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LOCAL EXAMINATION OF THE CHEST

	It is necessary for the patient to be stripped to the waist. Usually, the patient lies in a recumbent or semi-recumbent position with arms abducted, when the anterior and lateral aspects of the chest are being examined, and sit upright with arms folded across the chest, when the posterior aspect of the chest is being examined. When the patient cannot sit, the posterior chest may be examined by turning the patient on his lateral sides. Always compare between identical points or areas on both sides of the chest.

	The right lung is composed of three lobes (the upper, middle and lower lobes) separated from each other by the minor and major interlobar fissures, while the left lung is composed of two lobes only (the upper and lower lobes) separated by the major interlobar fissure only. The right lung is composed of 10 bronchopulmonary segments: the upper lobe has three segments (anterior, apical and posterior), the middle lobe has two segments (medial and lateral) and the lower lobe has five segments (apical, anterior, posterior, medial and lateral), while the left lung is composed of 8 bronchopulmonary segments only: the upper lobe has two segments (anterior and apicoposterior), the lingula has two segments (superior and inferior) and the lower lobe has four segments (apical, anterior, posterior, and lateral). 	Surface anatomy of various organs: 1-	Lungs: The apices of the lungs rise 2-3 cm above the medial thirds of the clavicles. From this point the inner margins of the lungs and their covering pleurae slant towards the sternum, meeting each other in midline at the sternal angle, then on the right side: The lung margin continues down as far as the 6th costal cartilage, where it turns laterally to meet the midclavicular line at the 6th rib, the midaxillary line at the 8th rib and the scapular line at 10th thoracic vertebra and then a line ascends along the paravertebral line to join the apex. On the left side: The landmarks are the same with the exception that the lung border turns away from sternum at 4th till the 6th costal cartilage (to the parasternal line) where it turns laterally, due to the heart, which lies in contact with chest wall in this area. 2-	Pleurae: The pleura lies so close to the lungs at the apices and along the inner margins, so following the same surface markings, but the at the lower borders of the lungs the pleura extends farther (reaching the level of 8th rib in the midclavicular line, level of the 10th rib in the midaxillary line and level of 12th thoracic vertebra in paravertebral line).

Anterior Posterior Surface anatomy of the lungs and pleurae from anterior and posterior

3-	Kronig’s isthmus: a-	Anterior: Medial 2/3 of the clavicle. b-	Posterior: Medial 1/3 of spine of scapula. c-	Medial:   A line joining sternoclavicular joint with the 7th cervical spine posteriorly. d-	Lateral: A line joining point A (junction of medial 2/3 of clavicle with outer 1/3) and point B (junction of medial 1/3 of spine of scapula with lateral 2/3). 4- Lung fissures: a-	The oblique fissure (both lungs): a line drawn from the 3rd thoracic spine posteriorly slanting downwards and laterally to cut the 5th rib in the midaxillary line and ends at the 6th costal cartilage anteriorly 3 inches from middle line. It also divides the axilla into upper and lower axillary areas. b-	The transverse fissure (right lung only): a line drawn laterally from the costal cartilage of the 4th rib to meet the oblique fissure at the 5th rib in midaxillary line.

Surface anatomy of the lung fissures from anterior

Surface anatomy of lung fissures from lateral positions

Surface anatomy of lung fissures from posterior

5- Traube’s area: It is an area of tympanitic resonance overlying the fundus of the stomach: a-	Upper border: Base of the Left Lung. b-	Lower border: Left Costal Margin c-	Left border:   Anterior border of spleen d-	Right border:  Lower border of left lobe of liver. 6- Bare area of Heart: An area over the anterior chest wall extending from the 4th to the 6th costal cartilages and from the left sternal border to the left parasternal line.

7- Heart: a-	Left 5th  intercostal space, 3.5 inches from median plane. b-	Left 2nd costal cartilage, 1.5 inches from median plane. c-	Right 3rd costal cartilage, 1.0 inches from median plane. d-	Right 6th costal cartilage, 0.5 inches from median plane.

