIDER ALPHA – 1 ANTITRYPSIN
RECURRENT RESPIRATORY INFECTIONS AND STERILITY IN A YOUNG ADULT MALE – CONSIDER CYSTIC FIBROSIS, IMMOTILE CILIA OR YOUNG’S SYNDROME
PULMONARY NODULE AND HYPOXEMIA – CONSIDER OSLER WEBER RENDU

13. Family History: Hereditary factor.
Exposure to same etiological circumstances.

14. THE HISTORY OCCUPATIONAL - CHRONOLOGIC ORDER EXPOSURE :
BRAKE SHOES, PIPE FITTERS (ASBESTOS)
SANDBLASTING, QUARRY (SILICOSIS)
FARMING – (FARMERS LUNG)
MILITARY – (BERYLLIOSIS)
TRAVEL- FAR EAST (PARAGONIMIASES)
SOUTH AMERICA (BRUCELLOSIS)
SOUTHWEST USA (COCCIDIOMYCOSIS)
DRUGS – INTERSTITIAL LUNG DISEASE (NITROFURANTOIN)
HABITS – TOBACCO, NOSE DROPS, ILLICIT DRUGS

15. Habits:
Smoking.
Physical efforts.
Addiction.

16. SYMPTOMS

17. History
Dyspnoea
Wheeze
Cough
Sputum
Haemoptysis
Chest pain

18. MAIN SYMPTOMS OF PULMONARY DISEASE
COUGH
DYSPNEA
HEMOPTYSIS
CHEST PAIN – PLEURITIC
WHEEZING
CYANOSIS
SPUTUM PRODUCTION
SNORING

19. LUNG
KIDNEY
SPLEEN
LIVER
SKIN
BRAIN
HEART

20. DESCRIBE THE COUGH PRODUCTIVE – NONPRODUCTIVE ACUTE – CHRONIC
TIME OF DAY
PRECIPITANTS – RELIEF
BLOODY – NON BLOODY
BARKING – HACKY

21. COUGH SYMPTOM ETIOLOGY MORNING NON-PRODUCTIVE RECUMBENT BARKING
NOCTURNAL
PRODUCTIVE
BLOODY
ETIOLOGY
CHRONIC BRONCHITIS
VIRAL, ILD,TUMOR
SINUSITUS, CHF,REFLUX
CROUP,LARYNGEAL
ASTHMA, CHF
INFECTIOUS
TUMOR,CHF

22. THE PNEA’S DYSPNEA – SOB : ACUTE – (PULMONARY EMBOLISM, PNTX, ASTHMA)
CHRONIC – (COPD, CHF, ILD)
TACHYPNEA – RR>20 BR/MIN
BRADYPNEA - RR< 8 BR/MIN (DRUGS, AGONAL)
PND - PAROXYSMAL NOCTURNAL DYSPNEA SUDDEN ONSET OF SOB DURING SLEEP (CHF)
ORTHOPNEA – SOB LYING FLAT (CHF)
PLATYPNEA – SOB SITTING UP AND BETTER LYING FLAT (R TO L SHUNT)
TREPOPNEA – SHORTNESS OF BREATH IN ONE LATERAL DECUBITUS POSITION WHICH IS IMPROVED BY TURNING ON THE OPPOSITE SIDE

23. DYSPNEA MY CHEST FEELS TIGHT I CANNOT TAKE A DEEP BREATH
I FEEL LIKE I HAVE A PILLOW OVER MY MOUTH
I AM SMOTHERING

24. THE NUMEROUS ETIOLOGIES OF CHEST PAIN
PLEURITIC – PARIETAL PLEURA – SHARP STABBING – INSPIRATION
ESOPHAGEAL – REFLUX
CARDIAC – MYOCARDIAL INFARCTION
GALL BLADDER – CHOLECYSTITIS
CHEST WALL – COSTOCHONDRITIS
GREAT VESSELS – DISSECTION
PULMONARY - PNEUMOTHORAX

