Chest Examination

By :
Dr. Eman M. Abd El Halim
Respiratory assessment
• Respiratory assessment is performed as
➢part of a physical examination or
➢when patient presents with a respiratory problem (dyspnea
(shortness of breath ), cough , chest pain ) or
➢ patient with a history that suggests a pathology of the lungs.
➢BEFORE processing to assessment put the followings in your consideration :
• Position: patient should sit upright and his/ her hands remain at their sides.
When examining the patients back, the patient is usually asked to move their
arms forward (hug himself/herself) so to make the scapule away from the
upper lung fields
• Lightening
• Draping : chest fully exposed but exposure time should be minimized
• Quiet room
• The assessment of chest patient includes 2 major category :
• I- Subjective assessment : patient interview with open ended questions
about signs and symptoms related to chest cases ( dyspnea, cough , chest
pain, wheezing, sputum and hemoptysis)
• II- Objective assessment: GENERAL AND LOCAL ( inspection, palpation,
percussion & auscultation )
• I) Subjective assessment
• A- (History) : (PERSONAL-PAST-PRESENT-FAMILY-SOCIAL)
• 1) Personal history:
• ☞ Name: to enable the therapist to be familiar with the patient.
• ☞ Age: some diseases are related to age as following :
• Infantile: cystic fibrosis, bronchial asthma.
• Young age: chronic bronchitis, TB (due to malnutrition).
• Old age: senile emphysema, corpalmonale.
☞ Sex:
☞ occupation: occupational lung diseases as asbestosis, silicosis
☞ Habits: smoking, alcoholism.
☞ Address & FLOOR: some diseases are related to place as black lung diseases.
Humidity is more in first floor
2) Past medical history:
-Diseases: Diabetes mellitus, hypertension, rib fracture,….etc
- Surgeries: lung resection, open heart surgeries, thoracic surgeries,…etc
-Medications: know the patient's medications as certain medications,
particularly diuretics antihypertensive cause fluid and haemodynamic changes.
These decrease patient's tolerance to positional changes and postural drainage
3) Present history:
-And this include the taking of the chief complain of patient in his own words.
-for the chief complain we look for:
• Onset: sudden, gradual onset.
• Course: progressive, regressive, stationary OR remission and relapse.
• Duration: the time the complaint appeared for the first time.
• 4) Family history:
Same disease , other diseases HTN/DM, any family genetic disease
• Assessment
1) General examination:
1. Decubitus: (means patient position)
-sitting with leaning forward and supporting upper limbs as in asthmatic patient.
-long sitting lying as in orthopnea.
-Side lying as in patient with unilateral diseases. (LIE ON AFFECTED SIDE: PLEURISY
OR PNEUMONIA) (LIE ON HEALTHY SIDE: # RIB, HERPS ZOSTER TO DECREASE PAIN )
2. Body built:
▪ Obese patient … in COPD patients’ bronchitic type (or called blue bloater) and this is
non-compensated COPD. ALSO IN DM TYPE 2
▪ Thin patient… Cachectic is a sign of chronic disease as in COPD patients’
emphysematic type (or called pink puffer) and this is called compensated COPD….or in
thyrotoxicosis. ALSO THIN OR CATHESTICS IN MALIGNANCY
• Diaphoretic: sign of fear, pain or anxiety
• GAIT
• ODOUR
• EMOTIONAL STATE
3. face:
• Pale: in anemic patient.
• Moon face: Cushing syndrome.
• Mangolism: this is congenital diseases.
4. Eyes:
A) Sclera:
- Red fissure indicates: chronic cough or chronic hypertension.
- PALE: ANEMIA
- Yellow color indicates: jaundice.
B) Conjunctiva:
- Blue discoloration of mucous membranes indicates cyanosis.
- SUB- ConjunctivaL haemorrhage in whooping cough
C) Eye lid:
- Buffiny indicates chronic cough or liver cirrhosis.
- Black color under the eye indicate anemia.
5. MOUTH:
-Lips :*COLOUR: cyanosed (BLUE) : central cyanosis. If red : fever
*PUSED LIP BREATHING: COPD
6. Neck :
- Shape and size : if short and thick ( obesity or lung emphysema)
- Neck veins (jugular vein) :
-Normally just visible.
-Abnormally congested and pulsating. jugular vein engorgement ( congestive heart failure/
right side heart failure )
- Acessory muscles : look for the muscles of neck itself if there is a spasm (CORD LIKE) so he
use the accessory muscles in breathing and may complain from dyspnea.
- Arterial pulsation: normally non-pulsating but if pulsating may be due to fever or aortic
regurgitation
-Thyroid gland: normal or abnormally enlarged
-Scars
- Lymphnodes normally not visible and not palpable
6. level of consciousness:
- Conscious – Semi conscious - Just alert – Comatose