INSPECTION Chest is inspected from the head or from the foot. If the patient is too ill to sit up, the back is examined by rolling the patient on each side in turn. 1-	Shape of the chest: The healthy chest is an ellipse in cross section (the anteroposterior to transverse diameters in the ratio of 5:7), bilaterally symmetrical with smooth contours, the ribs are oblique and the subcostal angle is about 70-110o. Chest diameters are measured by the pelvimeter. Abnormal shapes of chest that may be present are: a-	Barrel chest: The anteroposterior diameter is increased, ribs are horizontally placed with wide intercostals spaces, spine becomes concave forwards, sternum is much more arched and the subcostal angle is obtuse. This deformity is present in emphysema. b-	Funnel chest: An exaggeration of normal depression seen at end of the sternum, often congenital but may be acquired in shoemakers (pectus excavatum). It is due to fibrous replacement of the anterior portion of the diaphragm. It is usually asymptomatic, but when there is marked degree of depression of the sternum, the heart may be compressed and apex shifted to left with reduction in the lungs ventilatory capacity. c-	Rachitic chest: A groove in the region of costochondral junctions during inspiration (Harrison’s sulcus) with swellings of costochondral junctions (Rachitic rosary). d-	Pigeon’s chest: The sternum becomes prominent and the chest acquires a triangular form (pectus carinatum). The congenital form is due to malinsertion of anterior portion of the diaphragm, being inserted in posterior rectus sheath rather than the sternum while the acquired form occurs in rickets. e-	Spinal deformities: kyphoscoliosis and lateral scoliosis. f-	Unilateral enlargement: pleural effusion, pneumothorax, lung or chest wall tumors, compensatory emphysema and precordial prominence secondary to pericardial effusion or valvular heart disease. g-	Unilateral retraction: fibrothorax and lung collapse. 2- Movement of the chest: a-	Inspection is the best way of assessing any limitations of movements of the chest. b-	The degree of chest expansion is measured by placing a tape measure below the nipples and instructs the patient to breathe deeply in and out. Normal chest expansion is about 4-6 cm. Generalized decrease of movement means expansion less than 2cm. c-	Compare movement of the two sides while the patient is breathing quietly. A delay in movement on one area means that there is an element of bronchial obstruction in the corresponding bronchus e.g. adenoma or early bronchial carcinoma. This will not be evident if the patient breathes deeply because it tends to overcome the obstruction. d-	Note abnormal inspiratory movements produced by contraction of the accessory muscles of inspiration (sternomastoids, scaleni and trapezii). e-	Paradoxical movement of the chest wall (indrawing of chest wall during inspiration) is seen in patients with double fractures of a series of ribs or of the sternum (flail chest). f-	Unilateral reduction of chest wall movement occurs in pleural effusion, empyema, pneumothorax, lung consolidation or collapse and lung or pleural fibrosis. The affected side, whatever the type of pathology, always moves less than the sound side. g-	Generalized decrease of chest expansion occurs in asthma, pulmonary fibrosis, and emphysema and in conditions, which restrict chest movement as ankylosing spondylitis, systemic sclerosis and obesity. 3- Symmetry of the chest: a.	Healthy chest is bilaterally symmetrical with smooth contours. b.	Causes of asymmetry: pleural effusion or fibrosis and lung collapse or fibrosis. 4- Rate and type of respiration: a-	Rate of breathing should be observed without the patient’s knowledge. Respiratory rate varies in normal individuals between 14 and 18 per minute. Respiratory rate is increased in pyrexia, acute pulmonary infections, bronchial asthma and acute pulmonary edema and it is decreased during sleep and with use of narcotics. b-	In men respiration is usually abdominothoracic (diaphragmatic) while in women it is thoracoabdominal (costal). A change in type of breathing may be significant of disease. Respiration is mainly thoracic in peritonitis, ascites, large ovarian cyst or pregnancy and mainly abdominal in ankylosing spondylitis, intercostal paralysis, fracture ribs or pleurisy. c-	Abnormal breathing patterns are: 1)	Purse lip breathing: in COPD to decrease collapse of bronchi in expiration. 2)	Bitot’s breathing: sudden deep breathing with apnea in tuberculous meningitis. 3)	Cheyne-stokes breathing: periods of apnea alternating with periods of hyperventilation that begins gradually. It is observed in respiratory or heart failure and is probably due to delay in circulation time between the central and the peripheral chemoreceptors or decreased sensitivity of the respiratory center to CO2. 4)	Kussmaul’s breathing: rapid deep breathing in renal and hepatic failure. 5)	Hyperventilation: in meningitis, encephalitis, cerebral hemorrhage, fevers, hyperthyroidism, anxiety and salicylate overdose. Hyperventilation causes respiratory alkalosis (due to CO2 wash) with tetany and drowsiness. 5- Pulsations over the Chest Wall: a-	The cardiac pulsations should be examined. In emphysema, the hyperinflated lungs may obscure all the precordial pulsations except those on epigastrium. b-	 The apex may be displaced to opposite side by pneumothorax or pleural effusion, or drawn to same side by pulmonary collapse or fibrosis or pleural fibrosis. It is a guide to the position of the mediastinum. 6- Skin and Chest wall: a-	Inspect the skin for scars of pleural tapping (in midaxillary or scapular lines), scars of intercostal intubations (in 5th space in midaxillary line) or thoracotomy scar. b-	Inspect the chest wall for dilated veins, which indicate superior vena cava obstruction. If obstruction is proximal to the azygos vein, dilated veins will be seen all over the chest wall and if obstruction is distal to the azygos vein, dilated veins is seen mainly around the shoulder. c-	Cutaneous lesions such as skin eruptions, sarcoid nodules (especially in scar areas), malignant nodules, purpuric spots, bruises or discharging sinuses should be noticed. 7- Position of the Trachea: (Trill’s sign): a-	Trachea is central in its cervical part & it is an indicator of the mediastinal position. b-	Tracheal displacement is suspected if prominence of the sternomastoid muscle on one side is present. c-	The trachea may be displaced to opposite side by pneumothorax or pleural effusion or drawn to the same side by pulmonary fibrosis or collapse or pleural fibrosis. 8- Lower Intercostal Spaces (Litten’s sign): a-	Indrawing of the lower 6 intercostal spaces is normally present in deep inspiration and in thin persons but when it is present during quite breathing, it indicates a low flat diaphragm. b-	Contraction of a low flat diaphragm causes pull on the lower intercostal spaces. 9- Subcostal angle: a-	Normally, the subcostal angle is from 70– 110o. b-	Increased obtuseness indicates gradual increase in intrathoracic or intra-abdominal pressures and increased acuteness indicates abnormal protrusion of the sternum as in pectus excavatum or emphysema.

