Chest and Lung Exam Part 1

Vertical Axis Landmarks: Sternal Angle (Angle of Louis) Location

5 cm inferior to sternal notch

horizontal ridge joining manubrium to body of sternum

Visceral vs. Parietal Pleurae vs. Pleural Space

visceral:

• lacks sensory nerves

• serous membrane

• covers outer surfaces of each lung

parietal:

• innervated by intercostal+phrenic nerves

• lines pleural cavity along rib cage+upper surface of diaphragm

pleural space:

• contains serous pleural fluid

• space between visceral+parietal pleurae

Muscles of Respiration

principal:

• diaphragm

• internal+external intercostals

accessory:

• sternocleidomastoid

• scalenes:
  -anterior
  -middle
  -posterior

other:

• abdonimals:
  -rectus abdominis
  -external oblique
  -internal oblique
  -transversus abdominis

ROS

dyspnea (shortness of breath)
-orthopnea→supine
-paroxysmal nocturnal dyspnea→sitting+HS

cough

hemoptysis

chest pain

daytime sleepiness

snoring

disordered sleep
-snoring
-choking sensation
-morning headache

apnea (stops breathing for 10+ seconds)

Orthopnea vs. Paroxysmal Nocturnal Dyspnea

orthopnea: shortness of breath when supine

paroxysmal nocturnal dyspnea: shortness of breath at night
relieved by sitting up

Dyspnea Health Hx

onset:
-acute
-chronic

triggers:
do certain activities/environmental exposures trigger sx/make sxs worse

severity:
-how severe
-are they affective ADL

associated sxs

medical hx
-respiratory dxs
-social hx→smoking

mxs

Cough Hx

response to
-irritant of trachea
-larynx
-bronchi

ex: allergens
dust
foreign body
extreme temp air
inflammation of respiratory tract
tumors

ask

• duration
  -acute→u3 wks
  -subacute→3-8 wks
  -chronic→8+ wks

• productivity

• triggers

• associated sxs

• medical hx

• mxs

Hemoptysis Health Hx

• blood tinged sputum

• onset

• amount
  -small
  -frank/large

• location
  -mouth
  -pharynx
  -respiratory tract
  -GI tract→darker color+hematemesis (“coffee ground emesis”)

• associated/other sxs

• medical hx

• mxs→anticoagulants

Chest Pain Health Hx

aka: angina

• location/quality
  -sharp
  -dull
  -recent radiation exposure

• associated sxs

• mx history

• mxs

key details

• pain breathing in→pleuritic pain

• lung tissue→no pain fibers→irritation/inflammation of pleural surface

• chostocondritis→muscle pain from coughing

Associated Sxs

fever

sweats

chills

weakness

dizziness

lightheaded

syncope

recent weight change

exertional chest pain

palpitations

orthopena (dyspnea when supine)

paroxysmal nocturnal dyspnea (dyspnea at night+sitting up)

edema

reflux/burning sensation

Pertinent Past Medical Hx

childhood/adult illnesses:

• asthma

• COPD

• tuberculosis

• pneumonia

• cancer

• cystic fibrosis

• pneumothorax

accidents/injuries: chest trauma

immunizations+vaccinations:

• flu shot

• pneumococcal vaccine

• COVID vaccine

screening tests:

• last chest x-ray

• last ppd

surgeries

• chest

• lung

• cardiac

hospitalizations: asthma→ask if ever intubated

Family Hx

cancer

tuberculosis

asthma

cystic fibrosis

emphysema

chronic bronchitis

pulmonary embolism

Pertinent Psycho-Social Hx

home situation:

• flight of stairs

• community-type living

occupation: exposure to physical/environmental hazards

travel: foreign countries

sleep:

• daytime sleepiness

• snoring

• apnea

• morning headache

• waking up with sense of choking

exercise: exercise-induced dyspnea

tobacco:

• smoking hx

• second-hand smoke exposure

• vaping

• illicit mx use

General Survey

vitals

facial expression

color:
-cyanosis
-pallor

pursed-lip breathing

nasal flaring

use of accessory muscles

tripod position (leaning forward to breathe)

tachypnea (rapid breathing)

stridor/other breathing sounds

clubbing of digits

shape of chest

Physical Exam (General) List

general survey:
rate
rhythm
depth
effort of breathing
signs of distress
IPPA

inspect chest

palpate chest

percuss chest

auscultate chest

Normal Breathing

adults→14-20/min

infants→ 44/min

Tachypnea

rapid shallow breathing

Hyperpnea/Hyperventilation

rapid deep breathing

Kussmaul Breathing

systemic acidosis→compensatory overbreathing

Bradypnea

slow breathing

±increase in tidal volume

Cheyne-Stokes Breathing

hyperpnea alternating with apnea

Ataxic/Biot Breathing

unpredictable irregularity

Sighing Respiration

hyperventilation syndrome

Obstructive Breathing

prolonged expiration secondary to airway narrowing

Normal Adult Thorax/Chest

lateral diameter greater than AP diameter

ratio: 0.7-0.9

aging: increased diameter
chest wall stiffer→decreased movement
weakened respiratory muscles
lessened elastic coil
skeletal changes