7. vital signs:
- Temperature (normal 36.5 – 37.5 )
- Blood pressure (normal 100 – 140 systole / 60 -90 diastole). Average Blood
Pressure Equals 120/80.
- Heart rate (normal 60 – 90 beat/min with average 72 beat/min ) : rate, rhythm ,
volume, force, equality
- Respiratory rate (normal 12 – 20 breath/m). 1-rate 2-rhythm 3-depth 4-pattern
5-character of breathing
- Oxygen Saturation by Pulse Oximetry. (95:100%)
- Pain Index by VAS (0-10 scale)
( to compare and know improvement)
8. Extremities: we look for…….
A- Edema

- It my be (unilateral / bilateral…pitting / non-pitting). (How?) .

- a test is used to know if there is edema or not and to identify the type of edema pitting or non-pitting
- By applying a pressure by your thumb on a bony prominence of the patient body for a few seconds or
till one minute then release and see the time the skin fold return to its previous state before applying
the pressure.
- If prolonged time taken to return to previous state before pressure → (pitting edema)….edema of
fluids.
- If short time taken to return to previous state before pressure → (non-pitting)…edema of protein.
- peripheral edema : ventricular failure or lymphatic dysfunction
 Grade Depth Rebound time
0 NO pitting edema
2 millimeter (mm) depression, or
1 immediate
barely visible
3-4 mm depression, or a slight
2 15 seconds or less
indentation
3 5-6 mm depression 10-30 seconds
8 mm depression, or a very deep
4 more than 20 seconds
indentation
B- Cyanosis (peripheral).

N.B:

Central cyanosis
- C- Temperature (hotness / coldness).
- D- clubbing fingers

- It is defined as the obliteration of the angle of nails bed. It may be due to toxic or
hypoxic cause. and its grades are:
1. Just obliteration of the angle of nails bed (reversible).
2. Parrot peak appearance (reversible).
3. Drums stick appearance (reversible).

4. Pulmonary osteoarthropathy and this grade there is

an enlargement of distal ends of long bones
(irreversible).
what is the test name for examining clubbing finger?
-clubbing finger test.
-Diamond test.
–Window test.
–Schamroth`s test.

9- Signs and symptoms:

1. DYSPNEA: is awareness (difficulty ) of respiration concerning rate, rhythm or depth
2. COUGH (DRY/PRODUCTIVE): is a protective mechanism aiming at expulsion of inhaled particles from respiratory
tract
3. EXPECTORATION (COLOR, CONSISTENCY, : passage of sputum out of respiratory tract
4. Hemoptysis: Expectoration of blood originating from below the vocal cords
• 2) Objective assessment: ( local examination: )
• -Inspection:
• -palpation:
• -Percussion:
• -Auscultation:
I-Inspection: involves things you can see and don’t need to touch the patient
In inspection we look for the following by using eyes only:
1) Skin. 2) Shape of the chest. 3) Movement of respiration.
1) Skin:
- Nodules
- Scar, incision, ulcer, hematoma, something elevated.
- Color of skin.
- Enlargment of Axillary lymph nodes.
- Subcutaneous emphysema.
- Vascular spiders
- Prominent blood vessels
- Discharge sinuses
- Lesion of the breast
2) Shape of the chest:
- Normal the chest is symmetrical bilaterally
- chest have transverse, anteroposterior & vertical diameters.
- Transverse diameter = Width of the ribs measured from anterior or posterior.
- Anteroposterior = distance from sternum anteriorly towards the vertebra
posteriorly or = diaphragm + intercostal spaces.
- Vertical diameter=from diaphragm from down up to the highest point on the
chest.
• All these diameters increase with inspiration.
• Normally: Anteroposterior : TRANSVERSE diameter 1:2
• Normally ribs run diagonally downwards and laterally
• Normally costal angle is 90 degree
Abnormalities of chest shape:

