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INSPECTION1. Shape of the chest Normal: Bilaterally symmetrical and elliptical in
cross section AP:Trans=5:7
Chest deformity Flat chest: AP:Trans=1:2
Pulmonary TB Fibrothorax
Contd.. Barrel shaped chest: AP:Trans=1:1
Physiological: Infancy,old age Pathological: COPD
Pigeon chest(Pectus carinatus): Forward protrusion of sternum and adjacent costal cartilages Rickets Childhood asthma Marfan’s syndrome
Contd.. Funnel chest(Pectus excavatum): Exaggeration of
the normal hollowness on the lower end of sternum Development defect: Apex beat is shifted further to the left
and the vital capacity is restricted Marfan’s syndrome
Scorbutic rosary: Sharpangulation with or without beading or rosary formation of the ribs
D/t backward displacement of sternum Vit C deficiency
Contd.. Harrison’s sulcus: D/t indrawing of the ribs to form
symmetrical horizontal groove above the costal margin,along the line of attachment of the diaphragm d/t hyperinflamation of the lung and reapeated strong contraction of the diaphragm Chronic respiratory Dzs in childhood Childhood asthma Rickets
Rickety rosary: Bead like enlargement of costochondral junction Rickets
2. Movement of the chest: Movement of the chest with respiration Movement of the chest equally on both side
a) Unilateral: b) Bilateral
• Pleural effusion • Emphysema• Chest trauma • Hydrothorax• Pneumothorax • Obesity• Hydropneumothorax • Bronchial asthma• Consolidation • Diffuse interstitial
fibrosis• Fibrosis of lung • Myasthenia gravis
Contd..3. Apical Impulse: Stand on the right side of the patient and look
tangentially over the precordium Helps to note the precordial shift
4. Tracheal deviation: Ask the patient to look forward an look for any
deviation
Contd..5. Respiration: Rate Rhythm Type
6. Venous Prominance: Superior venacava syndrome: Presence of distended
vein over the chest wall
Contd..7. Retraction/Fullness of intercostal space: Abnormal retraction:
Severe asthma COPD Upper airway obstruction
Fullness of intercostal space: Pleural effusion Haemothorax pneumothorax
Contd..8. Level of nipple: Whether both the nipple are at the same level or not
9. Skin over the chest:• Cold abscess• Ulcer• Swelling• Scar mark
Contd..10. Accessory muscle: Whether accesory muscles of respiration are
working or not Inspiration:Active process d/t contraction of the intercostal
muscles and diaphragm Muscles:
Scalene Sternocleidomastoid Platysma Pectoralis Serratus anterior
Expiration: Passive process d/t elastic recoil of the lung Muscles
Abdominal recti muscles latissimus dorsi
PALPATION1. Surface temperature
2. Tenderness:• Rib tenderness: Trauma, fracture • Intercostal tenderness: Liver abscess, empyema thoracis
3. Corroboration of inspetory findings
4. Spinal deformity
Contd..5. Position of trachea and apex beat
Palpate in the standing or sitting position with arm placed symmetrically on two sides.
Flex the neck with left hand so that chin remain in same side
Insert the tip of index finger in suprasternal notch
Feel the tracheal ring
Now side the index finger in the angle between sternocleidomastoid muscles and trachea on both side
On the deviated side angle is narrowed and feel resistant
Contd..• Shift of trachea:
To the same side
To the opposite side
Fibrosis of lung Massive pleural effusion
Collapse of lung Pneumothorax
pneumonectomy Hydropneumothorax
Contd..6. Movement of chest:
Upper part of thorax:
Face the patient’s back
Place both hands over the patient’s supraclavicular fossa.