25. SPUTUM - WHAT ARE ITS CHARACTERISTICS ?
YELLOW – GREEN (PNEUMONIA, BRONCHIECSTAIS)
RUSTY (PNEUMOCCOAL PNEUMONIA)
ANCHOVY PASTE (AMEBIASIS)
PINK – BLOOD TINGED (EPISTAXIS, BRONCHITIS)
FROTHY (CHF)
BLOODY (MALIGNANCY, BRONCHIECSTASIS, PULMONARY RENAL SYNDROME)
SMELL – FOUL? (ANAEROBIC LUNG ABCESS)
SANDLIKE (BRONCHOLITHIASIS)
BLACK – COAL DUST INHALATION

26. HEMOPTYSIS - REQUIRES CAREFUL QUESTIONING
THIS SYMPTOM USUALLY DENOTES A SERIOUS ILLNESS. TB, TUMOR, BRONCHIECSTASIS, PE, CARDIAC DISEASE
THE PATIENT SHOULD BE QUESTIONED CAREFULLY REGARDING HOW MUCH, FREQUENCY WEIGHT LOSS ETC.

27. CLUES TO DIFFERENTIATING HEMOPTYSIS FROM HEMATEMESIS
NAUSEA – VOMITING
NOT FROTHY
COFFEE GROUNDS
FOOD
NAUSEA
GI DISEASE
HEMOPTYSIS
COUGH
FROTHY
COLOR- BRIGHT RED
PUS
DYSPNEA
CARDIAC DISEASE

28. THE PULMONARY EXAMINATION
SIGNS

29. WHAT SHOULD WE KNOW ABOUT THE EXAMINATION OF THE CHEST?
HISTORY
SYMPTOMS
LANDMARKS
PERTINENT VOCABULARY
SIGNS
HOW TO PERFORM AN EXAM
HOW TO FORMULATE A DIFFERENTIAL DIAGNOSIS
HOW TO PRESENT THE INFORMATION

30. TOPOGRAPHY OF THE CHEST

31. TOPOGRAPHY OF THE BACK

32. The Chest
Inspection
Palpation
Percussion
Auscultation

33. Inspection of the chest
Important:
- SHAPE
- MOVEMENT
- VISIBLE PULSATIONS!
SHAPE of the chest:
Deformities: - kyphosis
- scoliosis
- depressed sternum (pectus excavatum)
- bulges in left parasternal area
(congenital malformation)
e.g. VSD
of the thorax

34. Chest wall
Pectus carinatum
Pectus excavatum

35. Pectus Excavatum

36. Inspection Shape Scars Lesions Resp rate Resp depth Mode of breathing
Abnormal inspiratory movements
Abnormal expiratory movements
Asymmetry of movement

37. Nicotine staining

38. 2 liters of O2

39. BARREL CHEST

40. Barrel Chest
AP Diameter = Transverse Diameter

41. PALPATION FEELING WITH THE HAND – FINGERTIPS TEXTURES DIMENSIONS
CONSISTENCY
TEMPERATURE

42. Palpation
Chest expansion
Tactile vocal fremitus

46. Chest Expansion

47. Chest Expansion

48. Chest Expansion

50. Trachea exam

51. Percussion Illustrate resonance Compare both sides
Map out abnormal area

53. METHODS OF PERCUSSION
DIRECT
INDIRECT
DISEASE A MONTH 41; :1995

54. METHODS OF PERCUSSION

55. METHODS OF PERCUSSION

56. Percussion Impaired(dull)resonance obtained –
Aerated lung tissue is separated from the chest wall e.g. fluid, pleural thickening
Lung tissue is airless e.g. consolidation, collapse, fibrosis
“stony dullness”- pleural effusion
Hyperresonance - pneumothorax

57. Percussion technique
Place left hand on chest wall, palm downwards with fingers separated
2nd phalanx over area of intercostal space
Right middle finger strikes the 2nd phalanx producing hammer effect
Entire movement comes from wrist