N.B:
KYPHOSIS: curvature of the spine – anteror-posterior
SCOLIOSIS: curvature of the spine – lateral
Abnormalities of chest shape:
1. General abnormal shape of chest : (General means that abnormality affects both sides of the chest)
A) Barrel chest:
- Means that AP diameter =Transverse diameter
- Ribs & interspaces are wider
- Ribs are horizontal.
- Subcostal angle increased.
- raised shoulder.
- Example: emphysema (hyper inflated lung). COPD

B) Flat chest or Alar chest:

- AP decreases.

- Scapula is winged.

- Ribs are oblique & interspaces are narrowed.

- Example: bilateral pulmonary fibrosis , cachexia, advanced bilateral tuberculosis, and bilateral collapse
C) Funnel chest or pectus excavatum:
- The lower part of sternum is indented inwards.
- AP diameter affected and decreased as well as lung volume.
- May be congenital.
- May be acquired or occupational as in shoe maker.
D) pigeon chest or pectus carniatum:
- AP> Transverse.
- There is a protrusion of the sternum.
- As in rickets.

☞ All previous chest deformities lead to hypoventilation.

2- Local abnormal Shape of chest: (local means that it affect one side of the chest)
A) Retraction: due to:
- Fibrosis: (pleural thickening after pleural effusion, lung abscess, T.B)
- Collapse: intrabronchial obstruction.
- Causes in chest wall: Kyphoscoliosis. Thoracoplasty (resection of ribs on one
side).
B) Bulging:
- Causes in chest wall: Subcutaneous emphysema. Edema & inflammation.
Tumors.
- Causes in pleura : Tense pleural effusion. Empyema. Tension pneumothorax.
Pleural tumors.
- Cause in lung : Apical bronchial carcinoma & Obstructive emphysema.
• 3) Movement of respiration:
• Rate. • Rhythm. • Depth. •Mode • Type (character). • Accessory muscles. • Signs of
respiratory distress •Latin’s sign.
A)Rate:
- Normal adult: 12 -20 breath/ min.
- In infants: 30 -60 breath / min.
- In old: there is increased RR.
- Tachypnea : (increased RR) may be caused by exertion, fever, hypoxia or pain
- Bradypnea : (decreased RR) may be caused by hypothermia or effect of medication
- If there is increased Respiratory rate (RR) so it may be associated with shallow rapid breath. So we
determine the severity of disease through the depth of breathing.
B) Rhythm:
- Should be regular with expiration longer than inspiration. The ratio between inspirations to expiration
(I:E) is 1:2.
- Abnormality if irregular breath.
- If expiration time is longer : COPD
C) Depth: - may be shallow or deep but normally it is in between.

D) mode : nose or mouth breather

E) Type of breathing:

1) Abdominothoracic breathing :

• Normal in males because of the well-developed diaphragm

• If female use abdominothoracic breathing so it is abnormal and there is a problem and Chest disease
as rib fracture, neuralgia, myositis, pleural disease, intercostal muscles paralysis , pleural pain and
COPD .

2)Thoracoabdominal breathing:

- Normal in females because of presence of uterus in the abdominal cavity.

