DPx Paru.pdf

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Examination of the posteriorchest

By

dr.H.R.Handojo Padmosoeparto, SpP, Msc

Inspection Shape of the chest

The way in which it moves

Deformities / asymmetry

Inspiration:

Normal retraction of the interspaces

Lower interspaces : most apparent

Retraction : often present

Eg : Severe astma

COPD

Upper airway obstruction


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Impaired respiratory movement :

One / both sides / unilateral lag

Suggests : disease of the underlyinglung / pleura

Palpation

Focus:

Tenderness

Abnormalities in the overlying skin

Respiratory expansion

Fremitus

Tender areas: Palpate carefully : pain / lesions / bruises

Eg : fractured rib


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…..palpation Abnormalities :

Masses

Sinus tracts ( infection of underlying pleura and lung )

Chest expansion :

Thumbs - level ribs X

Finger - loosely grasping

Unilateral decrease in chest expantion:

- chronic fibrotic disease of lung / pleura

- pleural effusion

- lobar pneumonia

- bronchial obstruction

…..palpationFremitus :

patient speaks palpable vibrationsbronchopulmonary tree chest wall

ball words : 99 / 1-1-1

ulnar surface words : 99 / 1-1-1

both hands : detection of differences tocompare differences


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location for feeling fremitus :

interscapular area > lowerlung fields

right side > left

below the diafragma -

…..palpation

Vibration : larynx chest wall is impeded:

Obstructed broncus

COPD

Pleural effusion

Fibrosis ( pleural thickening )

Pneumothorax Infiltrating tumor

Very thick chest wall


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Percussion

Underlying tissue : air / fluid filled / solid ( ± 5-7cm deep-seated )

Technique :

Middle finger of left hand = pleximeter

Distal interphangeal joint firmly on the surfaceto be percussed

Thumb, fingers 2nd, 4th, 5th. free, nottouching the chest

Right forearm quite close to the surface

trying to transmit vibrations throug the bones ofthis joint to the underlying chest wall


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…..percussion

Characteristics:

Flatness : (thigh) : large pleural effusion

Dullness: (liver) : lobar pneumonia

Resonance normal lung : simple chronic bronchitis

Hyperresonance : none normally : emphysema,pneumothorax

Tympany :

gastric airbubble : large pneumothorax Puffed-out check


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Auscultation

= assessing air flow through thetracheobronchial tree

Listening :

to the sounds generated by breathing

for any adventitions ( added ) sounds

to the sounds of the patient`s spoken /

whispered voice ( if abnormalities aresuspected)

…..auscultation

Normal breath sounds :

Vesicular : inspiration expiration without pause fade away

Bronchovesicular : inspiration expiration :

equal in length

seperated by a silent interval

Bronchial : inspiration expiration : a short silence

expiratory sounds last longer than inspiration


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…..auscultation

Normal breath sounds :

Tracheal breath sounds, heart by listeningover the trachea in the neck:

Vesicular-over most of both lungs

Bronchovesicular : in the 1st and 2nd

interspaces anteriorly

Bronchial : over the manubrium

…..auscultation

Added breath sounds :

Crackles / Rales :

Pneumonia

Fibrosis

Wheezes / ronchi :

Wheezes ( narrowed airways ) : astma,COPD, bronchitis

Ronchi : = secretions in large airways


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…..auscultation

Listening the breath sounds :

The patient breathes deeply through anopen mouth

Listen to at least one full breath in eachlocation

Allow the patient to rest as needed (discomfort due to hyperventilation )

Examination on theanterior chest


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Inspection

Position : supine / sitting

Inspection : observe

The shape

The movement of the chest wall

Note :

Deformities / asymmetry

Inspiration : abnormal retraction of the lower

interspaces Local impairment in respiratory movement

Palpation

Identification of tenderness : chest pain has amusculoskeletal origin

Assessment of

Observed abnormalities

Chest expansion:

how far your thumbs diverge as the thoraxexpands

feel for the extend & symetry of respiratorymovement

Tactile fremitus over the precordium : or –(decreased or absent)


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Chest pain

Pulmonary :