62. PERCUSSION SOUNDS TYMPANY – HEARD OVER THE ABDOMEN
RESONANCE – HEARD OVER NORMAL LUNG
DULLNESS – HEARD OVER LIVER OR THIGH

63. Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)

64. AUSCULTATORY PERCUSSION
METHOD
THE STETHOSCOPE IS PLACED OVER THE POSTERIOR CHEST WALL, THE CLINICIAN THEN TAPS LIGHTLY OVER THE MANUBRIUM, EQUIVALENT SOUNDS SHOULD BE HEARD OVER CORRESPONDING AREAS OF THE LUNG. ASYMETRY SUGGESTS DISEASE.

65. AUSCULTATORY PERCUSSION
MANGIONE PHYSICAL DIAGNOSIS SECRETS 2000

66. Auscultation of the front

67. Auscultation of the back

69. Breath Sounds Vesicular - normal Diminished - localised or diffuse
Bronchial - consolidation

71. TACTILE FREMITUS
A THRILL OR VIBRATION WHICH IS FELT ON THE CLINICIANS HAND WHILE RESTING IT ON THE PATIENTS CHEST WALL AT T HE SAME TIME THE PATIENT SPEAKS. 99 – 1-2-3
SYMETRY MAY BE SEEN IN NORMALS
ASYMETRY – IS ABNORMAL

73. TACTILE FREMITUS INCREASED DECREASED PNEUMOTHORAX PNEUMONIA
PLEURAL EFFUSION
COPD
FAT
PNEUMONIA

74. VOCAL FREMITUS
THE PATIENTS VOICE IS HEARD THROUGH A STETHOSCOPE PLACED ON THE PATIENTS CHEST – NORMALLY THE SOUNDS ARE INDISTINCT
ABNORMALITIES – BRONCHOPHONY, PECTORILOQUY, EGOPHONY
CONSOLIDATION

75. VOCAL FREMITUS
BRONCHOPHONY – SOUND OF THE BRONCHI – SOUND MUCH LOUDER THAN NORMAL - WORDS INDISTINCT
PECTORILOQUY – VOICE OF THE CHEST – WHISPER – WORDS INDISTINCT
EGOPHONY – VOICE OF THE GOAT – BLEATING - E – A CHANGES – COMPARE SIDE TO SIDE
REMEMBER - ALL SUGGEST CONSOLIDATION OF THE LUNG

76. THORACIC EXPANSION
ASYMETRY IN EXPANSION OF THE THORAX CAN BE DETECTED DURING INSPECTION OF THE CHEST
DURING PROMPTED INHALATION OBSERVE THE MOVEMENT OF THE THORAX
PLEURAL EFFUSION, PNEUMOTHORAX

78. CYANOSIS
PERIPHERAL – HANDS, FEET – WARMING DECREASES CYANOSIS – DECREASED CARDIAC OUTPUT
CENTRAL- LIPS, TONGUE,SUBLINGUAL - RIGHT TO LEFT SHUNTS
PSEUDOCYANOSIS – BLUE PIGMENTS IN SKIN - AMIODARONE

79. Central Cyanosis
Results from pulmonary dysfunction, the mucous membrane of conjunctiva and tongue are bluish.
If there was chronic hypoxemia and secondary erythrocytosis, you can detect the conjunctival and scleral vessels to be full, tortuous and bluish.