- if male use thoracoabdominal so it is abnormal and there is a problem as abdominal pain, phrenic
lesion or paralysis (diaphragmatic paralysis), ascites, and distension.
F) Accessory muscles:
- Normally 75% of working lie on diaphragm and accessory muscles doesn`t work.
- If problem + effort = Accessory muscle will work. -→ means patient increase WOB
- Accessory muscles of inspiration are Upper and middle fibers of trapezius,
Sternocleidomastoid, Scalene muscle, Pectorals major, Serratus anterior.
- N.B: I determine tenderness of accessory muscles by palpation while by inspection I see if
there is elevated shoulder or forward head deformity or not.
- Expiration: abdominal muscles which work only during forced expiration
G) Signs of respiratory distress:
• Cynosis
• Pursed lip breathing (COPD )
• Accessory muscle use (scalenes muscle )
• Diaphragmatic paradox : Diaphragm moves opposite of the normal direction on inspiration; (
flail segment in trauma )
• Intercostal indrawing: Occurs where the skin between t h e rib s is drawn
inwards during inspiration. It may be seen in patients with sever inspiratory
airflow resistance. Large negative pressures during inspiration suck the soft
tissues i n w a r d s . Intercostal indrawing c a n b e a n important sign of
respiratory distress in children.
■ Supraclavicular indrawing: Occurs when the skin above clavical is drawing
inwards during inspiration. It is also seen in patients with severe airflow
resistance who generate high negative pressures during inspiration; for example,
acute asthma.
■ Flail chest: Occurs with multiple rib fractures when two or more breaks in
each rib result in loss of integrity of the thoracic cage. During inspiration the
loose segment is drawn inwards as the rest of the chest wall moves out. In
expiration the reverse occurs.
■ Paradoxical breathing: Is where the entire chest wall moves inwards on
inspiration and outwards on expiration. Chest wall paradox occurs in bilateral
diaphragm weakness or paralysis as observed in the ptient with high cervical
spine injury . It is most apparent when the patient is supine.
• II) Palpation: touching patient’s chest wall to evaluate quality
of breathing
• Palpate sternum and ribs to Identify areas of tenderness or deformity.
• Palpate skin an subcutaneous tissue: note and subcutaneous emphysema also
crackling or paper like sound : pulmonary air leak
• Tracheal shifting.
• Cricosternal distance.
• Chest expansion.
• Tactile vocal fremitus (TVF).
• Localized TENDERNESS
1) POSITION OF MEDIASTIMNUM

trachea indicator of upper mediastinum position while heart

position is indicator of lower mediastinum position(WHEN ITS SIZE
IS NORMAL ONLY) .
A- Tracheal shift:
- Normally trachea centrally positioned as the distance between
trachea & SCM equal in both sides.
☞ Procedure: - Patient sitting erect with a semi flexed head.
Therapist: use both index fingers then introduce it in the sternal notch between trachea & SCM in one
side and compare it with the other side . Or use index and ring fingers put it on medial end of the
clavicles in either side and then with middle finger assess the space between the trachea and SCM and
compare it with the other side
-Don’t apply both index in the two sides at same time & if you do so then apply pressure in one side only.
-• If one index entered easy and the other difficult so shifting is towards the difficult side.
Interpretation of tracheal shifting ( Cause of shifting to ONE side) :

1. Compression coming from one side (push trachea) as in space occupying lesion (pneumothorax, pleural effusion and large mass
lesions) as they will compress the lung toward the left side. E.g: shift to lt due to RT pneumothorax

2. Attraction from the one side (pull trachea) as in (atelectasis, collapse, fibrosis, surgical resection, pleural fibrosis).

N.B: - Tracheal shift occurs only when there is a unilateral disease.

- There is no tracheal shift in Emphysema as it is a bilateral disease.

- B- Lower mediastinum position : only if heart size is not enlarged. Locate the apex of heart by inspection and palpation

2) Cricosternal distance: Crico= coracoid cartilage upper Adam’s apple. Sternal= sternal notch. It is done to determine if the patient is
hyperventilating.

- Procedure: Locate cricoid cartilage ( below thyroid cartilage or Adam’s apple) Insert fingertips between the cricoid cartilage and the
suprasternal notch, measuring the distance following full inspiration.

- Normally: distance is about 3 fingers between coracoid cartilage and sternal notch during deep breath.

- If distance decreased less than 3 of the patient’s fingers so there will be hyperventilation (deep breath ) as in COPD ,Emphysema.

