OSCE ppt for Chest examination

1. EXAMINATION OF THE
CHEST
BY:
ALLEN ROJER
AB PSYCHOLOGY, STUDY FOR MD

2. LOCAL EXAMINATION OF THE
CHEST
Inspection
Palpation
Percussion
Auscultation

3. INSPECTION
1-Shape of the chest.1-Shape of the chest.
2-Spine Deformity2-Spine Deformity
3-Symmetry and Mobility3-Symmetry and Mobility
4-Respiratory movements4-Respiratory movements
5-Skin5-Skin
6-Pulsations6-Pulsations

4. INSPECTION2
1- Shape of the chest
Normal Shape
Barrel shaped chest
Pigeon chest
Rachitic chest
Funnel-shaped chest (Pectus
Excavatum)

5. 2002/2003 Clinical Examination of the Chest 5
SHAPE: INCREASED AP DIAMETER

6. 2- SPINE DEFORMITY:2- SPINE DEFORMITY: KYPHOSIS

7. 7
SCOLIOSIS

8. 3- SYMMETRY AND MOBILITY3- SYMMETRY AND MOBILITY
Both sides of normal chest are
symmetrical in shape and mobility.
The diseased side or part is less
mobile than the healthy one.

9. SYMMETRY AND MOBILITY
BulgiongBulgiong RetractionRetraction
•Pleural effusion
•Pneumothorax
•Hydropneumothorax
•Empyema
•Precordial bulge
•Chest wall causes
•Pulmonary collapse
•Pulm. Fibrosis
•Pleural fibrosis

10. 4- RESPIRATORY MOVEMENTS
Respiratory rateRespiratory rate
Mode of BreathingMode of Breathing
Respiratory DepthRespiratory Depth
Maximum Chest ExpansionMaximum Chest Expansion ( use a tape measure)
Abnormal Respiratory MovementsAbnormal Respiratory Movements
- Abnormal Inspiratory Movements- Abnormal Inspiratory Movements
- Abnormal Expiratory Movements- Abnormal Expiratory Movements

11. 5- SKIN5- SKIN
Skin eruption e.g HZ
Nodules (inflammatory,metastatic,lipoma, neurofibroma…)
Subcutaneous emphysema
Purpuric spots,Vascular spiders, Bruises
Prominent bl vessels (arterial in coarctation of aorta and venous
in SVC obstruction)
Scars (previous operation,trauma, intercostal tube…)
Discharging sinuses
Lesions of the breasts and enlargement of axillary LNs

12. 12
6- PULSATIONS6- PULSATIONS
ApicalApical
ParasternalParasternal
EpigastricEpigastric

13. 13
PALPATIONPALPATION
To confirm Respiratory Movements
Pulsations (see before)
Palpable Adventitious Sounds
Tactile Vocal Fremitus (TVF)
Position of the Trachea

14. 14
PALPATION OF RESPIRATORYPALPATION OF RESPIRATORY
MOVEMENTSMOVEMENTS
1. Respiratory movements in the
infraclavicular regions
2. Respiratory movements at the costal
margins
3. Respiratory movements of the lower ribs
posteriorly

15. 15
PALPATION: CHEST EXCURSION

16. 16
SIGNIFACANCE OF REDUCED RESPIRATORY
MOVEMENTS
Unilateral reduction of chest wall movements
•Pleural effusion
•Empyema
•Pneumothorax
•Pulmonary consolidation
•Pulmonary collapse
•Pleural or parenchymatous pulmonary fibrosis
Bilateral reduction of chest wall movements
•Bronchial asthma
•Emphysema
•Diffuse pulmonary fibrosis

17. TVF
17
How to test for TVF?

18. 18
TVF
Increased TVF Decreased TVF
•Consolidation
•Cavitation
•Collapse with patent main
bronchus
•Thick chest wall
•Pleural effusion
•Pleural fibrosis
•Pneumothorax
•Emphysema
•Collapse

19. 19
PALPABLE ADVENTITIOUS
SOUNDS
Palpable Rhonchi
•Diffuse
•Localized and Persistent
Palpable Pleural Rub

20. POSITION OF THE
TRACHEA
How to test for the position of the
trachea?
Trill’s sign:Bulging of the sternomastoid
muscle in front of the deviated trachea.
To evaluate the position of the upper mediastinum.

21. 21
POSITION OF THE
TRACHEA
Causes of deviation of the trachea
Ipsilateral
(To pull)
Contralateral
( To push)
•Collapse
•Fibrosis
•Apical mass
•Pleural effusion
•Pneumothorax

22. 22
PERCUSSION:TECHNIQUE

23. 23
PERCUSSION2
Cut your nails

24. 24
PERCUSSION:ANTERIOR
CHEST1. Percuss from side to side
and top to bottom using
the pattern shown in the
illustration.
2. Compare one side to the
other looking for
asymmetry.
3. Note the location and
quality of the percussion
sounds you hear.

