Chest examination

1. ‫الرحيم‬‫الرحمن‬‫هللا‬‫بسم‬

2. Chest examination

3. BY
Prof. Ali abo- Elmagd

4. Anatomical landmarks :

5. CHEST AREAS ( Front )

6. CHEST AREAS ( Lateral )

7. CHEST AREAS ( posterior )

8. Inspection
– Respiratory rate
– Shape of the Chest
– Respiratory movements
– Intercostal paces
– Chest retractions & Indrawing
– Nasal flaring
- Any other abnormalities ( Dilated veins ,
Swellings
Important
– Equality of both sides

9. Respiratory rate
You should count number of breathing
movements over 60 seconds to get
respiratory rate expressed as
cycles/minute.

10. Normal respiratory rate
Age Respiratory rate
(cycle /min)
Neonate 30 - 60
Infants 25 - 40
Preschool 20 - 30
School 15 - 20

11. SHAPE
1- Normal
2- Abnormal

12. Normal chest

13. Pigeon chest
It is Charachterized by
the following
 The sternum is
protruded forward,
 Subcostal angle is
acute

14. pectus-excavaturn
 The lower part of
the sternum is
indented inward

15. Rachitic chest
1- Rachitic
rosaries
2-Harrison
sulcus
3-Longitudinal
sulcus

16. Barrel shaped chest
 Increased antero-
posterior diameter to
become equal to the
transverse
 Ribs become more
transverse and the
intercostal spaces
becomes wider.

17. Note abnormal bulging which
may be found In
• asthma
• massive pleural effusion
• pneumothorax
Intercostal spaces

18. RETRACTIONS

19. Respiratory retractions
WATCH

20. Chest indrawing)
It is inward direction of the lower costal
margin during inspiration
WATCH
Watch2
Watch3

21. Nasal flaring
Watch

22. PALPATION
1- Position of mediastinum
2-Tactile fremitus
3-Respiratory movements

23. Position of mediastinum
 Position of the trachea
Feel the trachea in the suprasternal notch
In healthy people it is normally central or slightly deviated to
the right
 Position of the cardiac apex
It is defined as the lowermost and outermost point of
definite cardiac pulsation
In adults it is normally in the 5th intercostal space
just outside the midclavicular line . In children it may
be in the left 4th space
WATCH

24. MEDIASTINAL SHIFT
 To the same side of the lesion
 Fibrosis
 Collapse of the lung

25. MEDIASTINAL SHIFT
 To the opposite side of the lesion
 Pleural effusion
 Pneumothorax
 Mediastinal tumor

26. Tactile fremitus (TVF )
 Tactile fremitus refers to
vibrations produced by
phonation and felt through the
chest wall during palpation
 The palm of the hand is applied
flat on the chest wall and move
symmetrically while the child
says 44 (in Arabic and in clear
voice )and try to feel distinct
vibrations

27. TVF
 Increased in
consolidation

28. Respiratory movements :
 This is done by fixing the fingers of either
hands at the chest sides and making the
tips of the thumbs just meet in the middle
line
 Normally the two sides of the chest moves
approximately to the same extent
WATCH

29. Respiratory movements
Limited movements
 Unilateral (effusion, collapse, fibrosis
and pnannothorax )
 Bilateral (severe asthma )

30. PERCUSSION
 To begin place the left hand on the chest
wall.
 Put the distal phalynx of the middle
finger (pleximeter) in a rib interspace.
 Spread the other fingers of the hand
slightly.

