Internal Medicine (Physical Examination) Examination of the Chest MUDr. Yvona Pospíšilová, FN Brno a LF MU MUDr. Andrea Křivanová, Ph.D., FN Brno STATUS PRAESENS  Examination of the CHEST ⚫ Examination of the Chest  INSPECTION ⚫ Shape of the chest ⚫ Deformities ⚫ Changes of the skin and the musculature and the fat deposition etc. ⚫ Respiratory movements  PALPATION (tumors, painfulness of the chest etc.) ⚫ Examination of the Lungs  PERCUSSISON  AUSCULTATION ⚫ Breath sounds ⚫ Voice Sounds - Bronchofonie – Bronchophony (auscultation of speech)  PALPATION – fremitus pectoralis – vocal (tactile, pectoral) fremitus ⚫ Examination of the Heart ⚫ Examination of the Breasts Examination of the CHEST  Orientational landmarks – anterior surface 1. – anterior midline 2. - sternal lines 3. - parasternal lines 4. - midclavicular lines Examination of the CHEST  Orientational landmarks – posterior surface 8. – posterior midline 7. - paravertebral lines 6. – scapular lines Examination of the CHEST – přední axilární čára – střední axilární čára – zadní axilární čára  Orientational landmarks – axillary lines  anterior lines  midaxillary lines  posterior lines Examination of the CHEST- inspection Inspection ⚫ Shape of the CHest ⚫ Deformities ⚫ Changes of the skin and of the other parts of the chest ⚫ Respiratory movements Examination of the CHEST- inspection  Shape of the chest ⚫ Normal habitus - normostenic  pyknic – obese person  asthenic – slender person Examination of the CHEST- inspection  Shape of the chest ⚫ PATOLOGIES  Funnel breast – pectus excavatum  Pigeon breast – pectus carinatum (lack of vit. D, rachitis) Examination of the CHEST- inspection  Shape of the chest ⚫ PATOLOGIES  Barrel chest ( in emphysema, consequence of chronic obstructive pulmonary disease) Examination of the CHEST- inspection  Shape of the chest ⚫ PATOLOGIES  kyphoscoliosis – backward and lateral curvature of the spine Examination of the CHEST- inspection  Chest deformities ⚫ retractio hemitoracis – pull on one side of the chest due to fibrotic and adhesive changes ⚫ ⚫ enlargement of the chest – great amount of air or fluid in the pleural cavity Examination of the Lungs  Examination of the Lungs ⚫ Percussion ⚫ Auscultation ⚫ Breath sounds ⚫ Voice Sounds - Bronchofonie – Bronchophony (auscultation of speech) ⚫ Palpation (fremitus pectoralisvocal fremitus) PERCUSSION  Direct (finger on chest)  Indirect (finger on finger)  By comparison (to compare symmetrical areas on both sides of the chest)  Topographic (to establish the border of the change of the sound) Changes in percussion sounds over the Lungs  Sonorous, resonant, clear  over normal lungs  Dull to flat  over consolidated, dense lung tisssue, which loses its air content (infiltration, fluid, tumor, inflamation)  Hypersonorous, hyperresonant  over lungs more expanded and filled with air (emphysema, pneumothorax) Examination of the Lungs - Percussion  Topographic (to establish the border of something by change of the sound)  TOPOGRAFICKÝ POKLEP – určení dolní hranice plicDecreased border of the lung •On both sides – emphysema •On one side - pneumothorax Increased border of the lung • On both sides – (fluid in abdomen - ascites, obesitas) • On one side – effusion in the pleural cavity - fluidothorax Examination of the Lungs - Percussion  Topographic (to establish the border) ⚫ border of the diaphragma excursion in inspirium and expirium ⚫ norm. – 4-6 cm Decreased excursion of diaphragma On both sides – fluid in abdomen - ascites, obesitas, emphysema •On one side – fluidothorax, pneumothorax Examination of the Lungs - Auscultation Auscultation:  By comparison (to compare symmetrical areas on both sides of the chest) - breathing - voice sounds - bronchophony Examination of the Lungs - Auscultation  direct – by placing one´s ear directly on the chest wall  indirect – by stethoscope Breath sounds Main Vesicular breathing Weakened (decreased) vesicular breathing Increased vesicular breathing …with prolonged expiration Normal lungs fff-f (INSP:EXP = 3:1 Obesita, fluid or air in the cavity, emphysema, Inflamation of small bronchies Obstruction of small bronchies ff-ff (INSP:EXP = 1:1 Adventitious breath sounds - RALES adventitious Crackles (moist ralesú accentuated Inflamation of the lungs Sound „near“ Liguid material in bronchi and lungs unaccentuated Left heart failure Sound „far“ Wheezes, whistles (dry rales) Thick or viscous exudate + spasm of bronchi (asthma bronchiale) crepitations Crackling rales in the beginning and the end of pneumonia Pleural friction rub Friction of the inflammed pleural layers Examination of the Lungs - palpation  Fremitus pectoralis – vocal fremitus ⚫ Perception of vibration of the chest caused by talking of the patient – we compared the both sides Decreased – on one side • fluid or air in the pleural cavity • fluidothorax, pneumothorax Increased – on one side • inflammation or tumor – consolidation of the lung tissue PERCUSION Normal or hyperresonant AUSCULTATION Vesicular breathing with a prolonged expiration Auscultation – adventitious sounds - rales Presence of dry rales, wheezes, whistles, sometimes crackles (moist rales), changeing with cought BRONCHO- PHONY Normal or sligtly decreased FREMITUS PECTORALIS Normal or sligtly decreased Syndrome of bronchial obstruction, asthma bronchiale PERCUSION Dull or flat AUSCULTATION Vesicular breathing, sometimes redused Auscultation – adventitious sounds – rales Moist accentuated rales, sometimes initial and final crepitation, sometimes pleural friction rub BRONCHO- PHONY Increased FREMITUS pectoralis Increased Syndrome of lung consolidation, pneumonia PERCUSION dull or flat in the base of the lungs při AUSCULTATION Vesicular breathing, sometimes redused In the base Auscultation – adventitious sounds – rales Moist unaccentuated rales, Not changeing with cought BRONCHO- PHONY Normal FREMITUS PECTORALIS Normal Syndrome of left heart failure PERCUSSION Slightly dull and painfull AUSCULTATION Vesicular breathing Auscultation – adventitious sounds – rales Pleural friction rub BRONCHO- PHONY Normal FREMITUS PECTORALIS Normal Syndrome of pleuritis sicca PERCUSSION Dull or flat AUSCULTATION Decreased vesicular breathing or no breathing at all Auscultation – adventitious sounds – rales BRONCHO- PHONY Decreased FREMITUS PECTORALIS Decreased Syndrome of fluid in the pleural cavity(fluidothorax – hydrothorax, hemothorax, chylothorax ) PERCUSSION Hyperresonant AUSCULTATION None Auscultation – adventitious sounds – rales None BRONCHO- PHONY Decreased FREMITUS PECTORALIS Decreased Syndrome of air of pleural cavity (pneumothorax)