80. Central Cyanosis

81. Corpulmonale

82. Sleep apnea syndrome

83. Clubbing Hereditary Interstitial Fibrosis Tumor Bronchiecstasis
Heart Disease
Endocarditis

84. Clubbing

85. Significance: Clubbing Observed In:
Intrathoracic malignancy: Primary or secondary (lung, pleural, mediastinal)
Suppurative lung disease: (lung abscess, bronchiectasis, empyema)
Diffuse interstitial fibrosis: Alveolar capillary block syndrome
In association with other systemic disorders

86. CLUBBING PAINLESS – FINGERNAILS CURVED AND WARM
ENLARGEMENT OF THE CONNECTIVE TISSUES IN THE TERMINAL PHALANGES OF THE FINGERS >TOES

87. SCHAMROTH’S SIGN – LOSS OF THE SUBUNGUAL ANGLE
CLUBBING
SCHAMROTH’S SIGN – LOSS OF THE SUBUNGUAL ANGLE
CLIN CHEST MED 8: ,1987

88. CLUBBING
LOVIBOND’S ANGLE – THE ANGLE BETWEEN THE BASE OF THE NAIL AND SURROUNDING SKIN.
CLIN CHEST MED 8: ,1987

89. DO NOT FORGET THE TRACHEA
TRACHEAL DEVIATION
AUSCULTATE - STRIDOR
TRACHEAL TUG (OLIVERS SIGN) – DOWNWARD DISPLACEMENT OF THE CRICOID CARTILAGE WITH VENTRICULAR CONTRACTION – OBSERVED IN PATIENTS WITH AN AORTIC ARCH ANEURYSM
TRACHEAL TUG (CAMPBELL’S SIGN) – DOWNWARD DISPACEMENT OF THE THYROID CARTILAGE DURING INSPIRATION – SEEN IN PATIENTS WITH COPD

90. ABNORMAL BREATHING PATTERNS
APNEA - CARDIAC ARREST
BIOTS – INCREASED INTRACRANIAL PRESSURE – DRUGS- MEDULLA
CHEYNE STOKES – CONGESTIVE HEART FAILURE – DRUGS – CEREBRAL
KUSSMAULS – METABOLIC ACIDOSIS

91. WHITE NOISE (NOISY BREATHING)
THIS NOISE CAN BE HEARD AT THE BEDSIDE WITHOUT THE STETHOSCOPE
LACKS A MUSICAL PITCH
AIR TURBULENCE CAUSED BY NARROWED AIRWAYS
CHRONIC BRONCHITIS

93. BREATH SOUNDS
VESICULAR – NORMAL BREATH SOUNDS - SITE OF PRODUCTION THE ALVEOLI
TRACHEAL – TUBULAR – LIKE BLOWING AIR THROUGH A HOLLOW TUBE – PHYSIOLOGIC
BRONCHIAL – TUBULAR ALWAYS PATHOLOGIC WHEN THEY OCCUR OVER POSTERIOR OR LATERAL CHEST WALL
BRONCHOVESICULAR – CHARACTERISTICS OF BOTH VESICULAR AND TUBULAR – DO THEY EXIST?
ADVENTITOUS – EXTRA SOUNDS

94. BREATH SOUNDS TIMING CHARACTERISTIC TRACHEAL BRONCHIAL BV VESICULAR
INTENSITY
VERY LOUD
LOUD
MODERATE
LOW
I:E RATIO
1:1
1:3
3:1

95. Breath sounds

96. Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea, bronchi to chest wall
Rustling quality
Inspiration continuous with expiration
Intensity increases during inspiration & fades during first 1/3rd expiration

97. Diminished breath sounds
Conduction limited by
Airflow limitation
e.g. diffusely – asthma, emphysema
localised – tumour, collapse
Something separating chest wall from lung
e.g. effusion, fibrosis

98. Bronchial breathing “blowing” inspiratory & expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched e.g. consolidation
Low-pitched e.g. fibrosis

99. Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds

100. Rhonchi
Due to passage of air through narrowed bronchus e.g. bronchospasm, mucosal oedema
Musical quality
High or low pitched
Usually expiratory
Expiration prolonged

101. Crepitations Inspiratory noises, usually 2nd half Non-musical
Due to explosive reopening of peripheral small airways during inspiration which have become occluded during expiration

102. Pleural Rub Creaking noise
Movement of visceral pleura over parietal pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and early expiration

