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History Taking & Chest Examination
Dr. Waseem HAJJAR, MD. FRCS. Assistant professor & Consultant Thoracic Surgeon
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A good history should be both:
Concise. Cover the important points.
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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
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Questions: Complete the immediate description.
Elucidate the vague points. Fill in the gaps the history not mentioned by patient. Emphasize the important points.
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Types of questions: Neutral questions.
Simple direct questions (yes/No). Leading questions.
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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
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Personal data: Name. Age. Sex. Occupation. Residence.
The patients complaint: A simple statement in the patients own words and its duration.
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HISTORY
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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.
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History Acute/chronic disorder Preceding systemic disturbance
Past medical history Drug history Social history Family history Occupational history
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Past History: Childhood diseases. Trauma. Residences or travel abroad.
Drug therapy. Operations.
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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
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Family History: Hereditary factor.
Exposure to same etiological circumstances.
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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
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Habits: Smoking. Physical efforts. Addiction.
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SYMPTOMS
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History Dyspnoea Wheeze Cough Sputum Haemoptysis Chest pain
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MAIN SYMPTOMS OF PULMONARY DISEASE
COUGH DYSPNEA HEMOPTYSIS CHEST PAIN – PLEURITIC WHEEZING CYANOSIS SPUTUM PRODUCTION SNORING
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LUNG KIDNEY SPLEEN LIVER SKIN BRAIN HEART
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DESCRIBE THE COUGH PRODUCTIVE – NONPRODUCTIVE ACUTE – CHRONIC
TIME OF DAY PRECIPITANTS – RELIEF BLOODY – NON BLOODY BARKING – HACKY
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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
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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
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DYSPNEA MY CHEST FEELS TIGHT I CANNOT TAKE A DEEP BREATH
I FEEL LIKE I HAVE A PILLOW OVER MY MOUTH I AM SMOTHERING
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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
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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
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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.
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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
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THE PULMONARY EXAMINATION
SIGNS
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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
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TOPOGRAPHY OF THE CHEST
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TOPOGRAPHY OF THE BACK
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The Chest Inspection Palpation Percussion Auscultation
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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
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Chest wall Pectus carinatum Pectus excavatum
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Pectus Excavatum
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Inspection Shape Scars Lesions Resp rate Resp depth Mode of breathing
Abnormal inspiratory movements Abnormal expiratory movements Asymmetry of movement
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Nicotine staining
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2 liters of O2
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BARREL CHEST
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Barrel Chest AP Diameter = Transverse Diameter
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PALPATION FEELING WITH THE HAND – FINGERTIPS TEXTURES DIMENSIONS
CONSISTENCY TEMPERATURE
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Palpation Chest expansion Tactile vocal fremitus
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Chest Expansion
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Chest Expansion
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Chest Expansion
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Trachea exam
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Percussion Illustrate resonance Compare both sides
Map out abnormal area
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METHODS OF PERCUSSION DIRECT INDIRECT DISEASE A MONTH 41; :1995
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METHODS OF PERCUSSION
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METHODS OF PERCUSSION
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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
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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
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PERCUSSION SOUNDS TYMPANY – HEARD OVER THE ABDOMEN
RESONANCE – HEARD OVER NORMAL LUNG DULLNESS – HEARD OVER LIVER OR THIGH
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Auscultation Breath sounds Added sounds Vocal sounds (vocal resonance)
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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.
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AUSCULTATORY PERCUSSION
MANGIONE PHYSICAL DIAGNOSIS SECRETS 2000
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Auscultation of the front
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Auscultation of the back
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Breath Sounds Vesicular - normal Diminished - localised or diffuse
Bronchial - consolidation
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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
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TACTILE FREMITUS INCREASED DECREASED PNEUMOTHORAX PNEUMONIA
PLEURAL EFFUSION COPD FAT PNEUMONIA
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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
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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
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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
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CYANOSIS PERIPHERAL – HANDS, FEET – WARMING DECREASES CYANOSIS – DECREASED CARDIAC OUTPUT CENTRAL- LIPS, TONGUE,SUBLINGUAL - RIGHT TO LEFT SHUNTS PSEUDOCYANOSIS – BLUE PIGMENTS IN SKIN - AMIODARONE
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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.
