1. Local ExaminationLocal Examination
Of The ChestOf The Chest
Iman GalalIman Galal
Assistant Professor Pulmonary MedicineAssistant Professor Pulmonary Medicine
Ain Shams UniversityAin Shams University
E-mail: dr.imangalal@gmail.comE-mail: dr.imangalal@gmail.com

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InspectionInspection
PalpationPalpation
PercussionPercussion
AuscultationAuscultation
Local Examination of the Chest:Local Examination of the Chest:

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Local Examination of the ChestLocal Examination of the Chest
1- Shape of the chest & Spine Deformity1- Shape of the chest & Spine Deformity
2-MovementMovement
3-Symmetry3-Symmetry
4-Pulsations4-Pulsations
5-Respiratory movements5-Respiratory movements
6-Skin6-Skin
7-Subcostal angel7-Subcostal angel
8-Special signs8-Special signs
Inspection:Inspection:

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Normal ShapeNormal Shape
Barrel shaped chestBarrel shaped chest
Pigeon chestPigeon chest
Rachitic chestRachitic chest
Funnel-shaped chest (Pectus Excavatum)Funnel-shaped chest (Pectus Excavatum)
Shape of the Chest:Shape of the Chest:
Local Examination of the ChestLocal Examination of the Chest

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Shape:Shape: ↑↑ AP diameterAP diameter
Local Examination of the ChestLocal Examination of the Chest

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Shape: Pectus ExcavatumShape: Pectus Excavatum
Local Examination of the ChestLocal Examination of the Chest

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Spine Deformity: KyphosisSpine Deformity: Kyphosis
Local Examination of the ChestLocal Examination of the Chest

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Spine Deformity: ScoliosisSpine Deformity: Scoliosis
Local Examination of the ChestLocal Examination of the Chest

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Both sides of normal chest areBoth sides of normal chest are
symmetrical in shape and mobility.symmetrical in shape and mobility.
The diseased side or part is less mobileThe diseased side or part is less mobile
than the healthy one.than the healthy one.
Movement & Symmetry :
Local Examination of the ChestLocal Examination of the Chest

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Shape: Pigeon ChestShape: Pigeon Chest
Local Examination of the ChestLocal Examination of the Chest

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Significance ofSignificance of ↓↓ respiratory movements:respiratory movements:
 UnilateralUnilateral ↓↓ of chest wall movements:of chest wall movements:
•Pleural effusionPleural effusion
•EmpyemaEmpyema
•PneumothoraxPneumothorax
•Pulmonary consolidationPulmonary consolidation
•Pulmonary collapsePulmonary collapse
•Pleural or parenchymatous pulmonary fibrosisPleural or parenchymatous pulmonary fibrosis
 BilateralBilateral ↓↓ of chest wall movements:of chest wall movements:
•Bronchial asthmaBronchial asthma
•EmphysemaEmphysema
•Diffuse pulmonary fibrosisDiffuse pulmonary fibrosis
Local Examination of the ChestLocal Examination of the Chest

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BulgingBulging RetractionRetraction
 Pleural effusionPleural effusion
 PneumothoraxPneumothorax
 HydropneumothoraxHydropneumothorax
 EmpyemaEmpyema
 Precordial bulgePrecordial bulge
 Chest wall causesChest wall causes
 Pulmonary collapsePulmonary collapse
 Pulm. FibrosisPulm. Fibrosis
 Pleural fibrosisPleural fibrosis
Local Examination of the ChestLocal Examination of the Chest
Movement & Symmetry :

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 Respiratory rate
 Type of respiration
 Regularity of respiration
 Pulse Rate: Respiratory Rate Ratio
Respiratory Movements:Respiratory Movements:
Local Examination of the ChestLocal Examination of the Chest