Compare on both sides the extent of upward movement of the hands during quiet respiration
Contd.. Anterior thoracic movement:
Face the patient
Keep the finger tip of both the hands on either side of patients rib cage so that the tip of thumbs approximate each other in midline without touching the chest wall
Ask the patient to take deep breath
Compare the movement of thumbs on both sides away from midline
It can also be assessed by holding a loose fold of skin between the thumbs and noting their separation
Contd.. Posterior thoracic movement
Perform at the infrascapular region
Contd..7. Chest expansion:
Done using inch tape
In male: measure at the level of nipple
In female: measure just below breast
Measure normal circumference of chest
Ask to take deep inspiration, again measure the chest circumference
Difference between the two is known as chest expansion
Normal expansion=5-8cm
Contd.. Decreased chest expansion
Unilateral Bilateral
Pleural effusion Emphysema
Pneumothorax Hydrothorax
Collapse of lung Bronchial asthama
Fibrosis of lung Myasthenia gravis
Contd..7. Vocal fremitus: palpation of laryngeal vibration on the
chest wall when patient is asked to repeat 9-9 or 1-1-1
• Place the flat of hand or ulnar border of the right hand over the intercostal space
• Compare the patient to tell 9-9 or 1-1-1
• Compare on both side Increased: Consolidation Decreased: Pleural effusion
PERCUSSION Cardinal rules: Method:
Place the middle finger of the left hand(pleximeter) of the examiner firmly over the chest wall over the ICS such that other finger don’t touch the chest wall
Then strike the centre of middle phalanx of the pleximeter finger with the tip of middle finger of right hand(plexor)
The finger should be moved immediately after the striking action in tapping movement. The percussion finger is bent to make its terminal phalanx right angled so that it strikes the other finger perpendicularly
Contd.. The percussion movement should be sudden originating
from the wrist
Always percuss the opposite side of chest on the equivalent position and compare with notes on other side
Contd.. Position of the patient: Sitting position is the best for percussion Supine position is not desirable because of the alteration of percussion note by the underlying structure in which patient lies
Contd..i. For anterior percussion: Patients should sit erect with hands by his side
ii. For posterior percussion: patient should bend his head forward and keep his hands over the shoulder.This position keep the two scapula away so that more lung field is available for percussion
iii. Lateral percussion: The patient should sit with his hand held over the head
Area of percussioni. Anterior chest wall:
a) Clavicle: Direct percussion Percussion is done within middle 1/3rd of clavicle
b) Supraclavicular region It is a band of resonance 5-7cm size over the
supraclavicular fossa
Boundaries: Medially: Scalenus muscle of neck Laterally: Acromian process of scapula Anteriorly: Clavicle Posteriorly: Trapezius
The percussion is done by standing behind the patient and resonance of the lung apices is assessed
Hyper resonance: Emphysema Impaired resonance: Pulmonary TB
c) Infraclavicular: 2nd to 6th ICS; however the percussion note cannot be compared due to relative cardiac dullness on the left side
Contd..ii. Lateral chest wall Percuss from 4th to 8th ICS in mid axillary line
Contd..iii. Posterior chest wall
a) Suprascapularb) Interscaularc) Infrascapular region upto the 11th ICS
Types of percussion note
Lesion
1. Tympanitic Hollow viscus2. Sub tympanitic Above the level of pleural
effusion3. Hyper-resonant Pneumotharax4. Resonant Normal lung5. Impaired Pulmonary fibrosis6. Dull Consolidation,collapse7. Stony dull Pleural effusion,haemothorax
AUSCULTATIONPreliminaries Auscultation is carried out with diaphragm of
stethoscope as most respiratory sound are high pitched
Listen with the patient relaxed and breathing deeply through an open mouth.
Instruct the patient to turn the face to one side, ask to breath regularly and deeply through open mouth
Contd.. Auscultate the both sides alternately
Avoid auscultation within 3cm of the midline anteriorly and posteriorly as these area may transmit sounds directly from the trachea or main bronchi
Listen anteriorly from above the clavicle down to the 6th rib, laterally from axilla to the 8th rib and posteriorly down to the level of the 11th rib
In each area listen to the quality and amplitude of breath sound
Contd..Position of the patient: Sitting position
Auscultatory area:
i. Anterior: From an area above the clavicle down to 6th rib
ii. Axilla: Area upto 8th rib
iii. Posterior: Above the level of spine of scapula down to 11th rib
Contd..1. Breath sounds Breath sounds are produced by vibration of vocal cord due to turbulent air flow in larger airways which is conducted by the overlying lung tissue to the chest wall
Contd..i. Vesicular breath sound:
Vesicular breathing. Respiratory sounds known as vesicular breathing arise due to vibration of the elastic elements of the alveolar walls during their filling with air in inspiration.
The alveoli are filled with air in sequence. Therefore, the summation of the great number of sounds produced during vibration of the alveolar walls gives a long soft (blowing) noise that can be heard during the entire inspiration phase, its intensity gradually increasing.
Contd.. Normal vesicular breathing is better heard over the
anterior surface of the chest, below the 2nd rib, laterally of the parasternal line, and also in the axillary regions and below the scapular angle, i.e. at points where the largest masses of the pulmonary tissue are located.
