This document provides information on assessing the chest and lungs through physical examination. It discusses the relevant anatomy, history taking, and examination techniques including inspection, palpation, percussion, and auscultation of the chest. Examination points for different populations like neonates, infants, pregnant women, and older adults are also reviewed. The goal is to evaluate the lungs, breathing, and chest wall in a systematic manner.

1. ASSESSMENT OF THE
CHEST AND LUNGS
DR.QURATULAIN MUGHAL
ISRA UNIVERSITY
1

2. Reference Lines
 Anterior Chest
 Midsternal line
 Anterior axillary lines
 Midclavicular lines
 Posterior Chest
 Vertebral line
 Midscapular lines
 Axilla
 Anterior axillary lines
 Midaxillary lines
 Posterior axillary lines

3. Anterior Chest

4. Posterior Chest

5. Axilla

6. Anatomy Points to Remember
 Lungs are symmetric
 Lungs are divided into lobes
 Right lung = 3 lobes
 Left lung = 2 lobes
 Primary muscles of respiration
 Diaphragm – divides chest from abdomen
 External intercostal muscles
 Accessory muscles

7. Anatomy Points to Remember
 Upper Airway
 Nose, pharynx, larynx, intrathoracic trachea
 Functions in respiration

Conduct air to lower airway

Filter to protect lower airway

Warm and humidify inspired air

8. Anatomy Points to Remember
 Lower Airway
 Trachea, bronchi, bronchioles

Functions in respiration
 Conduct air to alveoli
 Clear mucociliary structures
 Alveoli

Functional unit
 Gas exchange
 Production of surfactant

9. Anatomy Points to Remember
 Lower Airway
 Trachea splits into left and right mainstem
bronchi which are further subdivided into
bronchioles

Right bronchus is shorted, wider and more
upright than the left

Functions in respiration
 Conduct air to alveoli
 Clear mucociliary structures

10. History
 Chief Complaint and HPI
 Cough
 Shortness of breath/Dyspnea

11. Cough
 Onset – sudden, gradual
 Duration
 Nature – dry, moist, hacking, barking
 Sputum – amount, color, odor
 Severity – disrupts activities
 Associated symptoms – sneezing, dyspnea, fever, chills,
congestion, gagging
 What brings it on? – anxiety, talking, activity
 What makes it better?
 What has been tried? – medications, treatments
 Anything similar in the past?

12. Shortness of Breath (SOB) /
Dyspnea
 Onset – sudden, gradual
 Duration
 Severity – disrupts activities
 Associated symptoms – night sweats, pain, chest
pressure, discomfort, ankle edema, diaphoresis, cyanosis
 What brings it on? – position, time of day, exercise,
allergens, emotions
 What makes it better?
 What has been tried? – medications, inhalers, oxygen
 Anything similar in the past?

13. History
 Past Health History
 Lung disease or breathing problems

Frequent severe colds, asthma, emphysema,
bronchitis, pneumonia, tuberculosis
 Last PPD and/or chest x-ray
 Allergies
 Medication use
 Family History

14. History
 Personal and Social History
 Tobacco
 Alcohol
 Drugs
 Home environment
 Occupational environment
 Travel
 Health Promotional Activities

15. PHYSICAL
EXAMINATION
15

16. Equipment and Techniques
 Equipment
 Stethoscope
 Techniques
 Inspection
 Palpation
 Percussion
 Auscultation

17. Inspection
 General
 Appearance
 Posturing
 Breathing effort
 Trachea position

Midline

18. Inspection
 Chest Wall Configuration
 Form
 Symmetry
 Muscle development
 Anterior-Posterior (AP) diameter

Approximately ½ the transverse diameter

Transverse: Anterior-Posterior = 2:1
 Costal angle

90 degrees or less

19. Inspection
 Oxygenation: cyanosis
 Nails
 Skin
 Lips
 Respiratory Effort
 Respiratory rate and depth
 Breathing pattern
 Chest expansion

20. Palpation
 Trachea – for position
 Chest wall – for symmetry

21. Palpation
 Thoracic Expansion (Excursion)
 Place both thumbs at about 7th
rib
posteriorly along the spinal process
 Extend the fingers of both hands
outward over the posterior chest wall
 Have the person take a deep breath
and observe for bilateral outward
movement of thumbs

Normal: bilateral, symmetric
expansion

Abnormal: unilateral or unequal
Click on the pictures to view video

22. Palpation
 Vocal (Tactile) Fremitus
 Use palmar or ulnar surfaces of hands
 Systematically position hands over both sides of
posterior chest
 Have person repeat “1 – 2 – 3” or “99” as you
move from the apices to the bases

Normal: bilaterally symmetrical vibrations

Decreased or absent: obstruction of transmission
0bronchitis, emphysema)

Increased: consolidation (compression) of lung
tissue (pneumonia)

23. Auscultation
 Auscultate in a systematic manner
 Compare one side to the other
 Listen one full respiration at each spot
 Displace breast tissue to listen directly over
chest wall
 DO NOT
DO NOT listen through gowns, clothes, etc.
 Place your stethoscope over bare skin

24. Auscultation
 Evaluate posterior, lateral, and anterior chest
 Instruct person to sit upright and breathe in
and out slowly through the mouth
 This makes it easier to hear the air movement
 Use the diaphragm of the stethoscope
 Move from the apices to the bases

25. Auscultation
 Evaluate for normal sounds
Sound Pitch Intensity Quality I:E Location
Bronchial High Loud Blowing/ hollow I < E Trachea
Bronchovesicula
r
Moderate Moderate Combination I = E Between scapulae,
1st
& 2nd
ICS lateral to
sternum
Vesicular Low Soft Gentle rustling/
breezy
I > E Peripheral lung

26. Auscultation
 Evaluate for adventitious sounds
Sound Intensity/ Pitch I/E Quality Clear with Cough
Crackles/
Rales
Soft (fine)/ High
Loud (coarse)/ Low
I Discontinuous,
nonmusical, brief
Possibly
Wheeze High E Continuous musical
sounds
Possibly
Ronchi Low E Continuous snoring
sounds
Possibly
Pleural
Friction Rub
I & E Continuous or
discontinuous creaking or
brushing sounds
Never
Stridor I Continuous, crowing Never

27. Auscultation
Copy this URL into your Web browser to hear normal and abnormal lung sounds :
http://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htm

28. Developmental Variations
 Neonates
 Measure the chest circumference

Usually 2-3 cm smaller than head circumference

Chest is round (i.e. AP diameter = transverse)
 Obligate nose breathers
 Periodic breathing is common

Sequence of vigorous breathing followed by apnea
for 10-15 seconds

Only concern if it is prolonged or baby becomes
cyanotic

29. Developmental Variations
 Neonates
 Breathing is diaphragmatic and abdominal
 Signs of compromise

Stridor (“crowing”)

Grunting

Central cyanosis

Flaring nares

30. Developmental Variations
 Infants and Young Children
 Roundness of the chest persist for first 2 years
 Chest walls are thinner than the adult’s

Breath sounds may sound louder, and more
bronchial than the adult
 Bronchovesicular sounds may be heard
throughout the chest

31. Developmental Variations
 Pregnancy
 Costal angle increases to about 105 degrees in
the third trimester
 Dyspnea and orthopnea are common
 Breathes more deeply

32. Developmental Variations
 Older Adult
 Chest expansion is often decreased
 Bony prominences are marked
 AP diameter is increased with respect to
transverse (but not 1:1)