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Skin eruptionSkin eruption e.g HZe.g HZ
NodulesNodules (inflammatory,metastatic,lipoma, neurofibroma…)(inflammatory,metastatic,lipoma, neurofibroma…)
Subcutaneous emphysemaSubcutaneous emphysema
Purpuric spots,Vascular spiders, BruisesPurpuric spots,Vascular spiders, Bruises
Dilated prominent blood vesselsDilated prominent blood vessels (SVC obstruction)(SVC obstruction)
ScarsScars (previous operation,trauma, intercostal tube…)(previous operation,trauma, intercostal tube…)
Discharging sinusesDischarging sinuses
Lesions of the breastsLesions of the breasts
Skin:Skin:
Local Examination of the ChestLocal Examination of the Chest

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Skin:Skin: SVC ObstructionSVC Obstruction
Local Examination of the ChestLocal Examination of the Chest

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 ApicalApical
 ParasternalParasternal
 EpigastricEpigastric
Pulsations:Pulsations:
Local Examination of the ChestLocal Examination of the Chest

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Palpation:Palpation:
 To confirm Respiratory Movements +/- ExpansionTo confirm Respiratory Movements +/- Expansion
 Pulsations (see before)Pulsations (see before)
 Palpable Adventitious SoundsPalpable Adventitious Sounds
 TTactileactile VVocalocal FFremitus (TVF)remitus (TVF)
 Position of the TracheaPosition of the Trachea
Local Examination of the ChestLocal Examination of the Chest

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Palpation of Respiratory MovementsPalpation of Respiratory Movements
1.1. Respiratory movements in the infraclavicular regionsRespiratory movements in the infraclavicular regions
2.2. Respiratory movements at the costal marginsRespiratory movements at the costal margins
3.3. Respiratory movements of the lower ribs posteriorlyRespiratory movements of the lower ribs posteriorly
Local Examination of the ChestLocal Examination of the Chest

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Symmetry & Movement:
Local Examination of the ChestLocal Examination of the Chest

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Palpation: Chest ExcursionPalpation: Chest Excursion
Local Examination of the ChestLocal Examination of the Chest

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TVFTVF
Increased TVFIncreased TVF Decreased TVFDecreased TVF
 Consolidation
 Cavitation
 Collapse with patent main
bronchus
 Thick chest wall
 Pleural effusion
 Pleural fibrosis
 Pneumothorax
 Emphysema
 Collapse
Local Examination of the ChestLocal Examination of the Chest

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Palpable Adventitious SoundsPalpable Adventitious Sounds
Palpable RhonchiPalpable Rhonchi
•Diffuse
•Localized and Persistent
Palpable Pleural Rub
Local Examination of the ChestLocal Examination of the Chest

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Position of the Trachea:Position of the Trachea:
 How to test for the position of the trachea?How to test for the position of the trachea?
 Trill’s sign:Bulging of the sternomastoid muscle inTrill’s sign:Bulging of the sternomastoid muscle in
front of the deviated trachea.front of the deviated trachea.
To evaluate the position of theTo evaluate the position of the
Upper Mediastinum.Upper Mediastinum.
Local Examination of the ChestLocal Examination of the Chest

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Position of the Trachea:Position of the Trachea:
Local Examination of the ChestLocal Examination of the Chest

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Causes of deviation of the trachea
IpsilateralIpsilateral
(To pull)(To pull)
ContralateralContralateral
( To push)( To push)
 CollapseCollapse
 FibrosisFibrosis
 Apical massApical mass
 Pleural effusionPleural effusion
 PneumothoraxPneumothorax
Local Examination of the ChestLocal Examination of the Chest
Position of the Trachea:Position of the Trachea:

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Percussion:TechniquePercussion:Technique Local Examination of the ChestLocal Examination of the Chest

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Percussion
Cut your nails

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Percussion: Anterior ChestPercussion: Anterior Chest
1.1. Percuss from side to side andPercuss from side to side and
top to bottom using thetop to bottom using the
pattern shown in thepattern shown in the
illustration.illustration.
2.2. Compare one side to the otherCompare one side to the other
looking for asymmetry.looking for asymmetry.
3.3. Note the location and qualityNote the location and quality
of the percussion sounds youof the percussion sounds you
hear.hear.