31. Percussion

32. PERCUSSION
 Both sides of the child’s anterior , lateral
and posterior chest surfaces should be
compared in a consistent and orderly
fashion.
 Percuss at 2-3 cm intervals from upper to
lower chest
WATCH

33. TYPES OF PERCUSSION NOTES
Resonance
 Resonant notes are low-pitched
vibrations.
 Resonant note have a hollow
quality and heard in normal lung .
Impaired note
 Decreased resonance and heard in
cases with collapse or fibrosis

34. TYPES OF PERCUSSION NOTES
Dullness
 Dull notes have a thud-like quality
and are high in pitch.
 Dull sounds are encountered in
consolidation or thick pleura
Flat Notes
Flat notes are elicited in presence of pleural
effusion

35. TYPES OF PERCUSSION NOTES
Hyper-resonance
 Hyper-resonant notes are long in
duration
 They are normally heard in the
peripheral lungs of small children
owing to their small thin chest wall.
 It is heard in cases with hyper-
inflated lung .

36. TYPES OF PERCUSSION NOTES
Tympanitic
 Tympanic sounds have a high pitch
and a drum-like quality.
 These sounds are normally only
heard in the abdomen when the area
over the stomach is percussed .
 It is heard in pneumothorax.

37. AUSCULTATION
 It includes the following :
Air entry
Breath sounds
Added sounds
Vocal resonance
WATCH

38. AUSCULTATION

39. Air entry
 The intensity of the breath sounds should
be identified as normal ( Listen )or
decreased LISTEN
 Decreased intensity of the breath sounds
may be encountered in :
 Pleural effusion
 pneumothorax
 Consolidation

40. Breath sounds
Vesicular breathing
 Bronchial breathing

41. Normal breath sounds.
Inspiration> expiration.
No pause between inspiration and expiration
Listen Listen 2
Harsh vesicular breathing
(It is vesicular breathing but is louder and harsher
due to thin chest wall ) . It is Normal in infants
and young children )
Vesicular breathing

42. Bronchial breathing
 It is Charachterized by The following :
 Hollow in character
 Inspiration = expiration.
 A pause Is present between inspiration and
expiration.
 It is normally heard on the trachea. LISTEN
 Pathologically it is heard in consolidation (usually
pneumonia).
LISTEN

43. Vocal resonance
 It refers to vibrations produced
by phonation and felt during
auscultation of the chest

44. ADVENTESIOUS SOUNDS
 These sounds are not normally present
.
 They are pathological may arise in the
lung or in the pleura
 It includes
1. rhonchi
2. crepitations
3. pleural friction rub .

45. wheeze
 A wheeze is a continuous sound with a
musical quality created by partial airway
obstruction, usually of intrathoracic
bronchi.
 Usually heard during expiration
 The most common cause of wheezing is
diffuse bronchial obstruction

46. Sonorous rhonchi
 It Indicates tracheal and large bronchial
involvement and have the following characters:
 Continuous Sound
 Low pitched
 May be cleared with coughing
LISTEN

47. Sibilant rhonchi
It Indicates the presence of obstruction in smaller
airways and have the following characters :
 Continuous sound
 musical
 High pitched
 Usually heard in expiration
 May be audible without a stethoscope.
LISTEN
Listen 2

48. Crepitations
Crepitations (crackles, rales )
 Thy refer to a nonmusical, interrupted
respiratory sounds that may be detected
on auscultation of the lungs.
 Crackles may result from disease of the
lung parenchyma (e.g. pneumonia) or the
airways (e.g. bronchitis ) .
 Crepitations may be either fine or coarse .

49. Fine crepitations
 Indicative of fluid in alveoli
 It is heard in Consolidations.
LISTEN
Listen 2

50. Coarse crepitations
 It indicates air bubbling through fluid in
larger bronchi.
 It may be cleared with coughing.
 Heared in bronchitis
LISTEN
Listen 2

51. Pleural friction rub
 A pleural rub implies inflammation of the
pleural membranes (i.e. pleurisy),
 it is superficial friction sound occurring too
and fro during both inspiration and
expiration
 It is usually exaggerated by deep breathing
and pressure by the stethoscope
LISTEN

52. Noisy breathing
Snoring
Stridor
Grunting
Rattling
Wheezing

53. Stridor
LISTEN

54. Secretions
LISTEN

55. Grunting
Watch
Watch 2

56. Grunting
LISTEN

57. Croup
Listen