This document provides guidance on performing a physical examination of the chest, including inspection, palpation, auscultation, and relevant anatomy. It describes how to count ribs and locate landmarks like the sternal angle. Common chest complaints like cough, chest pain, and dyspnea are discussed. Abnormal findings on inspection like decreased chest expansion are outlined. The document also covers assessing breath sounds, respiratory rate, and tactile fremitus.

2. ANTERIOR VIEW

3. POSTERIOR VIEW

4. PALPATION OF ANTERIOR CHEST
• PRACTICE COUNTING THE RIBS AND INTERSPACES. THE STERNAL ANGLE, ALSO TERMED THE ANGLE OF
LOUIS, IS THE BEST GUIDE.
• PLACE YOUR FINGER IN THE HOLLOW CURVE OF THE SUPRASTERNAL NOTCH, THEN MOVE YOUR FINGER
DOWN APPROXIMATELY 5 CM TO THE HORIZONTAL BONY RIDGE JOINING THE MANUBRIUM TO THE BODY
OF THE STERNUM.
• MOVE YOUR FINGER LATERALLY AND FIND THE ADJACENT 2ND RIB AND COSTAL CARTILAGE
• FROM HERE, USING TWO FINGERS, “WALK DOWN” THE INTERSPACES, ONE SPACE AT A TIME, ON AN
OBLIQUE LINE

5. PALPATION OF POSTERIOR CHEST
• POSTERIORLY, THE 12TH RIB IS ANOTHER POSSIBLE STARTING POINT FOR COUNTING RIBS AND
INTERSPACES
• THE INFERIOR TIP OF THE SCAPULA IS ANOTHER USEFUL BONY LANDMARK; IT USUALLY LIES AT THE LEVEL
OF THE 7TH RIB OR INTERSPACE

6. DEFORMITIES OF THORAX

7. COMMON COMPLAINTS
COUGH
CHEST PAIN
DYSPNEA
WHEEZING
COUGH
HEMOPTYSIS

8. CHEST PAIN
• COMPLAINTS OF CHEST PAIN OR CHEST DISCOMFORT RAISE CONCERN ABOUT HEART DISEASE BUT
OFTEN ARISE FROM STRUCTURES IN THE THORAX AND LUNG AS WELL.
• A CLENCHED FIST OVER THE STERNUM SUGGESTS ANGINA PECTORIS; A FINGER POINTING TO A TENDER
AREA ON THE CHEST WALL SUGGESTS MUSCULOSKELETAL PAIN; A HAND MOVING FROM NECK TO
EPIGASTRIUM SUGGESTS HEARTBURN.
• QUESTIONS TO BE ASKED: ”DO YOU HAVE ANY DISCOMFORT OR UNPLEASANT FEELINGS IN YOUR CHEST?”

9. DYSPNEA
• PROMINENT SYMPTOM OF CARDIAC AND PULMONARY DISEASE
• SHORTNESS IN BREATH
• MAKE EVERY EFFORT TO DETERMINE ITS SEVERITY BASED ON THE PATIENT’S DAILY ACTIVITIES
INCLUDING THEIR OCCUPATION SITE(WHERE THEY WORK OR LIVE)
• QUESTIONS TO BE ASKED:“HAVE YOU HAD ANY DIFFICULTY BREATHING?” HOW MANY STEPS OR FLIGHTS
OF STAIRS CAN THE PATIENT CLIMB BEFORE PAUSING FOR BREATH? WHAT ABOUT CARRYING BAGS OF
GROCERIES, MOPPING THE FLOOR, OR MAKING THE BED?
• WHEEZES ARE MUSICAL RESPIRATORY SOUNDS THAT MAY BE AUDIBLE TO THE PATIENT AND TO OTHERS.