PALPATION

1-	Form of the chest: Diameters of the chest are measured by the pelvimeter. The sternum and ribs should be palpated for any masses. It is important to examine the vertebral column by passing your fingers (the thumb and index fingers) along the lateral borders of the spine from above downwards to see if there is kyphosis, scoliosis or kyphoscoliosis. Scoliosis may be acquired (secondary to lung or pleural diseases where the curve of spine is towards the diseased side) or congenital (curve of spine is towards the healthy side). 2-	Trachea: a-	Position of the trachea is determined by thrusting the tip of the index finger gently into the suprasternal notch and noticing the resistance on each side of the trachea, the side with least resistance indicates that the trachea is shifted to the other side. b-	Normally, trachea is central in its cervical part and slightly shifted to the right in its intrathoracic part, this shift is not felt clinically. c-	A downward movement of the trachea and larynx during inspiration, detected by thumb and index fingers on the sides of the thyroid cartilage, is felt in COPD patients due to contractions of the low flat diaphragm. d-	Tracheal tug (downward pull on the trachea and larynx during systole) is felt in cases of aortic aneurysm. 3-	Local tenderness: •	Search for local tenderness by superficial palpation of the chest while looking at the patient’s face to see if there is pain at special areas. •	Subcutaneous emphysema is recognized by the crackling sensation. 4- Tactile vocal fremitus (TVF): a-	This sign detects vibrations transmitted to the hand from the larynx. While putting palm of the same hand on the chest in identical areas on the both sides in turn, the patient is asked to say 44 in Arabic. b-	Pathologically, vocal fremitus is diminished when a bronchus is blocked as in tumors and in pleural effusion or pneumothorax, which damps down vibrations. c-	Increased vocal fremitus occurs when vibrations are better conducted as in cases of: i-	Lung consolidation as in pneumonia. ii-	Consolidation collapse with a patent bronchus. iii-	A large cavity or cavity surrounded by consolidation. iv-	At upper level of a pleural effusion posteriorly because the collapsed lung floats on fluid and becomes in close contact with trachea and chest wall. v-	In tension pneumothorax because the lung is collapsed totally and transmission of vibrations is directly from the trachea. (1)                                   (2)                                  (3)            Infraclavicular area                 Mammary area              Inframammary area Steps in estimation of TVF anteriorly, note do each step on both sides in turn