Vesicular breathing is heard worse at the apices of the lungs and their lowermost parts, where the masses of the pulmonary tissue are less abundand. While carrying out comparative auscultation, it should be remembered that the expiration sounds are louder and longer in the right lung due to a better conduction of the laryngeal sounds by the right main bronchus, which is shorter and wider.
Contd..Condition with diminished vesicular breath sound:
Bronchial asthma Tumor Pleural effusion Pleural thickeing Emphysema
Contd..ii. Bronchial breath sound:
Respiratory sounds known as bronchial or tubular breathing arise in the larynx and the trachea as air passes through the vocal slit.
As air is inhaled, it passes through the vocal slit to enter wider trachea where it is set in vortex-type motion. Sound waves thus generated propagate along the air column throughout the entire bronchial tree. Sounds generated by the vibration of these waves are harsh.
Contd.. During expiration, air also passes through the
vocal slit to enter a wider space of the larynx where it is set in a vortex motion.
But since the vocal slit is narrower during expiration, the respiratory sound becomes louder, harsher and longer. This type of breathing is called laryngotracheal (by the site of its generation).
Contd.. Bronchial breathing is well heard in physiological
cases over the larynx, the trachea, and at points of projection of the tracheal bifurcation (anteriorly, over the manubrium sterni, at the point of its junction with the sternum, and posteriorly in the interscapular space, at the level of the 3rd and 4th thoracic vertebrae).
Bronchial breathing is not heard over the other parts of the chest because of large masses of the pulmonary tissue found between the bronchi and the chest wall.
Contd..Types of bronchial breathing:a. Tubular: They are high pitched and present in:
pneumonic consolidation collapse lung
b. Cavernous: They are low pitched and heard in the presence of thick walled cavity with a communicating bronchusc. Amphoric: They are low pitched, with a high tone and metallic quality and present in:
Bronchopleural fistula Tension pneumothorax
Contd..Causes of absent breath sound:
Pleural effusion(massive)
Thickned pleura
Pneumothorax
Collapsed lung
Contd..2. Added sounds
i. Crackles: They are non musical, interrupted added sounds of short duration. They are explosive in nature
Types:
Fine: less loud,short,arise from alveoli
Coarse: Low pitched,loud nd arise frombronchi and bronchioles
Contd..Crackles may be: Early inspiratory: Chronic bronchitis Mid inspiratory: Bronchiectasis Late inspiratory: Asbestosis,pulmonary
fibrosis,pneumonitis Expiratory: Chronic bronchitis
Mechanism of crackles: Bubbling or flow of air through secretion in the
bronchial level
Contd..ii. Ronchi They are musical,continuous added sounds. They may be:
Low pitched: arising from large airways High pitched: arising from small airways
Eg. Tumors Foreign body Bronchial asthma Emphysema
Contd..iii. Wheeze:
Wheezing is a high-pitched whistling sound made while breathing. Most commonly wheezing occurs during breathing out (expiration), but it can sometimes be related to breathing in (inspiration)
Wheezing results from a narrowing of the airways and typically indicates some difficulty breathing. The narrowing of the airways can be caused by inflammation from asthma, an infection, an allergic reaction, or by a physical obstruction, such as a tumor or a foreign object that's been inhaled.
Contd..The most common cause of recurrent wheezing is asthma. Possible causes of wheezing include: Allergies
Anaphylaxis (a severe allergic reaction, such as to an insect bite or medication)
Asthma
Bronchiectasis
Bronchiolitis (especially in young children)
Pneumonia
Respiratory syncytial virus (RSV)
Contd..Causes(contd..) Bronchitis
COPD(chronic obstructive pulmonary disease) and other lung diseases
Emphysema
Foreign object inhaled: First aid
GERD(gastroesophageal reflux disease)
Heart failure
Lung cancer
Contd..3. Vocal resonance: It is a voice sound heard with the chest piece of stethoscopei. Increased vocal resonance:
Consolidation Collapse with patent bronchus Open pneumothorax
ii. Decreased vocal resonance Pleural effusion Pneumothorax Emphysema
Contd..4. Aegophony The voice may sound nasal or bleating; heard over the level of a pleural effusion,or in some cases over an area of consolidation
5. Pleural rub It is superficial localized grating sound best heard with pressure of stethoscope It is produced when inflamed parietal and visceral pleura move over one another Not altered by coughing and usually associated with pleuritic pain