5/16/2008

Examination of the posterior

chest
By
dr.H.R.Handojo Padmosoeparto, SpP, Msc

Inspection
Shape of the chest
The way in which it moves
Deformities / asymmetry
Inspiration:
Normal retraction of the interspaces
Lower interspaces : most apparent
Retraction : often present
Eg :
Severe astma
COPD
Upper airway obstruction

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Impaired respiratory movement :

One / both sides / unilateral lag
Suggests : disease of the underlying
lung / pleura

Palpation
Focus:
Tenderness
Abnormalities in the overlying skin
Respiratory expansion
Fremitus
Tender areas:
Palpate carefully : pain / lesions / bruises
Eg : fractured rib

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..palpation
Abnormalities :
Masses
Sinus tracts ( infection of underlying pleura and lung )
Chest expansion :
Thumbs - level ribs X
Finger - loosely grasping
Unilateral decrease in chest expantion:
- chronic fibrotic disease of lung / pleura
- pleural effusion
- lobar pneumonia
- bronchial obstruction

..palpation
Fremitus :
patient speaks palpable vibrations
bronchopulmonary tree chest wall
ball words : 99 / 1-1-1
ulnar surface words : 99 / 1-1-1
both hands : detection of differences to
compare differences

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location for feeling fremitus :

interscapular area > lower

lung fields
right side > left
below the diafragma -

..palpation
Vibration : larynx chest wall is impeded:
Obstructed broncus
COPD
Pleural effusion
Fibrosis ( pleural thickening )
Pneumothorax
Infiltrating tumor
Very thick chest wall

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Percussion
Underlying tissue : air / fluid filled / solid ( 5-7
cm deep-seated )
Technique :
Middle finger of left hand = pleximeter
Distal interphangeal joint firmly on the surface
to be percussed
Thumb, fingers 2nd, 4th, 5th. free, not
touching the chest
Right forearm quite close to the surface
trying to transmit vibrations throug the bones of
this joint to the underlying chest wall

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..percussion
Characteristics:
Flatness : (thigh) : large pleural effusion
Dullness: (liver) : lobar pneumonia
Resonance normal lung : simple chronic bronchitis
Hyperresonance : none normally : emphysema,
pneumothorax
Tympany :
gastric airbubble : large pneumothorax
Puffed-out check

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Auscultation
= assessing air flow through the
tracheobronchial tree
Listening :
to the sounds generated by breathing
for any adventitions ( added ) sounds
to the sounds of the patient`s spoken /
whispered voice ( if abnormalities are
suspected)

..auscultation
Normal breath sounds :
Vesicular : inspiration expiration without pause
fade away
Bronchovesicular : inspiration expiration :
equal in length
seperated by a silent interval
Bronchial : inspiration expiration :
a short silence
expiratory sounds last longer than inspiration

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..auscultation
Normal breath sounds :
Tracheal breath sounds, heart by listening
over the trachea in the neck:
Vesicular-over most of both lungs
Bronchovesicular : in the 1st and 2nd
interspaces anteriorly
Bronchial : over the manubrium

..auscultation
Added breath sounds :
Crackles / Rales :
Pneumonia
Fibrosis
Wheezes / ronchi :
Wheezes ( narrowed airways ) : astma,
COPD, bronchitis
Ronchi : = secretions in large airways

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..auscultation
Listening the breath sounds :
The patient breathes deeply through an
open mouth
Listen to at least one full breath in each
location
Allow the patient to rest as needed (
discomfort due to hyperventilation )

Examination on the
anterior chest

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Inspection
Position : supine / sitting
Inspection : observe
The shape
The movement of the chest wall
Note :
Deformities / asymmetry
Inspiration : abnormal retraction of the lower
interspaces
Local impairment in respiratory movement

Palpation
Identification of tenderness : chest pain has a
musculoskeletal origin
Assessment of
Observed abnormalities
Chest expansion:
how far your thumbs diverge as the thorax
expands
feel for the extend & symetry of respiratory
movement
Tactile fremitus over the precordium : or
(decreased or absent)

