Thorax Examination

Pulmonology Departement
FKUB
General Examination
Respiratory rate ( tachypnoea: > 15/mnt )
Breathing patterns
Cheyne-Stokes : cyclically , RR, depth,
RR , ending in apnoea or hypopnoea
Kussmaul : hiperventilation with deep,
sighing respiration
Use of accessory muscles


Stridor
Harsh, rasping or croaking inspiratory noise
Foreign body or tumour partially occluding
the larynx, trachea or a main bronchus

Hoarseness
Cyanosis
Blood pressure
Hands : clubbing, discoloration of the
fingers & nails, tremor
Neck
Jugular venous pressure (JVP)
Neck nodes
Inspection
Shape & symmetry of the chest
AP > lateral barrel shape, hyperinflation,
asthma, emphysema.
Pigeon Chest (pectus carinatum) localised
prominence (outward bowing of the sternum &
costal cartilage) chronic childhood respiratory
illness, rickets.
Funnel chest (pectus excavatum) localised
depression of the lower end of sternum
aesthetic, restricted lung capacity.
Kyphoscoliosis, scarrs, deformity
Palpation
Chest Expansion thumbs should move
symmetricaly apart at least 5 cm.
Apex beat
displacement towards side of the lesion :
collapse of the lower lobe, localised
pulmonary fibrosis.
away from the side of the lession : pleural
effusion, tension pneumothorax


impalpable in hyperexpanded lung
(chronic airflow limitation).
Vocal fremitus : ninety-nine, front & back,
two comparable positions, ~ vocal
resonance.
Ribs : Pain ; rib fracture, tumor deposition,
bone disease.


Percussion
Symmetrical areas of the anterior, posterior,
axillary regions. In supraclavicular fossa apex
of the lung.
Resonant : normal, dull : consolidation, extremelly
dull/stony dull : fluid fill area (pleural effusion),
hyperresonant : pneumothorax
Liver dullness (upper level) : normally, the fifth rib
in right MCL. If resonant emphysema or
asthma.
Cardiac dullness : decreased in emphysema.
Auscultation
Normal (vesicular) breath sounds : louder &
longer on inspiration than on expiration, there
are no gap. Air turbulence in the large airways
filtered through the normal lung to the chestwall.
Bronchial breath sound :
without filtered, hollow-blowing quality, gap
between inspiration & expiration, higher intensity
& pitch exp sound, consolidation conducts the
sound.

Amphoric sound (very hollow) : air passes
over the top of a hollow jar. Large cavity.
Intensity of the breath sound :
reduce: emphysema, pleural effusion,
pneumothorax, large neoplasm, pulmonary
collaps.



Added (advetitious) sounds:
continuous wheezing, continuous
oscilation of opposing airway walls airway
narrowing. Louder on expiration, inspiratory
wheeze severe airway narrowing.
asthma (high pitched) or chronic (low pitched)
bronchial muscle spasm, mucosal oedema
& excessive secretions.
localised wheeze lung Ca.


Interrupted non- musical sounds
Crackles
low pitch rales, high pitch crepitation.
loss of stability of peripheral airways wich collapse
on expiration. High inspr pressure rapid air
entry into distal airways abrupt opening of
alveoli & small / medium sized bronchi containing
secretion.
early inspiratory: disease of small airways.
late / pan inspratory : alveoli, coarse crackles:
pools of retained secretions
Pleural Friction Rub :
thickened, roughened pleural surface rub
pleurisy, malignant of pleura, spontaneous
pneumothorax ( pleurodynia).
Vocal resonance :
Consolidated lung tend to transmit high
frequencies.
whispering pectoriloque : whispered speech
is distincly heard.
Comparison of the chest signs in common respiratory disorders


Disorder Mediastinal
displacement
Chest wall
movement
Percussion Breath
sounds
Added sounds
Consolidation none Reduced over
affected area
Dull Bronchial Crackles
Collapse Ipsilateral shift Decreased over
affected area
Dull Absent or
reduced
Absent
Pleural Effusion Heart displaced to
opposite side
Reduced over
affected area
Stony dull Absent over
fluid; may be
bronchial at
upper border
Absent,
pleural rub
maybe found
above
effusion
Pneumothorax Tracheal
deviation to
opposite side if
under tension
Decreased over
affected area
Resonant Absent or
greatly
reduced
Absent
Bronchial
asthma
none Decreased
symmetrically
Normal or
decreased
Normal or
reduced
Wheeze
Interstitial
pulmonary
fibrosis
none Decreased
symmetrically
(minimal)
Normal Normal Fine
inspiratory
crackles over
affected lobes
Thorax :
Inspection: static : D > S, dinamic : D < S
scarr ?
Palpation : Stem/vocal fremitus : D < S
Pain ?, Crepitation ?

Percussion : D S
D S
D S

Auscultation : - V Rh: - - Wh: - -
- V - - - -
- V - - - -