medicine

1. Chest local examination

2. Shape
Inspection Palpation Percussion Auscultation
Skin
Chest wall
Pulsations
Tracheal position
1. Scars 2. Dilated veins
3. Subcutaneous
emphysema
4. Others
Symmetrical
1. Elliptical
2. Barrel
3. Flat
4. P. carinatum
5. P. excavatum
6. Kyphosis
Asymmetrical
1. Unilateral bulge
2. Unilateral retraction
3. Scoliosis
Movement
1. Mode
2. Overaction (Insp or Exp)
3. Expansion
4. Rate (and depth)
5. Rhythm
1. Normal
2. Cheyne-Stoke
3. Ataxic (Biot’s)
4. Sighing
1. Normal
2. Tachypnoea
3. Bradypnea
4. Apnoea
5. Hypovent.
Trail’s sign
Trachea
1. Tracheal position
2. Tracheal length
3. Tracheal tug
4. Axial fixation
Tenderness
TVF
Palpable
rhonchi
Palpable rub
Pulsations
Expansion
Apical
Basal
1. Anterior basal
2. Posterior basal
3. Subcostal expansion
Swelling
Upper border
of the liver
Cardiac
borders
Lung
Anterior
1. Clavicle : Direct
percussion over medial 1/3
2. Infraclavicular
3. Midclav. Line : 2nd space
to 6th rib
Laterally
Midaxillary : 4th to 7th space
Posteriorly
1. Suprascapular
2. Infrascapular
3. Kronig’s isthmus
Heavily
Heavily
Bare area
Traub’s area
Breath sounds
Vocal
resonance
Adventitious
sounds
Special tests
Intensity
1. Normal
2. Increased
3. Decreased
Type
Vesicular Bronchial
1. Normal
2. Diminished
3. Increased
4. Aegophony
Wheezes
Crackles ( Early – Late)
Rub
Mediastinal crunch
1. Distribution (Gen. – Local)
2. Type ( Sibilant – Sonorous – Polyphonic)
3. Timing (Expiratory – Inspiratory – Both)
4. Cough
1. D’espine sign
2. Post tussive test
3. Succussion splash
4. Coin test
5. Waterfall sign

3. Examined by milking test
• Fills from above : SVC obstruction
Causes:
• Mediastinal mass
• SVC thrombus
• Fills from below : IVC obstruction (less common)

4. Examined by
Inspection: Diffuse swelling (Michelin man)
Palpation: Crackling sensation
Causes
• Emphysema
• Pneumothorax
• Chest trauma

5. Symmetrical chest
Elliptical: Normal
Barrel: Emphysema
Chronic bronchitis
B. Asthma in a young
Flat (Alar) : Normal in some persons
P. Carinatum (Pigeon) : B. asthma in a young
Rickets
Osteomalacia
Marfan
Familial
Sporadic
P. excavatum:
Congenital: Developmental defect
Acquired: Shoemakers
Associated: Ricket’s
Marfan
Kyphosis: Senile osteoporosis
Ankylosing spondylitis
Pajet’s disease
Acromegaly

6. Asymmetrical chest
• Unilateral bulge
Pneumothorax
Pleural effusion
• Unilateral retraction
Lung fibrosis (e.g., TB)
Lung collapse
• Scoliosis
2ry to thoracoplasty

7. Modes of respiration
• Thoraco-abdominal
Females
• Abdomino-thoracic
Males
Babies
• Thoracic only Diaphragmatic movement inhibited by:
Pain (Peritonitis)
High IAP (Ascites – Gas distension – Ovarian cyst – Pregnancy)
Diaphragmatic paralysis (= Abdominal paradox)
• Abdominal only Chest movement is reduced by:
Pain (Pleurisy)
Ankylosing spondylitis – Severe emphysema – Pleural effusion
Intercostal paralysis (= chest paradox)

8. Overaction of respiration
• Abnormal inspiratory movements
(Pump handle – Indrawing)
Obstructive lung disease & overinflation
Advanced emphysema
Severe asthma
Chronic bronchitis
Obstructed larynx and trachea
Restrictive lung disease : e.g.Lung fibrosis
• Abnormal expiratory movements
(shoulder fixation – Laboured breathing – accessory
muscles – Pursing of lips)
Obstructive lung disease
Emphysema
Asthma
Chronic bronchitis

