Chest Examination Chest Examination

Overview of Clinical Diagnosis: The Chest Examination

  • Primary focus on the techniques of Chest Examination, covering:
      - Landmarks of the chest surface
      - Four key examination methods: Inspection, Palpation, Percussion, Auscultation

Landmarks of the Chest

  • Key anatomical landmarks include:
      - Manubrium
      - Sternal body
      - Xiphoid process
      - Sternal angle
      - Intercostal spaces

Inspection

1. General Observation

  • Observe shape and symmetry of the chest:
      - Position: Sitting or lying down
      - Ensure the chest is fully exposed
      - Maintain a comfortable and warm environment
      - Lighting should be sufficient
      - Normal anteroposterior to transverse diameter ratio: 1:1.5

2. Measure Respiratory Rate

  • Important considerations:
      - Avoid asking the patient to breathe “normally”
      - Evaluate respirations post radial pulse assessment
      - Count each rise and fall of the chest as one breath
Normal Respiratory Rates
  • Adult: 12-20 breaths/min
  • Tachypnea: >20 breaths/min
  • Bradypnea: <12 breaths/min
  • Infant (birth - 1 year): 30-60 breaths/min
  • Toddler (1-3 years): 24-40 breaths/min
  • Preschooler (3-6 years): 22-34 breaths/min
  • School-age (6-12 years): 18-30 breaths/min

3. Breathing Movement

  • Differentiation between male and female breathing types:
      - Females often exhibit thoracic respiration
      - Males and children exhibit abdominal respiration

Respiratory Movement in Disease Context

  • Conditions affecting breathing movement:
      - Lung or pleural diseases (e.g., pneumonia, severe tuberculosis, pleurisy)
      - Chest wall diseases (e.g., intercostal neuralgia, rib fractures)
      - Abdominal influences (e.g., peritonitis, massive ascites, enlarged organs)

Respiratory Rate and Patterns

Normal Breathing

  • Eupnea: Normal breathing pattern; 12-20 breaths/min
  • Tachypnea: Rapid breathing; >20 breaths/min
  • Bradypnea: Slow breathing; <12 breaths/min
  • Apnea: Absence of breathing; 0 breaths/min
Factors Affecting Respiratory Patterns
  • Emotional state, physical fitness, internal temperature, health status
Hypopnea and Hyperpnea
  • Hypopnea: Reduction in airflow with oxygen desaturation without apnea
  • Hyperpnea: Abnormally deep or rapid breathing

Respiratory Rhythms

  • Types of abnormal breathing patterns include:
      - Cheyne-Stokes breathing: Gradual changes between Hypopnea and Hyperpnea followed by Apnea. Causes include brain injuries, increased intracranial pressure, heart failure, end-of-life conditions.
      - Biot's breathing: Periods of Hyperpnea followed by Apnea. Causes include stroke, CNS trauma, meningitis.
      - Kussmaul's breathing: Combination of Tachypnea and Hyperpnea. Associated with diabetic ketoacidosis and metabolic acidosis.

Inspection for Respiratory Distress

  • Visual indicators:
      - Appearance: Distress, shortness of breath, somnolence
      - Skin: Cyanosis, sweating
      - Body position/posture, breathing pattern, accessory muscle usage, nasal flaring

Palpation

1. Chest Expansion

  • Assess dynamics during respiration, focusing on lower thorax
  • Enhanced expansion indicators:
      - Contralateral diaphragm paralysis
      - Pulmonary atelectasis
      - Rib fracture
  • Decreased expansion indicators:
      - Pulmonary diseases
      - Pleural diseases
  • Conditions leading to enhanced bilateral expansion: Ascites, hepatosplenomegaly, large intra-abdominal tumors
  • Causes for decreased bilateral expansion: CNS diseases, peripheral neuropathy

2. Tactile Vocal Fremitus

  • Definition: Palpation of chest wall to detect changes in vibration intensity during spoken words, indicating lung pathology
  • Procedure for Assessment:
      1. Patient folds arms across chest, repeats “ninety-nine” or “one, two, three”
      2. Practitioner palpates simultaneously on both sides from lung apex to base
Changes in Vocal Fremitus
  • Increased fremitus: Pneumonia, lung abscess
  • Decreased fremitus: Pleural effusion, pneumothorax, emphysema

3. Pleural Friction Fremitus

  • Most easily palpated in lower anterior or lateral thoracic wall
  • Occurs where pleural layers are inflamed and have lost lubrication (tuberculous pleurisy, purulent pleurisy, tumors, dehydration, pulmonary lesions)

Percussion

What is Percussion?

  • Definition: Tapping or giving impact to produce audible vibrations in the body

Technique of Percussion

  • The plexor (finger giving impact) taps on the pleximeter (finger placed on patient).
  • Ensure that the movement involves primarily the wrist for accurate sound generation.
Types of Percussion Notes
  • Tympanic Note: Indicates hollow viscera filled with gas (typically over the abdomen)
  • Resonant Note: Found in viscous compartments like lungs containing air
  • Dull Note: Indicates solid viscera without air (soft tissue, hard bones)

Lung Anatomy

  • Lung Lobes:
      - Right Lung: Superior lobe, Middle lobe, Inferior lobe
      - Left Lung: Superior lobe, Inferior lobe

Lung Expansion Assessment

  • Expansion noted from T1 to T12 thoracic regions

Practice Case Analysis

Example Patient Presentation

  • Patient complaints: Cough, shortness of breath
  • Findings:
      - Left side: Normal breath sounds, percussion
      - Right side: Dullness in lower third, increased vocal resonance indicating possible consolidation or pneumonia

Auscultation

Definition

  • Auscultation: Listening to lung sounds during inhalation and exhalation using a stethoscope

Procedure for Auscultation

  1. Explain procedure to build rapport
  2. Stand close for better access
  3. Warm the stethoscope diaphragm if cold
  4. Earpieces fitted properly in the ears
  5. Press diaphragm firmly against skin while patient takes deep breaths
  6. Listen to sounds, noting intensity, location, strength, pattern, duration
  7. Start with anterior, then posterior side
  8. Compare left and right lung sounds
  9. Document findings

Normal Breath Sounds

  • Vesicular: Soft "Fu-Fu"
  • Bronchial: Louder "Ha"
  • Bronchovesicular: Mixed sound characteristics

Adventitious Breath Sounds

  • Crackles (Rales): Short, explosive sounds in small/middle airways. Caused by fluid
      - Types:
        - Fine crackles: Higher frequency, shorter duration
        - Coarse crackles: Lower pitch, longer duration
  • Wheezes: High-pitched sounds due to narrowed airway, most audible during expiration
  • Rhonchi: Low-pitched sounds in larger airways, heard during expiration, indicating mucus presence
  • Pleural Friction Rub: Loud grading sounds from inflamed pleura rubbing together, indicates low pleural fluid levels
Summary of Adventitious Breath Sounds
  • Crackles: Air moving through secretions in small/middle airways
  • Wheezes: Air moving through constricted airways
  • Rhonchi: Air moving through secretions in larger airways
  • Diminished Breath Sounds: Indicate decreased lung air movement
  • Pleural Friction Rub: Sounds from inflamed pleura with fluid decrease

Conclusion

  • Important signs of pulmonary diseases to note in future lessons:
      - Consolidation
      - Atelectasis
      - Pneumothorax
      - Pleural effusion

Thank You Message

  • Session concluded by Jiayi Lin, MD
  • Encouraged to enjoy life!