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Percussion: Posterior ChestPercussion: Posterior Chest
1.1. Percuss from side to side and top toPercuss from side to side and top to
bottom using this pattern. Omit thebottom using this pattern. Omit the
areas covered by the scapulae.areas covered by the scapulae.
2.2. Compare one side to the otherCompare one side to the other
looking for asymmetry.looking for asymmetry.
3.3. Note the location and quality of theNote the location and quality of the
percussion sounds you hear.percussion sounds you hear.
4.4. Find the level of the diaphragmaticFind the level of the diaphragmatic
dullness on both sides.dullness on both sides.

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Traube’s area:Traube’s area:
4 points:4 points:
Left 6Left 6thth
rib in the MCL to 8rib in the MCL to 8thth
costal cartilage in thecostal cartilage in the
parasternal line ,then along the left costal margin to the 11parasternal line ,then along the left costal margin to the 11thth
rib in the MAL, then the 9rib in the MAL, then the 9thth
rib in the MAL.rib in the MAL.

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Kronig’s Isthmus :Kronig’s Isthmus :
 It is a band of resonance representing lung apex.It is a band of resonance representing lung apex.
 LaterallyLaterally it is marked by a line joining 2 points:it is marked by a line joining 2 points:
1.1. The junction of the medial 2/3 of the clavicle with theThe junction of the medial 2/3 of the clavicle with the
lateral 1/3.lateral 1/3.
2.2. The junction of the medial 1/3 of the scapular spine withThe junction of the medial 1/3 of the scapular spine with
the lateral 2/3.the lateral 2/3.
 MediallyMedially marked by a line between the sternal end ofmarked by a line between the sternal end of
clavicle and the 7clavicle and the 7thth
cervical spine.cervical spine.

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Bare area of the heart :Bare area of the heart :
 Medial border: left lateral border of the sternumMedial border: left lateral border of the sternum
 Lateral border: left parasternal lineLateral border: left parasternal line
 Superior border: lower border of Lt 4Superior border: lower border of Lt 4thth
rib.rib.
 Inferior border: upper border of Lt 6Inferior border: upper border of Lt 6thth
ribrib

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Surface anatomy of liver:Surface anatomy of liver:
Upper border:Upper border:
It starts from the left 6It starts from the left 6thth
ribrib just inside the MCL, passing tojust inside the MCL, passing to
the Rt and slightly upwards to the 5the Rt and slightly upwards to the 5thth
rib in the MCL, thenrib in the MCL, then
the 7the 7thth
rib in anterior axillary line, to the 9rib in anterior axillary line, to the 9thth
rib in mid-axillaryrib in mid-axillary
line.line.

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1.1. Find the level of the diaphragmatic dullness on both sides.Find the level of the diaphragmatic dullness on both sides.
2.2. Ask the patient to inspire deeply.Ask the patient to inspire deeply.
3.3. The level of dullness (diaphragmatic excursion) should goThe level of dullness (diaphragmatic excursion) should go
down 3-5cmdown 3-5cm symmetricallysymmetrically..
4.4. Decreased or asymmetric diaphragmatic excursion mayDecreased or asymmetric diaphragmatic excursion may
indicate paralysis or emphysema.indicate paralysis or emphysema.
Diaphragmatic ExcursionDiaphragmatic Excursion
Local Examination of the ChestLocal Examination of the Chest

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1. It is used to differentiate supra-diaphragmatic from infra-
diaphragmatic dullness.
2. While the patient seated find the upper level of dullness
3. Ask the patient to take deep inspiration and to hold it then
percuss again.
4. If the note becomes resonant  infra-diaphragmatic cause.
5. If there is no change of the note  supra-diaphragmatic
cause as pleural effusion.
Tidal percussion:Tidal percussion: Local Examination of the ChestLocal Examination of the Chest

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Auscultation:Auscultation:
 Intensity of breath soundsIntensity of breath sounds
 Type of breath soundsType of breath sounds
 Adventitious soundsAdventitious sounds
 Voice sounds (vocal resonance)Voice sounds (vocal resonance)
Local Examination of the ChestLocal Examination of the Chest