9. Expansion
Apical & Basal

10. Rate
Hyperventilation
(Rapid & deep)
1. Exercise
2. Anxiety
3. Massive PE
4. Metabolic acidosis (Kaussmaull)
5. Hypoxia – Hypercapnea
6. Brain infarction
7. Hypoglycemia of MB or pons
Rapid & Shallow
breathing
1. Pulmonary oedema
2. Elevated diaphragm
3. Pleural pain
4. Bronchial asthma
5. Restrictive lung disease
6. Pulmonary infection
Bradypnea
1. Drugs : Morphia – Barbiturates
2. High ICT
3. DKA
Apnoea
1. Sleep apnoea syndrome
2. Obstructive apnoea
Hypoventilation
1. Less severe causes of apnoea
2. Respiratory failure type II
Normal 14-20
Tachypnoea

11. Rhythm
• Normal
• Cheyne-Stoke (Waxing and waning)
1. Severe HF (longer cycle)
2. During sleep
3. Narcotic drug poisoning
4. Uraemia
5. Hypoxia
6. Neurological disorders
• Ataxic (Biot’s) (Unpredictable irregularity)
1. Respiratory depression
2. Brain damage at medullary level
• Sighing
1. Normal
2. Hyperventilation syndrome

12. Tracheal deviation
• Thyroid enlargement
• Lesions of the upper half of the lung
o Ipsilateral pulling lesion: fibrosis – collapse
o Contralateral pushing lesion: Pneumothorax – Effusion (if very large)
• A slight deviation to the right may be considered normal
Tracheal Tug
• During inspiration: Campbell’s sign in COPD
• During systole: Oliver’s sign in aortic arch aneurysms

13. Tenderness
• Pleurisy (Lower axillary and beneath breasts)
• Chest wall
Traumatic
Inflammatory: Osteomyelitis – Teitz disease
Neoplastic: Leukaemia - Mets
• Muscle pain
• Thrombophlebitis: Mondor’s disease
• Skin: Dermatitis - HZ
• Pericarditis

14. TVF
Increased
3 C
1. Consolidation
2. Cavity
3. Collapse (with patent main
bronchus)
Diminished
(Obstruction)
1.Obstructed bronchus
2.COPD
3.Soft voice
Absent
(Barrier)
1. Pleural effusion
2. Pneumothorax
3. Pleural thickening
4. Obesity
Don’t forget
the back!

15. Palpable rhonchi
Generalized
Chronic bronchitis
Bronchial asthma
(COPD)
Localized
Partial obstruction
Tumour
Foreign body
Secretions

16. Palpable rub
Pleurisy
Chronic more than acute
So usually not associated with pain

17. Pulsations
Deviated apex
1. Vent. enlargement
2. Chest causes :
• Ipsilateral pulling lesion:
Fibrosis – Collapse
• Contralateral pushing lesion:
Effusion – pneumothorax
• Skeletal deformity:
Scoliosis – P. excavatum
Impalpable apex
Barrier
1. Emphysema
2. Left pleural effusion
3. Left pneumothorax
4. Thickened left pleura
RVE
Apex : Shifted outwards –
systolic retractions – Diffuse
Left parasternal pulsations
Epigastric pulsations
Cor-pulmonale

18. Expansion
Apical & Basal
Unilateral reduction in movement
Absent:
1. Pleural effusion
2. Empyema
3. Tension pneumothorax
Reduction
1. Pneumonia (Consolidation)
2. Collapse
3. Shallow pneumothorax
4. Fibrosis (e.g., TB)
Bilateral reduction in movement (See: Abnormal inspiratory movements)
Overinflation: - Emphysema - Bronchial asthma
Decreased distensibility: Diffuse lung fibrosis
If severe: Abrupt inspiratory halt occur (door stop phenomenon)
Subcostal
Emphysema
Limitation of normal inspiratory
widening or even inspiratory
decrease in subcostal angle
[Hoover’s sign]