Tracheobronchitis :

Process : inflamation of trachea & largebronchi

Location : upper sternal or on either sideof sternum

Quality : burning, mild to moderate

Factor that aggravate : coughingFactor that relieve : lying on the

involved side

Associated symptoms : cough


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……chest pain

Pulmonary :

Pleural pain:

Process : inflamation of the parietal pleura(pleurisy, pneumonia, pulmonary infarction orCa)

Location : chest wall overlying the process

Quality : sharp, knifelike, often severe

Factor that aggravate : breathing, coughing,movement of the trunk

PercussionChest : anterior & lateral ( comparing both sides )

The heart : left of the sternum ( 3rd - 5th interspaces )= area of dullness percuss the left lung lateral to it

COPD :

hyperresonance may totally replace cardiacdullness

often displaces the upper border of the liverborder lowers the level of diafragmaticdullness

Pleural effusion ; replaces resonance of the air

containing lung Right middle lobe pneumonia (woman : behind

the right breast

displace the breast)


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Auscultation

The patient breathes with mouth open.Compare symetric areas of the lungs

Vesicular breathing : the upper anteriorlung fields are usually louder

Bronchovesicular breath sounds : heardover the large airways, especially on theright

Adventitions sounds……….


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….auscultation

Adventitions sounds

Crackles :

late inspiratory crackles :

intertitial lung disease (fibrosis)

early congestive heart failure

Midinspiratory & expiratory cracles :

bronchiectasis ( not specific )

Early inspiratory cracles (relativelyfew in number)

chronic bronchitis astma

….auscultation Adventitions sounds:

Wheezes (air flow rapidly throughbronchi) :

astma ( may be heard only inexpiration or in both phases ofrespiratory cycle

Chronic bronchitis

COPD

cardiac asthma a persistent localized wheeze = partial

obstruction of a bronchus ( Ca / foreignbody, inspiratory / expiratory or both )


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….auscultation

Adventitions sounds:

Ronchi : secretions in the airways

chronic bronchitis ( wheezes & ronchioften clear with coughing )

Stridor : a wheeze that is entirely orpredominantly inspiratory. Louder in theneck than over the chest wall demands

immediate attention:

a partial obstruction of thelarynx/trachea

….auscultation

Adventitions sounds:

Pleural rub : inflamed & roughenedpleural surfaces grate against each other

Mediastinal crunch : a series ofprecordial crackles. Synchronous withthe heart beat, not with respiration (mediastinal emphysema /pneumomediastinum )


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Condition :

NORMAL :

Percussion :

resonant

Breath sounds :

vesicular

over the large bronchi = bronchovesicular,

trachea = bronchial

Adventitions sounds :

none

at the bases of the lungs : transientinspiratory crackles

Tactile fremitus :

normal

Chronic bronchitis

P: resonant

B: vesicular ( normal )

A: - none

-crackles

-wheezes / ronchiT: normal


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Consolidation

Pneumonia

Pulmonary edema

Pulmonaryhemorrhage

P: dull over theairless area

B: bronchial over theinvoled area

A: crackles over theinvoled area

T: increased over theinvolved area

bronchophony

egophony

whisperedpestoloquy

Atelectasis (lobar obstruction)

P: dull over the airless area

B: absent (usually) when bronchial plugpersists

A: none

T: usually absent


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Pleural effusion

P: dull over the fluid

B: -decreased to absent

-near top of large effusion: bronchial

A: -none

-possible pleural rub

T: -decreased to absent

-increased toward the top of a largeeffusion

Pneumothorax

P: hyperresonant / tympanitic over thepleural air

B: decreased to absent over the pleuralair

A: none, except a possible pleural rub

T: decreased to absent over the pleuralair


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C O P DP: hyperresonant diffusely

B: decreased to absent

A: - none

- crackles

- wheezes & ronchi (+chronicbronchitis)

T: decreased

A S T H M A

P: resonant hyperresonant

B: wheezes

A: wheezes + crackles

T: decreased

ref: BATES`. The Thorax and Lung. Guite to Physical

Examination and history taking: 253-64, 2007


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