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Technique of Auscultation
• While the patient relaxed and breathes normally with mouthWhile the patient relaxed and breathes normally with mouth
open, auscultate the lungs, making sure to auscultate theopen, auscultate the lungs, making sure to auscultate the
apices and middle and lower lung fields posteriorly, laterallyapices and middle and lower lung fields posteriorly, laterally
and anteriorly.and anteriorly.
• Alternate and compare both sides at each site.Alternate and compare both sides at each site.
• Listen to at least one complete respiratory cycle at each site.Listen to at least one complete respiratory cycle at each site.
• First listen with quiet respiration. If breath sounds areFirst listen with quiet respiration. If breath sounds are
inaudible, then have him take deep breaths.inaudible, then have him take deep breaths.
• First describe the breath sounds and then the adventitiousFirst describe the breath sounds and then the adventitious
sounds.sounds.
Local Examination of the ChestLocal Examination of the Chest

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Technique of AuscultationTechnique of Auscultation
• Note the intensity of breath sounds and make a comparisonNote the intensity of breath sounds and make a comparison
with the opposite side.with the opposite side.
• Assess length of inspiration and expiration. Listen for a pauseAssess length of inspiration and expiration. Listen for a pause
between inspiration, expiration and the quality of pitch of thebetween inspiration, expiration and the quality of pitch of the
soundsound
• Also compare the intensity of breath sounds between upperAlso compare the intensity of breath sounds between upper
and lower chest in upright position. Compare the intensity ofand lower chest in upright position. Compare the intensity of
breath sounds from dependent to top lung in the decubitusbreath sounds from dependent to top lung in the decubitus
position.position.
• Note the presence or absence of adventitious sounds.Note the presence or absence of adventitious sounds.
Local Examination of the ChestLocal Examination of the Chest

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Bronchial breathing may be heard in:Bronchial breathing may be heard in:
 ConsolidationConsolidation
 Collapse with patent large airwaysCollapse with patent large airways
 Compressed lung by a large pl effusion or a tensionCompressed lung by a large pl effusion or a tension
pneumothoraxpneumothorax
 Pulmonary fibrosisPulmonary fibrosis
 CavitationCavitation
Local Examination of the ChestLocal Examination of the Chest
Auscultation:Auscultation: Bronchial BreathingBronchial Breathing

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Auscultation:Adventitious soundsAuscultation:Adventitious sounds
 Crepitations: typesCrepitations: types
 Rhonchi: sibilant and sonorousRhonchi: sibilant and sonorous
 Pleural rubPleural rub
Local Examination of the ChestLocal Examination of the Chest

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Auscultation: Voice soundsAuscultation: Voice sounds
Voice Transmission Tests: are only used in special
situations. All these tests become abnormal in
consolidation. They include:
Bronchophony
Whispered Pectoriloquy
Egophony
Local Examination of the ChestLocal Examination of the Chest

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Auscultation: Voice sounds- BronchophonyAuscultation: Voice sounds- Bronchophony
1. Ask the patient to say "ninety-nine“ or 44 in arabic several
times in a normal voice.
2. Auscultate several symmetrical areas over each lung.
3. The sounds you hear should be muffled and indistinct.
Louder, clearer sounds are called bronchophony.bronchophony.
Local Examination of the ChestLocal Examination of the Chest

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Voice sounds: Whispered PectoriloquyVoice sounds: Whispered Pectoriloquy
1. Ask the patient to whisper "ninety-nine“ or 44 in arabic
several times.
2. Auscultate several symmetrical areas over each lung.
3. You should hear only faint sounds or nothing at all. If you
hear the sounds clearly this is referred to as whisperedwhispered
pectoriloquy.pectoriloquy.
Local Examination of the ChestLocal Examination of the Chest

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Voice sounds: EgophonyVoice sounds: Egophony
1.1. Ask the patient to say "ee" continuously.Ask the patient to say "ee" continuously.
2.2. Auscultate several symmetrical areas over each lung.Auscultate several symmetrical areas over each lung.
3.3. You should hear a muffled "ee" sound. If you hear an "ay"You should hear a muffled "ee" sound. If you hear an "ay"
sound this is referred to assound this is referred to as "E -> A" or"E -> A" or egophony.egophony.
Local Examination of the ChestLocal Examination of the Chest

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