Physical Diagnosis of the Chest

1
Physical Diagnosis of the Chest

• Waid Shelton, M.D.
• This lecture closely follows Bickley, LS,
  Szilagyi PG Bates Guide to Physical Examination
  and History Taking, 8th ed. Philadelphia,
  Lippincott Williams Wilkins, 2003, Chapter 6.

2
An Opportunity to Sense What Is Happening
Dynamically in the Chest

• Instead of Relying Solely on Imaging Studies

3
The chest examination and imaging studies often
complement each other.
4
We need to ask whether what we observe matches
with what we see on x-ray studies.

• Sometimes we must act on observation alone.

5
Some of the Questions We Ask

• What do I think is going on based on the exam?
• What do I think the x-ray will show?
• Do I have time for the x-ray study to be done?
• How do the findings on exam correlate with the
  findings on x-ray?

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On to the Exam

• The history comes first.

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Common Symptoms

• Chest pain
• Dyspnea
• Wheezing
• Cough
• Hemoptysis

8
The first concern about chest pain

• Is it angina?

9
Angina

• Central or left chest
• Often pressure or stabbing sensation (the
  elephant)
• Radiating to the arm, neck, jaw, or ear
• Occurs with exertion and is relieved by rest or
  sublingual nitroglycerine
• Lasts minutes, not seconds, hours, or days
• May be associated with dyspnea, diaphoresis, and
  nausea

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Other sources of chest pain

• Pericardium
• Aorta
• Major airways
• Pleura
• Chest wall
• Esophagus
• Extrathoracic structures

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Cardiovascular Sources of Chest Pain

• Pericardium
• Aorta

• Better sitting up associated with heartbeat
  may hear a rub
• Acute onset high,sustained level of pain may
  involve the back

12
Tracheobronchial Sources of Chest Pain

• Trachea and large airways
• Smaller airways (asthma)

• Central soreness, persistent, worse with cough
  or inspiration
• Central tightness, usually with enough exertion
  to cause dyspnea

13
Pleural Source of Chest Pain

• Usually there is an inspiratory component,
  sometimes only on deep inspiration
• The patient may avoid taking deep breaths, trying
  to splint the affected side
• A pleural friction rub may be heard

14
Chest Wall Sources of Chest Pain

• Ribs and cartilage
• Musculoskeletal
• Skin

• Point tenderness over a rib or costochondrial
  junction
• Pain with movement, as well as respiration
• Unexplained pain in an area which is followed by
  vesicles in a dermatome

15
Esophageal Sources of Chest Pain

• Positioned from suprasternal notch to the xyphoid
• May often be burning or present with a sense of
  occlusion
• Antacids and nitroglycerine may help

16
Chest Pain from Sources Outside the Chest

• Neck
• Cervical nerve root
• Gallbladder
• Stomach

• Cervical arthritis
• Dermatome pain
• Constant or colicky pain
• Burning or boring pain, sometimes relieved by
  antacids or food

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Characterization of Dyspnea

• Occurring at rest vs. occurring with effort
• Walking from room to room
• Sweeping a floor or making a bed
• Walking a distance on level ground
• Walking up an incline or carrying something
• Climbing stairs
• Associated with symptoms of chest pain, nausea,
  or diaphoresis

18
Wheezing

• Frequency
• Precipitants
• Infection
• Exercise or cold
• Exposure
• Relief

19
Cough

• Frequency
• Amount of sputum produced
• Nature of sputum produced
• Clear
• Mucoid (translucent white or gray)
• Purulent (yellow or green)
• Foul-smelling

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Questions about Hemoptysis

• Is it being coughed up from the chest does it
  just appear in the mouth or is it coming up from
  the stomach?
• Is there frank blood in quantity?
• Is the blood in otherwise clear or purulent
  sputum (blood streaking)?
• Is the blood part of pink, frothy sputum?

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Smoking

• Do you smoke?
• Did you ever smoke?
• When did you begin?
• How many packs did you smoke per day on average?
• When did you stop?
• Calculate pack years smoked.
• Do you want to stop?

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The Four As of Smoking Cessation, Plus One

• Ask about smoking
• Advise cessation
• Assist in stopping by inquiring about cessation
  date and providing information
• Arrange a return visit and inquire about success
  or failure in smoking cessation
• Additionally Avoid an accusatory stance

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Review of Anatomical Landmarks
24
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, p 210
25
Bickley LS, Szilagyi PG Bates Guide to
Physical Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, p 211
26
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, p 212
27
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, p 213
28
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, p 214
29
The Examination

• Inspection
• Palpation
• Percussion
• Auscultation

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Inspection

• Degree of comfort and posture
• Audible sounds of wheeze, stridor, or recurrent
  cough
• Apparent dyspnea moving about the room
• Use of accessory muscles
• Consider counting respirations
• Thoracic symmetry
• Nasal flaring and intercostal retractions

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Time to Decide

• Position and timing of the examination of the
  anterior chest

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Palpation

• Chest expansion
• Check for fremitus with ball or ulnar surface of
  the hand
• Check for fremitus on both sides of the chest at
  one time using both hands

33
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, p 223
34
Percussion

• Hyperextend the middle finger of your
  non-dominant hand (lefties, try this both ways).
• Press the DIP joint firmly down on the surface
  while elevating other fingers.
• Strike with the tip of the middle finger of the
  dominant hand in a sharp tap using mostly wrist
  motion.
• Feel and hear the result.