103. ADVENTITIOUS SOUNDS
THESE ARE SOUNDS HEARD DURING AUSCULTATION OTHER THAN BREATH SOUNDS OR VOCAL RESONANCE
NOMENCLATURE – HAS BEEN CONFUSING
CRACKLES – DISCONTINUOUS SOUNDS
WHEEZES AND RHONCHI – CONTINUOUS SOUNDS

104. ADVENTITIOUS LUNG SOUNDS (BRUITS ETRANGERS – FOREIGN SOUNDS)
WHEEZE – HIGH PITCHED
RHONCHI – LOW PITCHED
CRACKLE RALES - HAIR VELCRO (FINE – COARSE)
PLEURAL RUBS – CREAKING LEATHER
STRIDOR
SQUEAK – HIGH PITCHED WHEEZE HEARD AT THE END OF INSPIRATION

105. CRACKLES EARLY AND MID INSPIRATORY LATE INSPIRATORY COARSE FINE
LOW PITCHED
HIGH PITCHED
CLEAR WITH COUGHING
DO NOT CLEAR WITH COUGHING
SCANTY
PROFUSE
GRAVITY IN DEPENDENT
GRAVITY DEPENDENT
TRANSMITTED TO THE MOUTH
POORLY TRANSMITTED TO THE MOUTH
ASSOCIATED WITH OBSTRUCTION
ASSOCIATED WITH RESTRICTION
BRONCHITIS- BRONCHIECSTASIS
INTERSTITIAL FIBROSIS - INTERSTITIAL EDEMA

106. SIGNIFICANCE OF LATE AND EARLY CRACKLES
EARLY – CENTRAL AIRWAYS (BRONCHITIS)
LATE – PERIPHERAL AIRWAYS (FIBROSIS,EDEMA)

107. NOT ALL THAT WHEEZES IS ASTHMA
WHEEZING
ASTHMA
BRONCHITIS
VOCAL CORD DYSFUNCTION
FOREIGN BODY ASPIRATION
INFECTIONS – CROUP LARYNGITIS
CONGESTIVE HEART FAILURE
COPD
FORCED EXPIRATION IN NORMAL SUBJECTS
CYSTIC FIBROSIS
NOT ALL THAT WHEEZES IS ASTHMA

108. COPD
PINK PUFFERS
BLUE BLOATERS

109. DAHL’S SIGN
NICOTINE STAINS
SMOKERS FACE
THORAX 38: , 1983

110. BLUE BLOATER

111. PURSED – LIPS BREATHING
COPD – DECREASES DYSPNEA
DECREASES RR
INCREASES TIDAL VOLUME
DECREASES WORK OF BREATHING
CHEST 101:75-78, 1992

113. HOOVERS SIGN
COPD
IN COPD THE DIAPHRAGM MAY BE FLATTENED, DURING THE INSPIRATORY PHASE OF A BREATH THE RIBS ARE PULLED INWARD AND MEDIALLY RATHER THAN OUTWARD AND LATERALLY

114. RESPIRATORY ALTERNANS
NORMALLY BOTH CHEST AND ABDOMEN RISE DURING INSPIRATION
PARADOXICAL RESPIRATION IMPLIES THAT DURING INSPIRATION THE CHEST RISES AND THE ABDOMEN COLLAPSES
IMPENDING MUSCLE FATIGUE

115. PUTTING IT ALL TOGETHER
PNEUMONIA
PNEUMOTHORAX
PLEURAL EFFUSION
ASTHMA

116. PNEUMONIA INSPECTION – SPLINTING
PALPATION – INCREASED FREMITUS
PERCUSSION – DULL
AUSCULTATION – BRONCHIAL BREATH SOUNDS, CRACKLES, EGOPHONY, PECTORILOQUY, RHONCHI
ENDOBRONCHIAL OBSTRUCTION MAY MASK THE USUAL PHYSICAL FINDINGS OF PNEUMONIA