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Chest pain
Pulmonary :
Tracheobronchitis :
Process : inflamation of trachea & large
bronchi
Location : upper sternal or on either side
of sternum
Quality : burning, mild to moderate
Factor that aggravate : coughing
Factor that relieve : lying on the
involved side
Associated symptoms : cough

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chest pain
Pulmonary :
Pleural pain:
Process : inflamation of the parietal pleura
(pleurisy, pneumonia, pulmonary infarction or
Ca)
Location : chest wall overlying the process
Quality : sharp, knifelike, often severe
Factor that aggravate : breathing, coughing,
movement of the trunk

Percussion
Chest : anterior & lateral ( comparing both sides )
rd
th interspaces )
The heart : left of the sternum ( 3 - 5
= area of dullness percuss the left lung lateral to it
COPD :
hyperresonance may totally replace cardiac
dullness
often displaces the upper border of the liver
border lowers the level of diafragmatic
dullness
Pleural effusion ; replaces resonance of the air
containing lung
Right middle lobe pneumonia (woman : behind
the right breastdisplace the breast)

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Auscultation
The patient breathes with mouth open.
Compare symetric areas of the lungs
Vesicular breathing : the upper anterior
lung fields are usually louder
Bronchovesicular breath sounds : heard
over the large airways, especially on the
right
Adventitions sounds.

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.auscultation

Adventitions sounds
Crackles :
late inspiratory crackles :
intertitial lung disease (fibrosis)
early congestive heart failure
Midinspiratory & expiratory cracles :
bronchiectasis ( not specific )
Early inspiratory cracles (relatively
few in number)
chronic bronchitis
astma

.auscultation

Adventitions sounds:
Wheezes (air flow rapidly through
bronchi) :
astma ( may be heard only in
expiration or in both phases of
respiratory cycle
Chronic bronchitis
COPD
cardiac asthma
a persistent localized wheeze = partial
obstruction of a bronchus ( Ca / foreign
body, inspiratory / expiratory or both )

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.auscultation

Adventitions sounds:
Ronchi : secretions in the airways
chronic bronchitis ( wheezes & ronchi
often clear with coughing )
Stridor : a wheeze that is entirely or
predominantly inspiratory. Louder in the
neck than over the chest walldemands
immediate attention:
a partial obstruction of the
larynx/trachea

.auscultation

Adventitions sounds:
Pleural rub : inflamed & roughened
pleural surfaces grate against each other
Mediastinal crunch : a series of
precordial crackles. Synchronous with
the heart beat, not with respiration (
mediastinal emphysema /
pneumomediastinum )

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Condition :
NORMAL :
Percussion :
resonant
Breath sounds :
vesicular
over the large bronchi = bronchovesicular,
trachea
= bronchial
Adventitions sounds :
none
at the bases of the lungs : transient
inspiratory crackles
Tactile fremitus :
normal

Chronic bronchitis
P: resonant
B: vesicular ( normal )
A: - none
-crackles
-wheezes / ronchi
T: normal

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Consolidation
Pneumonia
Pulmonary edema
Pulmonary
hemorrhage

P: dull over the

airless area
B: bronchial over the
involed area
A: crackles over the
involed area
T: increased over the
involved area
bronchophony
egophony
whispered
pestoloquy

Atelectasis (lobar obstruction)

P: dull over the airless area
B: absent (usually) when bronchial plug
persists
A: none
T: usually absent

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Pleural effusion
P: dull over the fluid
B: -decreased to absent
-near top of large effusion: bronchial
A: -none
-possible pleural rub
T: -decreased to absent
-increased toward the top of a large
effusion

Pneumothorax
P: hyperresonant / tympanitic over the
pleural air
B: decreased to absent over the pleural
air
A: none, except a possible pleural rub
T: decreased to absent over the pleural
air

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COPD
P: hyperresonant diffusely
B: decreased to absent
A: - none
- crackles
- wheezes & ronchi (+chronic
bronchitis)
T: decreased

ASTHMA
P: resonant hyperresonant
B: wheezes
A: wheezes + crackles
T: decreased

ref: BATES`. The Thorax and Lung. Guite to Physical

Examination and history taking: 253-64, 2007

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