19. Swelling
• Fluctuation in Abscess
• Crepitations and spongy feeling in subcutaneous emphysema

20. Tidal percussion
• Normal
• Hyperinflation:
Emphysema
Right pneumothorax

21. Lung percussion
Normal
resonance
Normal lung
Tympanetic
resonance
1.Tension
pneumothorax
2.Hollow viscus
Hyper
resonance
1.Emphysema
2.Pneumothorax
Impaired
note
1. Fibrosis
2. Causes of
mild
dullness
Stony dull
1.Pleural
effusion
2.Lower half of
hydro-
pneumothorax
Dullness
1.Consolidation
2.Collapse
3.Pleural
thickening
4.Superficial
tumour or
abscess
Resonance Dullness

22. Percussion of Kronig’s isthmus
Causes of dullness
1. Friedlander's bronchopneumonia (Klebsiella pneumoniae)
2. Apical fibrosis
3. Apical collapse
4. Apical tumour
5. Apical consolidation
6. Apical Abscess
7. Apical pleural effusion (massive or encysted)

23. Traub’s area
Dullness
1. Splenomegaly
2. Left hepatic lobe enlargement
3. Pregnancy
4. Tense ascites
5. Pleural effusion
6. Pericardial effusion
7. Full stomach
8. Fundal tumour
9. Situs inversus totalis
Large Traub's area
1. Splenectomy
2. Shrunken liver
3. Pneumothorax
4. Pneumoperitoneum
5. Dilated stomach

24. Breath sounds
Intensity Type
Vesicular breathing
Cause: Normal lung
Vesicular with prolonged expiration:
Airway distortion:
1. Bronchial asthma
2. Chronic bronchitis
3. Tumour
Loss of elastic recoil:
1. Emphysema
2. Diffuse lung fibrosis
Bronchial breathing
Normally over airways
1. Consolidation
1. Pneumonia
2. Around superficial abscess
2. Cavity (Large superficial empty connected to
a bronchus)
3. Collapse
1. Upper level of pleural effusion
2. With patent main bronchus
4. Localized dense fibrosis
1. Chronic pulmonary TB
2. Chronic suppurative pneumonia
5. Open pneumothorax &
Tension pneumothorax
I. Barrier
1. Obesity
2. Thick musculature
3. Pleural thickening
4. Pleural effusion
5. Shallow pneumothorax
II. Diminished air entry
Airway obstruction
1. Localized e.g., Tumour
2. Generalized e.g., Asthma
Decreased movement
1. Muscle weakness
2. Patient induced
III. Damage of lung
1. Emphysema
2. Fibrosis
Decreased
Increased
1. Thin
2. Bronchial breathing
3. children

25. Vocal resonance
Normal
Increased
1.Consolidation
2.Collapse upper
level of pleural
effusion
3.Cavity with patent
main bronchus
4.Dense fibrosis
Diminished
1. Barrier
a. Pleural effusion
b. Pneumothorax
c. Thickened pleura
2. Obstruction
3. Emphysema
Aegophony
1. Upper level of
pleural
effusion
2. Consolidation
Same as causes of Low
intensity breath sounds
Same as causes of
bronchial breathing

26. Wheezes
1. Tumour
2. Foreign body
3. Secretions
(Cleared with cough)
1. Bronchial asthma
2. Bronchitis
1. Emphysema
2. Bronchial asthma
3. Bronchitis
4. At the end of
forced expiration
(normally)
1. Lung fibrosis
(Fibrosing alveolitis)
2. Lung collapse
Random
monophonic
wheezes
Fixed monophonic
wheezes
Sequential
inspiratory
wheezes
Expiratory
polyphonic
wheezes

27. Crackles
1.Fibrosis
2.Failure (LSHF)
3.Pneumonia
4.Abscess
5.Re-inflation of a
previously collapsed
lung
Late
1. Bronchiectasis
2. Bronchitis
3. Bronchial asthma
4. Secretions (Acute
pulmonary oedema)
5. Bronchiolitis
6. Localized lung
fibrosis
Early

28. Pleural rub
Pleurisy

29. Mediastinal crunch
Mediastinal emphysema (Emergency)