(1)                             (2)                             (3)                        (4)   Suprascapular            Upper interscapular    Lower interscapular       Subscapular Steps in estimation of TVF posteriorly, note do each step on both sides in turn

5- Movements of the chest wall: a-	Respiratory movements are compared on infraclavicular, mammary areas, inframammary, suprascapular, interscapular, scapular and infrascapular areas. b-	Hands are put (with fingers directed towards clavicles) to compare movements of the infraclavicular areas. For movements of the suprascapular areas hands are put also with the fingers directed upwards. c-	Grasping the sides of the chest with the outstretched thumbs near the middle line and asking the patient to take a deep breath examine movements of the mammary, inframammary and infrascapular areas. d-	Unilateral reduction of chest wall movement occurs in pleural effusion, pneumothorax, empyema and in pulmonary consolidation and collapse. In bronchial asthma, emphysema and diffuse pulmonary fibrosis movements of the chest wall are symmetrically reduced (in the first two cases due to over inflation of the lungs and in the last case the movement is restricted by the less distensible lungs).

(1)                          (2)                             (3)                            (4)                 Infraclavicular                                      Mammary               Inframammary Estimation of chest movement anteriorly

(1)                                                      (2)          Suprascapular areas                        Subscapular areas Estimation of chest movement posteriorly

6- Palpable adventitious sounds: a-	Palpable pleural rub may be present in the lower axillary or infrascapular areas. b-	Palpable rhonchi may be present in asthmatic patients.

7- Pulsations: a-	The hand should be placed on each side of chest to avoid overlooking dextrocardia. The apex, left parasternal 3rd and 4th spaces, pulmonary, aortic and epigastric areas should be palpated for pulsations. b-	Pulsations in pulmonary area indicate pulmonary hypertension or pulmonary artery aneurysm. A palpable pulmonary component of the 2nd heart sound “diastolic shock” is present in pulmonary hypertension.

PERCUSSION

1-	Percussion is setting up artificial vibrations in a tissue by means of a sharp tap with the fingers. The middle finger of the left hand is placed in close contact with the chest wall and a blow is made on the second phalanx with the middle finger of the right hand. The striking finger must be kept at right angle to the other finger and wrist movement makes striking and the finger must be lifted immediately to avoid damping vibrations. 2-	Usually percussion of the chest is light percussion except at the back (a large mass of tissue) or on determination of the upper border of the liver anteriorly. 3-	Percussion proceeds from resonant to dullness and parallel to the percussed border (except in Kronig’s isthmus where it proceeds from dullness to resonance). 4-	Normal resonance is found over lung tissue, hyperresonance is found in emphysema and pneumothorax and tympany is found over the stomach. Normal dullness is found over solid viscera such as the liver and the heart, impaired note is found over consolidated or collapsed lung and stony dullness is found in cases of pleural effusion. 5-	Percussion note should be compared on both sides of chest as follows: a-	Anteriorly: i-	Clavicles. ii-	From 1st intercostals space to upper border of liver on right and to the 6th intercostal space on the left side in midclavicular line. iii-	Percussion may be done also in the anterior axillary line. b-	Axillae: From 4th to 7th intercostals spaces in the midaxillary line. c-	Posteriorly: i-	Kronig’s isthmus. ii-	Suprascapular area. iii-	Interscapular areas. iv-	Scapular areas. v-	Infrascapular areas down to the 11th rib or 12th thoracic spine. 6-	We start percussion by determining the upper border of the liver in the midclavicular line then comparative percussion on both sides of chest (each side in turn space by space) in midclavicular, midaxillary and scapular lines. 7-	On reaching upper border of the liver, we fix the finger and ask the patient to take a deep breath and then we repercuss again to see whether the diaphragm is mobile or not (tidal percussion). After finishing tidal percussion, and the finger is still in place, we percuss lightly to see lung encroachment on liver dullness (hyperinflation or emphysema). 8-	During percussion of back, on reaching level of the diaphragm, we do tidal percussion to detect diaphragmatic mobility on each side. Tidal percussion differentiates between supra and infradiaphragmatic dullness and detects diaphragmatic paralysis. 9-	If there is dullness at any line we do shifting dullness to detect any fluid level (hydropneumothorax) and we repeat it in three planes to see if it is localized or not (while sitting in midclavicular line and in the midaxillary line and while lying flat). 10-	Bare area of the heart, normally dull by light percussion, becomes resonant in emphysema and left sided pneumothorax. When the heart is enlarged or in pericardial effusion the size of the dullness increases.