117. Consolidation Chest xray

118. PLEURAL EFFUSION INSPECTION – LAG AFFECTED SIDE
PALPATION – ABSENT FREMITUS
PERCUSSION – FLAT, DULL
AUSCULTATION – ABSENT OVER EFFUSION, BRONCHIAL IMMEDIATELY ABOVE EFFUSION, RUB OCCASIONALLY

119. PNEUMOTHORAX INSPECTION – LAG AFFECTED SIDE
PALPATION – ABSENT FREMITUS
PERCUSSION – TYMPANIC
AUSCULTATION – ABSENT BREATH SOUNDS

120. PNEUMOTHORAX

121. PNEUMOTHORAX

122. Interpretation of findings
Pleural effusion
reduced tactile vocal fremitus
reduced chest expansion
stony dull
reduced air entry
no added sounds
reduced vocal resonance
Consolidation
increased tactile vocal fremitus
reduced expansion
dull percussion
bronchial breathing
coarse creps
increased vocal resonance
whispering pectoriloquy

123. Pleural effusion

124. Pleural Effusion

125. Interpretation of findings
Pneumothorax
deviated trachea
reduced tactile vocal fremitus
hyper-resonance
reduced air entry
reduced vocal resonance
Collapse
deviated trachea
reduced tactile vocal fremitus
dull percussion
reduced air entry
+/- creps

126. pneumothorax

127. Symptoms of Cardiac disorders:

128. 1. Symptoms due to lung congestion:
Dyspnea.
Acute pulmonary edema.
Cough, hemoptysis.
Recurrent chest infections.

129. 2. Symptoms due to lung congestion:
Pain in the right hypochondrium.
Dyspepsia.
Swelling of lower limb.
Swelling of the abdomen.
Oliguria.

130. 3. Symptoms due to low cardiac output: (tissue hypoxia →brain, muscles, kidneys)
Exertional fatigue.
Blurring of vision.
Dizziness / Syncope.
Oliguria, Angina.

131. 4. Chest pain: Of Cardiac Origin:
Ischemia, pericarditis, Dissecting aorta, Aortic Aneurysm.
Other Causes:
Chest wall
Neurological
Mediastinum
Diaphragm
Abdominal. ( esophagus, stomach, gall bladder, pancreas).

132. Analysis:
Site & radiation.
Provocation & relief.
Duration.
Character.
Associated features.

133. 5. Symptoms due to changes in rate, Rhythm, or force → palpitation.
( time, mode of onset & offset, relation to exertion, duration, irregularity).

134. 6. Symptoms due to pressure on surrounding structures.
( esophagus, bronchi , nerves, spine)

135. General Examination General appearance.
Vital signs: pulse, temp. Blood pressure, respiration.
Hands: (cold, warm, clubbing, cyanosis, sweating)
Eyes
Neck:
Neck veins.
Pulsations (arterial vs. venous).
Carotid arteries.
Trachea, thyroid gland.

136. Lower Limbs ( edema, pulsations).
Abdomen.

137. 137

138. 138

140. Local Examination

141. 1. Combined Inspection and palpation:
Shape.
Cardiac impulses (apex beat, parasternal pulsations, epigastric, to the right of sternum, suprasternal notch, 2nd left space)
Thrills.
Palpable heart sounds.
Position of the mediastinum
Tactile vocal fremitus
Chest movements
Local tenderness,pulsations,wheezes.

142. 142

143. Apex beat

144. 2. Percussion Types of percussion notes Apices of the lungs
Anterior chest wall
Lateral chest wall
Posterior chest wall
Cardiac and hepatic dullness

145. 3. Auscultation:
Apex, lower end of sternum (tricuspid area), aortic area and pulmonary area .
Murmurs:
Timing
Character
Point of maximum intensity and propagation
Relation to respiration
Intensity
± Thrill.

146. Breath sounds.
Adventitious sounds.
Vocal resonance .

147. 147

148. 148