10. COUGH
• COUGH IS A REFLEX RESPONSE TO STIMULI THAT IRRITATE RECEPTORS IN THE LARYNX, TRACHEA, OR LARGE
BRONCHI. THESE STIMULI INCLUDE MUCUS, PUS, AND BLOOD, AS WELL AS EXTERNAL AGENTS SUCH AS DUST,
FOREIGN BODIES, OR EVEN EXTREMELY HOT OR COLD AIR
• DURATION OF THE COUGH IS IMPORTANT: IS THE COUGH ACUTE, LASTING LESS THAN 3 WEEKS; SUBACUTE,
LASTING 3 TO 8 WEEKS; OR CHRONIC, MORE THAN 8 WEEKS?
• ASK WHETHER THE COUGH IS DRY OR PRODUCES SPUTUM, OR PHLEGM. ASK THE PATIENT TO DESCRIBE THE
VOLUME OF ANY SPUTUM AND ITS COLOR, ODOR, AND CONSISTENCY.
• MUCOID SPUTUM IS TRANSLUCENT, WHITE, OR GRAY; PURULENT SPUTUM IS YELLOW OR GREEN FOUL-
SMELLING SPUTUM IS PRESENT IN ANAEROBIC LUNG ABSCESS; TENACIOUS SPUTUM IN CYSTIC FIBROSIS
LARGE VOLUMES OF PURULENT SPUTUM ARE PRESENT IN BRONCHIECTASIS OR LUNG ABSCESS

12. HEMOPTYSIS
• HEMOPTYSIS IS THE COUGHING UP OF BLOOD FROM THE LUNGS
• HEMOPTYSIS IS RARE IN INFANTS, CHILDREN, AND ADOLESCENTS, ALTHOUGH COMMON IN CYSTIC
FIBROSIS
• CONFIRM THE SOURCE OF THE BLEEDING-MAY ORIGINATE IN THE MOUTH, PHARYNX,OR
GASTROINTESTINAL TRACT

13. RESPIRATORY RATE
• RESPIRATORY RATE: A PERSON'S RESPIRATORY RATE IS THE NUMBER OF BREATHS YOU TAKE PER MINUTE.
THE NORMAL RESPIRATION RATE FOR AN ADULT AT REST IS 12 TO 20 BREATHS PER MINUTE. A
RESPIRATION RATE UNDER 12 OR OVER 25 BREATHS PER MINUTE WHILE RESTING IS CONSIDERED
ABNORMAL.

14. BREATHING TYPES
• TWO TYPES OF BREATHING
WOMEN-CHEST
MEN-ABDOMEN
• IDENTIFY PATTERNS OF BREATH SOUNDS BY THEIR INTENSITY, THEIR PITCH, AND THE RELATIVE DURATION OF THEIR
INSPIRATORY AND EXPIRATORY PHASES.
1. VESICULAR
2. BRONCHOVESICULAR
3.BRONCHIAL

16. INSPECTION
• DEFORMITIES OR ASYMMETRY IN CHEST EXPANSION
• ABNORMAL RETRACTION OF THE INTERSPACES DURING INSPIRATION. RETRACTION IS MOST APPARENT IN THE
LOWER INTERSPACES.
• IMPAIRED RESPIRATORY MOVEMENT ON ONE OR BOTH SIDES OR A UNILATERAL LAG (OR DELAY) IN MOVEMENT.
• ASYMMETRIC EXPANSION IN PLEURAL EFFUSION
• RETRACTION OCCURS IN SEVERE ASTHMA, COPD, OR UPPER AIRWAY OBSTRUCTION
• UNILATERAL IMPAIRMENT OR LAGGING INDICATES PLEURAL DISEASE FROM ASBESTOSIS OR SILICOSIS; IT IS
ALSO SEEN IN PHRENIC NERVE DAMAGE OR TRAUMA

17. PALPATION
• IDENTIFY TENDER AREAS
• ASSESS ANY VISIBLE ABNORMALITIES
• TEST CHEST EXPANSION
• FEEL FOR TACTILE FREMITUS
• IN WOMEN PALPATION HELPS IN DIAGNOSIS OF MASS OR TUMOR OF BREASTS

18. CHEST EXPANSION
• UNILATERAL DECREASE OR DELAY IN CHEST EXPANSION OCCURS IN CHRONIC FIBROSIS OF THE
UNDERLYING LUNG OR PLEURA, PLEURAL EFFUSION, LOBAR PNEUMONIA, PLEURAL PAIN WITH ASSOCIATED
SPLINTING, AND UNILATERAL BRONCHIAL OBSTRUCTION.

19. TACTILE FREMITUS
• FREMITUS IS DECREASED OR ABSENT WHEN THE VOICE IS HIGHER PITCHED OR SOFT OR WHEN THE
TRANSMISSION OF VIBRATIONS FROM THE LARYNX TO THE SURFACE OF THE CHEST IS IMPEDED BY A
THICK CHEST WALL, AN OBSTRUCTED BRONCHUS, COPD, OR PLEURAL CHANGES FROM EFFUSION,
FIBROSIS, AIR (PNEUMOTHORAX), OR AN INFILTRATING TUMOR.