35
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, pp 223-224
36
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, p 225
37
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, p 225
38
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, p 226
39
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, p 226
40
Auscultation

• Place the stethoscope on bare skin, please.

41
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, p 227
42
Adventitious (Added) Sounds

• Fine crackles (fine rales)
• Coarse crackles (coarse rales)
• Wheezes
• Rhonchi

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Crackles or Rales

• I think of crackles or rales as opening sounds of
  alveoli or small airways. This may not be
  entirely true, but it is helpful to me to think
  of them that way.
• Fine crackles often come at the end of
  inspiration in atelectasis, failure, or
  consolidation.
• Coarse crackles come earlier in inspiration, may
  sound like Velcro, and are associated with
  pulmonary fibrosis.

44
Note well

• Your text mentions crackles in early inspiration
  (and sometimes expiration) from chronic
  bronchitis and asthma (Bates, Table 6-6, p 241).
  It also mentions midinspiratory and expiratory
  crackles heard in bronchiectasis.

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Wheezes, Rhonchi, and Stridor

• Wheezes are high pitched sounds in inspiration
  and expiration. I think of these as turbulence
  in smaller bronchi.
• Rhonchi are lower pitched sounds in inspiration
  and expiration. I think of these as turbulence
  in larger bronchi.
• Stridor is a high pitched inspiratory sound heard
  best over the trachea or larynx. It demands
  attention.

46
Pleural Rubs

• May sound like the rubbing of shoe leather
• Occur over the affected area
• Usually are inspiratory or both inspiratory and
  expiratory
• May be hard to differentiate from a combination
  of rhonchi and crackles

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Testing for Transmitted Sounds

• Bronchial breath sounds or, possibly,
  bronchiovesicular breath sounds outside their
  expected area should trigger search
• Adventitial breath sounds call for testing
• Expectation of or concern about pulmonary
  pathology, such as pneumonia or atelectasis
  should cause search

48
Transmitted Sounds

• Bronchophony clear transmission of spoken voice
• Egophony ee is heard as ay
• Whispered pectoriloquy whispered ninety-nine
  is heard clearly
• These are signs of an open airway and less
  muffling by aerated lung tissue (consolidation or
  atelectasis).

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Examining the Anterior Chest

• Sitting or supine

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Inspection

• Symmetry
• Deformities
• Intercostal retraction
• Respiratory movement

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Palpation

• Points of tenderness
• Fremitus

52
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th
ed.Philadelphia, Lippincott Williams and
Wilkins, 2003, p 231
53
Percussion
54
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, p 231
55
The Female Breast

• Cover the opposite side
• Move the breast with your fingers or ask the
  patient to retract the breast

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The Liver

• Note the top edge by percussion
• The liver will be more caudal in patients with
  emphysema
• You will learn to sense the lower edge of the
  liver in examination of the abdomen.

57
Bickley LS, Szilagyi PG Bates Guide to Physical
Examination and History Taking, 8th ed.
Philadelphia, Lippincott Williams Wilkins,
2003, p 232
58
Deformities

• Barrel chest
• Flail chest
• Pectus Excavatum
• Pectus Carinatum
• Scoliosis
• See Table 6-4 of Bates, p 239

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Examples
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Example 1 Normal

• Fremitus present
• Normal resonance present
• Vesicular sounds present

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Example 2 Pleural Effusion

• Decreased fremitus
• Dullness to percussion
• Decreased breath sounds
• Possibly a small band of crackles just above the
  area of dullness to percussion

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Example 3 Emphysema

• Decreased fremitus
• Increased resonance
• Decreased breath sounds (a quiet chest)

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Example 4 Consolidation

• Increased fremitus
• Dullness to percussion
• Bronchial breath sounds
• Increased spoken voice
• Egophony
• Whispered pectoriloquy

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Example 5 Obstructive Atelectasis

• Decreased fremitus
• Dullness to percussion
• Decreased breath sounds
• No adventitial sounds
• No transmitted breath sounds

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Example 6 Pneumothorax

• Decreased fremitus
• Increased resonance
• Decreased breath sounds

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Thank you

• I always enjoy being with you.
• wshelton_at_uasom.meis.uab.edu
• 975-0787
• VH 102B
• BDB 398