25. 25
PERCUSSION:POSTERIOR
CHEST
1. Percuss from side to side and
top to bottom using this
pattern. Omit the areas covered
by the scapulae.
2. Compare one side to the other
looking for asymmetry.
3. Note the location and quality of the
percussion sounds you hear.
4. Find the level of the diaphragmatic
dullness on both sides.

26. Clinical Examination of the Chest 26
PERCUSSION

27. 27
DIAPHRAGMATIC EXCURSION
1. Find the level of the diaphragmatic dullness on
both sides.
2. Ask the patient to inspire deeply.
3. The level of dullness (diaphragmatic excursion)
should go down 3-5cm symmetrically.
4. Decreased or asymmetric diaphragmatic
excursion may indicate paralysis or emphysema.

28. 28
TIDAL PERCUSSION
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.

29. 29
AUSCULTATION
Intensity of breath sounds
Type of breath sounds
Adventitious sounds
Voice sounds (vocal resonance)

30. 30
TECHNIQUE OF
AUSCULTATION•While the patient relaxed and breathes normally with
mouth open, auscultate the lungs, making sure to auscultate
the apices and middle and lower lung fields posteriorly,
laterally and anteriorly.
•Alternate and compare both sides at each site.
•Listen to at least one complete respiratory cycle at each site.
•First listen with quiet respiration. If breath sounds are
inaudible, then have him take deep breaths.
•First describe the breath sounds and then the adventitious
sounds.

31. 31
TECHNIQUE OF
AUSCULTATION•Note the intensity of breath sounds and make a
comparison with the opposite side.
•Assess length of inspiration and expiration. Listen for a
pause between inspiration, expiration and the quality of
pitch of the sound
•Also compare the intensity of breath sounds between
upper and lower chest in upright position. Compare the
intensity of breath sounds from dependent to top lung in
the decubitus position.
•Note the presence or absence of adventitious sounds.

32. 2002/2003 Clinical Examination of the Chest 32
AUSCULTATION: NORMAL BREATH SOUNDS
The normal breath sounds heard over the lung
tissue are called vesicular breathing.
The vesicular breathing is heard over the lungs,
lower pitched and softer than bronchial breathing.
Expiration is shorter (I > E) and there is no pause
between inspiration and expiration.
The breath sounds are symmetrical and louder in
intensity in bases compared to apices in erect
position and dependent lung areas in decubitus
position.
 No adventitious sounds are heard.

33. 33
AUSCULTATION: NORMAL BREATH SOUNDS
The breath sounds heard over the tracheobronchial
tree are called bronchial breathing.
The only place where tracheobronchial trees are
close to chest wall without surrounding lung tissue
are trachea, right sternoclavicular joints and
posterior right interscapular space. These are the
sites where bronchial breathing can be normally
heard. In all other places there is lung tissue and
vesicular breathing is heard.
The bronchial breath sounds have a higher pitch,
louder, inspiration and expiration are equal and
there is a pause between inspiration and expiration.

34. 34
AUSCULTATION:VESICULAR
BREATHING WITH PROLONGED
EXPIRATION
A prolonged expiratory phase (E > I)
indicates airway narrowing, as in:
Bronchial asthma.
Chronic bronchitis

35. 35
AUSCULTATION:BRONCHIAL
BREATHING
Bronchial breathing may be heard in
pathological conditions as:
Consolidation
Collapse with patent large airways
Compressed lung by a large pl effusion or a
tension pneumothorax
Pulmonary fibrosis
Cavitation

36. 36
AUSCULTATION:ADVENTITIOUS
SOUNDS
Crepitations: types
Rhonchi: sibilant and sonorous
Pleural rub

37. 37
AUSCULTATION: VOICE SOUNDS
Voice Transmission Tests: are only used in special
situations. All these tests become abnormal in
consolidation. They include:
Bronchophony
Whispered Pectoriloquy
Egophony

38. 38
AUSCULTATION: 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.

39. 39
AUSCULTATION: VOICE 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 whispered pectoriloquy.

40. 40
AUSCULTATION: VOICE SOUNDS-
EGOPHONY
1. Ask the patient to say "ee" continuously.
2. Auscultate several symmetrical areas over
each lung.
3. You should hear a muffled "ee" sound. If
you hear an "ay" sound this is referred
to as "E -> A" or egophony.

41. THANK YOU

42. MAHESH JESU RAJA, ALLEN ROJER 16-0139-446
ANBARASAN,ARISHATH 16-0633-413
RUSSAL RAJ SUJIN RAJ 16-0249-472
GOVINDASAMY, KESAVAN 16-0615-962