- Usually evident as a visible descent of the trachea during inspiration ( tracheal tug)
3) Localized tenderness :

- Over ribs : in case of rib fracture and tumors

- Over sternum: in case of leukemia

- Over intercostal spaces : in case of myalgia, neuralgia , pleurisy and empyema

- Palpable adeventious sounds :

• Palpable Ronchi in bronchitis

• Palpable rub in pleurisy

4) Chest expansion:

- We judge from chest expansion on the quality , symmetry & depth of movement of chest wall

- This is represented in if the movement is free or not. And done to identify the side of abnormality

- Normally there is equal chest wall movement on both sides. Normal expansion 3:5 cm and deep expansion 7:9 cm

- Abnormally decreased chest movement may be unilateral or bilateral and if bilateral it will be difficult to be detected.

- Unilateral in case of: pneumothorax, pleural effusion, pneumonia or collapsed lung.

- Bilateral as in: COPD, Asthma.

☞ Procedure: - By fanning fingers of your hand directed laterally as far as possible (away from midline) & thumb directed
medially towards midline (Bare skin). And it can be done using tape measure

- PLACE the hands on either side of the patient’s anterior chest;

- Position the thumbs together just either side of the midline, ensuring to keep them off the chest (in the air), so they can move
freely with respiration;

- Ask patient t breath in and out as normal. During inspiration the thumbs should move apart; during expiration the thumbs
should return together; (With inspiration hands shifted away while closed in expiration).
- The following are types of chest expansion:
1.Apical chest expansion: (1-2 cm) – patient long sitting,
therapist in front of him, Palm on anterior chest wall just under
clavicle & rest of fingers on shoulder(above clavicle) with thumb
directed towards sternal notch ask patient to breath.
2. Upper chest expansion (sternum): (2-3 cm) - Fingers under
axilla. - Thumb towards Loise angle or called mandibular sternal
angle. N.B: Loise angle lies opposite to second rib between
manibulum & body of sternum.
3. Middle chest expansion (rib 5): (3-5 cm) - Fingers directed
outwards laterally. - Palm on the level of the nipple. - Thumb
directed medially.
4. Lower chest expansion ( rib 8) : (3-5 cm) - Hands on lateral
lower part of chest wall. - Thumb directed toward xyphoid
process.
5. posterior Basal expansion: (5-7 cm)
- Patient sitting leaning forward. Therapist behind patient
- Hands web space under the inferior angle of scapula.
- Fingers on lateral lower ribs.
- Thumb directed medially toward 10th vertebra (T10).
- 5) Tactile vocal fremitus (TVF) : vibration that felt
on chest wall when patient speaks
- Sound transmitted to trachea and chest wall when
saying 99 or ‫أربعة واربعين‬
- Normally sound transmitted well (increased) when
there is solid and poorly in air .
- So TVF increase in the following cases: Consolidation
, Collapse , Pneumonia. Pulmonary fibrosis.
- And decrease in the following cases :Emphysema.
Pneumothorax. Or fluids Pleural effusion. Pleural
fibrosis.
☞ Procedure:
- By using the palm of BOTH hands or by the ulnar
sides of hands on either side ( symmetrical position )
- Ask patient to repeat 99 or 44
- and feel the sound in different places over the chest
wall (ant, post between scapulae and under it )so can
feel changes in sound conduction .
III) Percussion: tapping on patient’s chest wall to create a vibration/ sound
☞ Procedure: - non-dominant hand with fingers fanning & middle finger
hyperextended with DIP joint on intercostal space and with end of your middle
finger (not pad) of dominant hand do percussion on middle finger of left one.
- Movement comes from the wrist.
• percussion done side to side and from top to bottom and omit areas covered
by scapula and you must compare both sides for symmetry. Note the location
and quality of percussion sounds you hear
• Interpretation of percussion sounds on lung fields:
• Normally on lung fields its resonant
• If flat or dull:
• Normally: over heart , liver & spleen
• Abnormally Decreased resonance : pleural effusion, mass, consolidation, lobar pneumonia
• If hyperresonant:
• Normally: air filled stomach
