Physical Diagnosis of the Chest

1. Physical Diagnosis of the Chest Waid Shelton, M.D. This lecture closely follows Bickley, LS, Szilagyi PG: Bates’ Guide to Physical Examination and History Taking, 8th ed. Philadelphia, Lippincott Williams & Wilkins, 2003, Chapter 6.

2. An Opportunity to Sense What Is Happening Dynamically in the Chest Instead of Relying Solely on Imaging Studies

3. The chest examination and imaging studies often complement each other.

4. We need to ask whether what we observe matches with what we see on x-ray studies. Sometimes we must act on observation alone.

5. Some of the Questions We Ask • What do I think is going on based on the exam? • What do I think the x-ray will show? • Do I have time for the x-ray study to be done? • How do the findings on exam correlate with the findings on x-ray?

6. On to the Exam The history comes first.

7. Common Symptoms • Chest pain • Dyspnea • Wheezing • Cough • Hemoptysis

8. The first concern about chest pain: Is it angina?

9. Angina • Central or left chest • Often pressure or stabbing sensation (the elephant) • Radiating to the arm, neck, jaw, or ear • Occurs with exertion and is relieved by rest or sublingual nitroglycerine • Lasts minutes, not seconds, hours, or days • May be associated with dyspnea, diaphoresis, and nausea

10. Other sources of chest pain • Pericardium • Aorta • Major airways • Pleura • Chest wall • Esophagus • Extrathoracic structures

11. Pericardium Aorta Better sitting up; associated with heartbeat; may hear a rub Acute onset; high,sustained level of pain; may involve the back Cardiovascular Sources of Chest Pain

12. Trachea and large airways Smaller airways (asthma) Central soreness, persistent, worse with cough or inspiration Central tightness, usually with enough exertion to cause dyspnea Tracheobronchial Sources of Chest Pain

13. Pleural Source of Chest Pain • Usually there is an inspiratory component, sometimes only on deep inspiration • The patient may avoid taking deep breaths, trying to “splint” the affected side • A pleural friction rub may be heard

14. Ribs and cartilage Musculoskeletal Skin Point tenderness over a rib or costochondrial junction Pain with movement, as well as respiration Unexplained pain in an area which is followed by vesicles in a dermatome Chest Wall Sources of Chest Pain

15. Esophageal Sources of Chest Pain • Positioned from suprasternal notch to the xyphoid • May often be burning or present with a sense of occlusion • Antacids and nitroglycerine may help

16. Neck Cervical nerve root Gallbladder Stomach Cervical arthritis Dermatome pain Constant or colicky pain Burning or boring pain, sometimes relieved by antacids or food Chest Pain from Sources Outside the Chest

17. Characterization of Dyspnea Occurring at rest vs. occurring with effort • Walking from room to room • Sweeping a floor or making a bed • Walking a distance on level ground • Walking up an incline or carrying something • Climbing stairs • Associated with symptoms of chest pain, nausea, or diaphoresis

18. Wheezing • Frequency • Precipitants Infection Exercise or cold Exposure • Relief

19. Cough • Frequency • Amount of sputum produced • Nature of sputum produced • Clear • Mucoid (translucent white or gray) • Purulent (yellow or green) • Foul-smelling

20. Questions about Hemoptysis • Is it being coughed up from the chest; does it just appear in the mouth; or is it coming up from the stomach? • Is there frank blood in quantity? • Is the blood in otherwise clear or purulent sputum (blood streaking)? • Is the blood part of pink, frothy sputum?

21. Smoking • Do you smoke? • Did you ever smoke? • When did you begin? • How many packs did you smoke per day on average? • When did you stop? • Calculate pack years smoked. • Do you want to stop?

22. The Four A’s of Smoking Cessation, Plus One • Ask about smoking • Advise cessation • Assist in stopping by inquiring about cessation date and providing information • Arrange a return visit and inquire about success or failure in smoking cessation Additionally: Avoid an accusatory stance

23. Review of Anatomical Landmarks

29. The Examination • Inspection • Palpation • Percussion • Auscultation

30. Inspection • Degree of comfort and posture • Audible sounds of wheeze, stridor, or recurrent cough • Apparent dyspnea moving about the room • Use of accessory muscles • Consider counting respirations • Thoracic symmetry • Nasal flaring and intercostal retractions

31. Time to Decide Position and timing of the examination of the anterior chest

32. Palpation • Chest expansion • Check for fremitus with ball or ulnar surface of the hand • Check for fremitus on both sides of the chest at one time using both hands

34. Percussion • Hyperextend the middle finger of your non-dominant hand (lefties, try this both ways). • Press the DIP joint firmly down on the surface while elevating other fingers. • Strike with the tip of the middle finger of the dominant hand in a sharp tap using mostly wrist motion. • Feel and hear the result.

40. Auscultation Place the stethoscope on bare skin, please.

42. Adventitious (Added) Sounds • Fine crackles (fine rales) • Coarse crackles (coarse rales) • Wheezes • Rhonchi

43. Crackles or Rales • I think of crackles or rales as opening sounds of alveoli or small airways. This may not be entirely true, but it is helpful to me to think of them that way. • Fine crackles often come at the end of inspiration in atelectasis, failure, or consolidation. • Coarse crackles come earlier in inspiration, may sound like Velcro, and are associated with pulmonary fibrosis.

44. Note well: • Your text mentions crackles in early inspiration (and sometimes expiration) from chronic bronchitis and asthma (Bates, Table 6-6, p 241). It also mentions midinspiratory and expiratory crackles heard in bronchiectasis.

45. Wheezes, Rhonchi, and Stridor • Wheezes are high pitched sounds in inspiration and expiration. I think of these as turbulence in smaller bronchi. • Rhonchi are lower pitched sounds in inspiration and expiration. I think of these as turbulence in larger bronchi. • Stridor is a high pitched inspiratory sound heard best over the trachea or larynx. It demands attention.

46. Pleural Rubs • May sound like the rubbing of shoe leather • Occur over the affected area • Usually are inspiratory or both inspiratory and expiratory • May be hard to differentiate from a combination of rhonchi and crackles

47. Testing for Transmitted Sounds • Bronchial breath sounds or, possibly, bronchiovesicular breath sounds outside their expected area should trigger search • Adventitial breath sounds call for testing • Expectation of or concern about pulmonary pathology, such as pneumonia or atelectasis should cause search

48. Transmitted Sounds • Bronchophony – clear transmission of spoken voice • Egophony – “ee” is heard as “ay” • Whispered pectoriloquy – whispered “ninety-nine” is heard clearly These are signs of an open airway and less muffling by aerated lung tissue (consolidation or atelectasis).

49. Examining the Anterior Chest Sitting or supine

50. Inspection • Symmetry • Deformities • Intercostal retraction • Respiratory movement