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Central Cyanosis
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Corpulmonale
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Sleep apnea syndrome
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Clubbing Hereditary Interstitial Fibrosis Tumor Bronchiecstasis
Heart Disease Endocarditis
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Clubbing
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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
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CLUBBING PAINLESS – FINGERNAILS CURVED AND WARM
ENLARGEMENT OF THE CONNECTIVE TISSUES IN THE TERMINAL PHALANGES OF THE FINGERS >TOES
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SCHAMROTH’S SIGN – LOSS OF THE SUBUNGUAL ANGLE
CLUBBING SCHAMROTH’S SIGN – LOSS OF THE SUBUNGUAL ANGLE CLIN CHEST MED 8: ,1987
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CLUBBING LOVIBOND’S ANGLE – THE ANGLE BETWEEN THE BASE OF THE NAIL AND SURROUNDING SKIN. CLIN CHEST MED 8: ,1987
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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
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ABNORMAL BREATHING PATTERNS
APNEA - CARDIAC ARREST BIOTS – INCREASED INTRACRANIAL PRESSURE – DRUGS- MEDULLA CHEYNE STOKES – CONGESTIVE HEART FAILURE – DRUGS – CEREBRAL KUSSMAULS – METABOLIC ACIDOSIS
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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
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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
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BREATH SOUNDS TIMING CHARACTERISTIC TRACHEAL BRONCHIAL BV VESICULAR
INTENSITY VERY LOUD LOUD MODERATE LOW I:E RATIO 1:1 1:3 3:1
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Breath sounds
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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
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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
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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
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Added sounds Rhonchi (wheeze) Crepitations (crackles) Pleural sounds
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Rhonchi Due to passage of air through narrowed bronchus e.g. bronchospasm, mucosal oedema Musical quality High or low pitched Usually expiratory Expiration prolonged
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Crepitations Inspiratory noises, usually 2nd half Non-musical
Due to explosive reopening of peripheral small airways during inspiration which have become occluded during expiration
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Pleural Rub Creaking noise
Movement of visceral pleura over parietal pleura Surfaces roughened by exudate 2 separate phases at end inspiration and early expiration
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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
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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
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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
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SIGNIFICANCE OF LATE AND EARLY CRACKLES
EARLY – CENTRAL AIRWAYS (BRONCHITIS) LATE – PERIPHERAL AIRWAYS (FIBROSIS,EDEMA)
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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
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COPD PINK PUFFERS BLUE BLOATERS
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DAHL’S SIGN NICOTINE STAINS SMOKERS FACE THORAX 38: , 1983
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BLUE BLOATER
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PURSED – LIPS BREATHING
COPD – DECREASES DYSPNEA DECREASES RR INCREASES TIDAL VOLUME DECREASES WORK OF BREATHING CHEST 101:75-78, 1992
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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
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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
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PUTTING IT ALL TOGETHER
PNEUMONIA PNEUMOTHORAX PLEURAL EFFUSION ASTHMA
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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
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Consolidation Chest xray
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PLEURAL EFFUSION INSPECTION – LAG AFFECTED SIDE
PALPATION – ABSENT FREMITUS PERCUSSION – FLAT, DULL AUSCULTATION – ABSENT OVER EFFUSION, BRONCHIAL IMMEDIATELY ABOVE EFFUSION, RUB OCCASIONALLY
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PNEUMOTHORAX INSPECTION – LAG AFFECTED SIDE
PALPATION – ABSENT FREMITUS PERCUSSION – TYMPANIC AUSCULTATION – ABSENT BREATH SOUNDS
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PNEUMOTHORAX
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PNEUMOTHORAX
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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
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Pleural effusion
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Pleural Effusion
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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
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pneumothorax
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Symptoms of Cardiac disorders:
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1. Symptoms due to lung congestion:
Dyspnea. Acute pulmonary edema. Cough, hemoptysis. Recurrent chest infections.
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2. Symptoms due to lung congestion:
Pain in the right hypochondrium. Dyspepsia. Swelling of lower limb. Swelling of the abdomen. Oliguria.
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3. Symptoms due to low cardiac output: (tissue hypoxia →brain, muscles, kidneys)
Exertional fatigue. Blurring of vision. Dizziness / Syncope. Oliguria, Angina.
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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).
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Analysis: Site & radiation. Provocation & relief. Duration. Character. Associated features.
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5. Symptoms due to changes in rate, Rhythm, or force → palpitation.
( time, mode of onset & offset, relation to exertion, duration, irregularity).
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6. Symptoms due to pressure on surrounding structures.
( esophagus, bronchi , nerves, spine)
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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.
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Lower Limbs ( edema, pulsations).
Abdomen.
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Local Examination
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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.
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Apex beat
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2. Percussion Types of percussion notes Apices of the lungs
Anterior chest wall Lateral chest wall Posterior chest wall Cardiac and hepatic dullness
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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.
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Breath sounds. Adventitious sounds. Vocal resonance .
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