Barrel Chest

increased AP diameter

normal: infancy
aging

DX: COPD

Pectus Excavatum/Funnel Chest

depression in lower part of sternum

compressed heart+great vessels→murmur

Pectus Carinatum/Pidgeon Chest

sternum sticks out→increased AP diameter

depressed costal cartilage adjacent to protruding sternum

Traumatic Flail Chest

multiple rib fractures→paradoxical movements of thorax/chest

inspiration→depression of injured area

expiration→injured area bulges outward

Thoracic Kyphoscoliosis

abnormal spinal curvature+vertebral rotation→deformed chest

Palpation: Tracheal Deviation

1. grab trachea with thumb+index finger below cricoid cartilage

2. ask pt to take deep breath in

Physical Exam: Palpation (General)

anterior chest:

• pt sitting/supine position

• discomfort→arms slightly abducted

P: anterior chest

• tenderness

• abnormalities

posterior+lateral chest:

• pt sitting

arms:

• posterior: across chest

• lateral: on hips

P: posterior+lateral chest

• posterior+lateral chest

• tenderness

• abnormalities

Palpation: Thoracic/Chest Expansion

aka: lung excursion
chest expansion

1. place thumb on each costal margin posteriorly
   -at level of+parallel to 10th rib→form loose skin fold
   -pt unable to sit→anterior chest→hands along each costal margin→form loose skin fold

2. ask pt to inhale deeply

3. observe:
   -extent of respiratory movement
   -symmetry of respiratory movement

Palpation: Tactile Fremitus

process

1. use ulnar surface of hand

2. ask pt to put hands on hips

3. ask pt to say+repeat “99”

3 anterior lung field positions

• 2 mid-clavicular

• 1 lower anterior axillary line region

4 posterior lung field positions

• 3 mid-scapular line

• 1 lower posterior axillary line region

increased fremitus→enhances the transmission of vibration

• consolidated tissue

• inflammation around a lung abscess

decreased/absent fremitus→obstruction of transmission of vibration

DX:

• thickened pleurae

• pleural effusion

• pneumothorax tumor

Physical Exam: Percussion Process

1. hyperextend middle finger on 1 hand

2. place distal IPJ firmly against pt’s skin

3. avoid surface contact→dampens out vibrations

4. end (not pad) of opposite middle finger→quick flick of wrist→strike dorsal aspect of first long finger

no long nails→can’t do percussion

Chest Anatomy+Anatomic Landmarks

superior

• clavicle

• neck tissue

anterior

• ribs

• sternum

lateral→ribs

inferior→diaphragm

Midsternal Line

runs vertically along center of sternum (breastbone)

divides chest in to L+R halves

Midclavicular Line

runs vertically from midpoint of clavicle (collarbone)

reference point for clinical assessments of chest+abdomen

Anterior Axillary Line

runs vertically from front/anterior axillary fold
-junction between chest+upper arm

helps ID specific landmarks on chest wall

Midaxillary Line

runs vertically from apex of axilla (armpit)

used to locate structures in the middle of the axillary region

Posterior Axillary Line

runs vertically from posterior axillary fold

helps ID specific landmarks on the back

Scapular Line

drops down from the inferior angle of the scapula (shoulder blade)

useful for

• assessing back injuries

• ID specific landmarks on the back

Vertebral Line

follows the path of the toracic spinous process (bony projections felt along the spine)

used for reference during spinal assessments+procedures

PE→Inspection (General)

I: posterior chest
anterior chest
lateral chest

• pattern of breathing

note: shape

note: skin

• lesions

• rashes

• scars

• any visible signs of trauma

Inspection→Thorax

I: thorax

• shape
  -normal→lateral diameter greater than AP diameter
  -0.7-0.9

• deformities

• asymmetry

• abnormal retractions of intercostal spaces

• use of accessory muscles

• tracheal position

Inspection→Skin

pallor

cyanosis

sinus tracts

bruising

rash

Fremitus

palpable vibrations transmitted through bronchopulmonary tree to chest wall

more prominent in interscapular areas than in lower lung fields

PE→Percussion General Locations

use “ladder” pattern

compare bilaterally

posterior (7 locations)

• 5 locations→apices to bases of lungs

• 2 locations→posterior axillary line regions (lateral)

anterior (6 locations)

• 4 locations→apices to base of lungs

• 2 locations→anterior axillary line regions (lateral)

PE→Percussion→Diaphragmatic Excursion

ID→descent of the diaphragm

measure

• distance between dullness
  -on full expiration

• full inspiration

normal→3 to 5.5cm

PE→Auscultation (General)

assessing airflow through tracheobroncheal tree

listening to sounds generated by breathing

• adventitious sounds

• transmitted voice sounds
  -bronchophony
  -egophony
  -whispered pectoriloquy

PE→Auscultation Process

1. ask pt to clear lungs/cough once/twice

2. ask pt to take deep breath in+out with open mouth each time the diaphragm of the stethoscope is placed against their skin

3. auscultate 7 locations on the posterior lung fields
   -5→from apices to bases of lungs
   -2→posterior axillary line regions (lateral)

4. auscultate 6 locations on the anterior lung fields
   -4→apices to bases of lungs
   -2→anterior axillary line regions (lateral)

use “ladder” pattern→compare symmetric areas

listen to full inspiration+expiration