11-	 Dullness in Traube’s area may be due to: a-	Left pleural effusion. b-	Left basal consolidation. c-	Enlarged left lobe of the liver. d-	Ascites. e-	Splenomegaly. f-	Full stomach and gastric carcinoma.

12-	 Increased resonance of Traube’s are may be due to: a-	Left basal collapse. b-	Pneumoperitoneum. c-	Cirrhotic shrunken liver. d-	Splenectomy. e-	Dilatation of the stomach.

Anterior                                           Posterior Areas of percussion Anterior                                                       Posterior Tidal percussion

AUSCULTATION 1-	Normal breath sounds are generated by turbulence of air in the large airways. They are composed of two elements: the bronchial and the vesicular elements. 2-	Normally, expiration is longer than inspiration, with inspiration/expiration ratio of 1:1.33, but clinically inspiration is heard longer than expiration because flow of air is turbulent (active process) while it is laminar in expiration (passive process). 3-	Auscultation determines: a-	Equality of Breath Sounds. b-	Intensity of Breath Sounds: Decreased in emphysema and in bronchial obstruction. c-	Character of the Respiratory sounds: 1.	Vesicular breathing: inspiration longer and expiration nearly inaudible. 2.	Bronchial breathing: inspiration= expiration with a gap in-between. i-	Ordinary bronchial: over trachea and in massive effusion. ii-	Cavernous: over large cavities. iii-	Tubular: in pneumonic consolidation. iv-	Amphoric: in tension pneumothorax. 3.	Bronchovesicular: Normally occurs near lung roots behind & in upper lobes near middle line anteriorly (inspiration=expiration without gap). d-	Vocal resonance: a.	Quantitative changes: i.	Increase: bronchophony and pectoriloquy. Vocal resonance is examined for by asking the patient to say 44 in Arabic in loud voice and then to whisper it to detect for whispering pectoriloquy. The presence of whispered pectoriloquy over the spinous process of the 4th, 5th and 6th thoracic vertebrae in adults & over the first 2 or 3 thoracic spines in infants is called D’Espin’s sign. Bronchophony and whispering pectoriloquy are heard in the same instances with bronchial breathing. ii. Decrease: as in pleural effusion and pneumothorax. b.	Qualitative changes: Egophony: It is a peculiar form of vocal resonance which is heard at the upper limit of pleural effusion posteriorly. It is detected by asking the patients to say “A” which will be heard as “E”. e-	Adventitious sounds: a.	Rhonchi: Sibilant (high pitched) and sonorous (low pitched). They are caused by vibrations of the walls of narrowed airways and are more evident during expiration. b.	Crepitations: i.	Coarse: They are mainly audible during inspiration and are usually due to increased secretions resulting from chronic bronchitis or bronchiectasis. Coarse bubbling crepitations occur in bronchopleural fistula. They may vary from breath to breath and be modified or abolished by coughing. ii. Fine: They represent the opening of a small airway previously closed (or opening of collapsed alveoli). They are most numerous during the second half of inspiration and are not influenced by cough. Such crackles are heard in pulmonary fibrosis & edema, allergic alveolitis, cystic fibrosis, miliary tuberculosis, pneumonic consolidation (especially as resolution begins) and over infarcted lung. Post-tussive crepitations may also be heard in cases of pulmonary tuberculosis. c.	Pleural rub: It is a coarse leathery sound that tends occurs in the same part of the respiratory cycle (during both inspiration and expiration). It is not altered by cough. The intensity of pleural rub is often increased by deep breathing and by firm pressure of the stethoscope. Pleural rub is distinguished from pericardial rub by its disappearance on holding breath. Anterior                                      Posterior Areas of auscultation الحمد لله