• Abnormally Increased resonance: lung distension e.g: asthma, emphyema, pneumothorax or
bullous disease
Diaphragmatic excursion (tidal percussion): it is the movement (contraction) of thoracic diaphragm during breathing
- Objective: can be done by ultrasonography taken from anterior. (not percussion )
- Subjective (percussion ):
1. Start percussion from inferior angle of scapula and hear sound as you move down with percussion
2. Ask patient to expire air and hold…with percussion normally it will be resonance till T9.
3. Then Take a mark when dullness appears.
4. Then ask him to inspire and hold….with percussion normally it will be resonance till T10 and T12 with full inspiration.
5. Then take mark when dullness appears.
6. Measure the distance between the two marks normally it will be nearly 3:5cm and up to 7:8 cm in athlete.
N.B: diaphragm is higher on RT side due to presence of liver
-What makes this distance change in position?
If less than 3 cm is abnormal may be due to pneumonia or pneumothorax
1- If diaphragm moves between T11 and T12 only then it is emphysema.
2- If diaphragm moves between T9 and T10 even there is full inspiration so there is ascites.
3- If diaphragm moves between T8 and T9 occurs in hepatomegaly or pregnancy.
➢ Special areas for percussion:
1. Bare area of heart: - The area of heart that not covered by lung
tissue from the 4th to 6th intercostal spaces between midline &
midclavicular line.
- Normally….dullness
- Abnormally…..resonance if there is air so lung is hyper inflated covering
more area of heart as is pneumothorax or emphysema
2. Upper border of liver: - Right 5th intercostal space midclavicular line.
- Normally…………dullness
- Abnormally…………….resonance if lung shifted downward as in
emphysema.
- If 4th intercostal space dullness then there may be hepatomegaly, or
pleural effusion or basal lung disease .
3. Splenic area:
- Left 9th, 10th, 11th intercostal spaces from mid axillary to scapular line.
- Normal…….. Dullness.
- Abnormally…….resonance as in hyperinflation of lung.
4. Apex of lung or Kronig`s isthmus:
- It lies between three lines or borders:
1. 1st line: From sternoclavicular junction anteriorly to C7 posteriorly.
2. 2nd line: The medial third and lateral two third of clavicle anteriorly.
3. 3rd line: Spine of scapula.
- Normally hyper resonance during deep breath.
- Causes of dullness: Apical pneumonia, apical fibrosis, Apical TB.
- PT behind patient and percuss from medial to lateral (dullness due to muscles then hyper resonance).
 5. Traube`s area:
- Area above fundus of stomach.
- All this area is in the left side & its borders are:
• Upper border: 6th rib to 9th rib.
6
•Left border: 9th rib to 11th rib.
9
8
• Right border: 6th rib to 8th rib.
• Lower border: 8th rib to 11th rib.
11
- N.B: appear in x-ray black because of gases.
- Normally tempany (tympanic resonance).
- causes of dullness:
• Physiological: full stomach.
• Pathological: Splenomegaly, Hepatomegaly, Gastric tumor or pleural effusion
5) Auscultation:
• It is the technique used to listen for sounds produced by the body
• Stethoscope is used to determine the equality, character and
intensity of breath sounds and adventitious sound
• auscultation is listening to breathing sounds using a Stethoscope.
• There are normal breath sounds, abnormal AND/OR adventitious
breath sounds
1-Normal breath sounds: more prominent at the top of the lungs
and centrally, with the volume decrease towards the base and
periphery.
A) Tracheal sound: - over trachea
B) bronchial: over bronchi
C) Bronchovesicular sound
D) Vesicular sound:
N.B:Bronchial= tracheal over upper and larger airways
➢Procedure : use diaphragm of the Stethoscope
• Done in quite environment
• Ask patient to breath in and out from mouth with turning face to one side away from you
• Done side to side and from top to bottom and you must compare both sides for symmetry
• Areas :
➢Anterior chest:
• Suprascapular fossa
• Axilla
• Anterior chest intercostal spaces
➢Posterior chest :
• Suprascapular
• Paraspinal between scapulae
• N.B: we can hear :
• A- normal breath sounds
• B- abnormal breath sounds which may be :
• 1- decreased normal /abscent breath sounds
• 2- adventitious or added sounds