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PHYSICAL DIAGNOSIS

PHYSICAL DIAGNOSIS. CHEST. INTRODUCTION.

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PHYSICAL DIAGNOSIS

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  1. PHYSICAL DIAGNOSIS

  2. CHEST

  3. INTRODUCTION • Though X-ray of the lungs has become wide-spread ,the physical examination of chest is still very important. A friction rub,rales, and wheezing cannot be seen on x-ray films and can be detected only by our senses.In fact,the findings on the x-ray film in many instances, can be interpreted intelligently only when coupled with the history and physical findings.Careful examination should enhance our ability to interpret the x-ray films and the chest film should serve as a check on the physical examination.

  4. INTRODUCTION • Experience would indicate that the following order of procedure has much to recommend it: (1)inspection,(2)palpation,(3)percussion,and (4)auscultation.The adoption of a systematic approach,in which each stage is performed in sequence,helps to prevent oversight of any important aspect of the examination.

  5. LINE LANDMARKS • On the anterior surface • Anterior midline (midsternal line):is located in the middle of the sternum • Midclavicular line (left and right):runs di rectly downward from the midpoint of each clavicle

  6. LINE LANDMARKS • On the anterior surface • Sternal line(left and right):vertical line runs along the vertical edges of the sternum and parallels to the anterior midline.

  7. LINE LANDMARKS • On the lateral wall of the chest • the anterior axillary line:drawn downward from the origin of the anterior axillary fold along the anterolateral aspect of the chest • the posterior axillary line:a continuation of the posterior axillary fold running downward along the posterolateral wall of the thorax • the midaxillary line :midway between those two lines and running directly downward from the apex of the axilla

  8. LINE LANDMARKS • On the posterior wall • the midspinal line or posterior midline:runs down the posterior spinous processes of the vertebrae • the scapular line(left and right): runs parallel to the spine through the inferior angle of the scapula

  9. For exact localization any abnormality should be described as being:(1)how many centimeters medial or lateral to the lines of reference,or (2)in a specific interspace or interspaces.

  10. BONE LANDMARKS • On the anterior thoracic wall • the sternal angle is a help landmark.This is a visible angulation of the sternum that corresponds to the second rib and serves as a convenient starting point for counting ribs.It is also significant in that it indicates the location of other important structures within the thorax that normally lie at the same level:(1)the fifth thoracic vertebra,(2)the bifurcation of the trachea,and (3)the upper level of the atria of the heart.

  11. BONE LANDMARKS • Rib • A total of 12 pairs.Each connects to the corresponding thoracic vertebra.The ribs run obliquely to the lateral and then to the anterior direction,with smaller oblique angle above and larger angle lower.

  12. BONE LANDMARKS • Interspace • The space between two adjacent ribs,used to mark the position of any lesion. • Beneath the first rib is the first interspace, and so forth.

  13. BONE LANDMARKS • On the posterior thorax • the vertebra prominens (seventh cervical vertebra)is usually found with ease at the base of the neck and serves as a convenient landmark to help identify the thoracic vertebrae and posterior ribs.

  14. BONE LANDMARKS • Scapula • Its inferior end is called inferior angle. When the patient is in standing position with his arms hanging naturally, the inferior angle acts as the mark of the seventh rib,or the seventh interspace.

  15. In additions,you must have exact knowledge of the location of the underlying thoracic structures and those in the upper abdomen.

  16. NATURAL FOSSA AND ANATOMIC REGION • On the anterior thorax: Suprasternal fossa,supraclavicular fossa(left,right),infraclavicular fossa(left,right) • On the lateral wall of the chest: Axillary fossa(left,right) • On the posterior thorax: Suprascapular region (left,right),infrascapular region (left,right),interscapular region

  17. The boundary of lung and pleura • Trachea bifurcates into the left and the right primary bronchus at the sternal angle level,then enters into the left and right lungs. • The right primary bronchus:wider,shorter and steeper • The left primary bronchus:slender and oblique

  18. The boundary of lung and pleura • The right lung: 3 lobes (upper,middle and lower) the left lung: 2 lobes(upper,lower)

  19. The apices of the lungs extend for approximately 3 cm above the clavicle on each side. • Boundaries between lobes called fissure.On the right the fissure between the upper and middle lobes and the lower lobe is often called right oblique fissure,the fissure between the upper and middle lobes is often called the horizontal fissure.On the left the fissure between the upper and lower lobes is the left oblique fissure.

  20. It will be seen that the anterior aspect of the right chest is composed principally of the upper and middle lobes,and the upper lobe lies beneath the major portion of the left anterior hemithorax.On both hemithoraces the lower lobes present only a small portion anterolaterally and inferiorly.Posteriorly a very large proportion of the thorax is occupied by the lower lobes with only a small area of the upper lobes presenting superiorly.

  21. The boundary of lung and pleura • Pleura Visceral pleura:the pleura covering the surface of the lung Parietal pleura: the pleura covering the inner surface of the chest wall,the diaphragm,and the mediastinum

  22. On the right, the dome of the diaphragm is situated at a level approximating the fifth rib or fifth interspace at the midclavicular line.The dome of the left diaphragm is ordinarily about 1 inch lower than the right.

  23. THORAX AND LUNGS

  24. INSPECTION Inspection of the chest,productive of the maximum amount of information, requires the following: • 1. First and foremost,a definite desire to see and to appreciate every visible abnormality • 2. The patient stripped to the waist • 3. Good lighting

  25. INSPECTION • 4. A thorough knowledge of topographic anatomy • 5. The examiner and patient in a comfortable position throughout the examination. If either the physician or patient is uncomfortable,the examination may be hurried and consequently less thorough. It is important that the patient be absolutely straight,whether seated or supine.

  26. INSPECTION Normal thorax You should appreciate that in normal subjects there is a wide variation in the size and shape of the thorax.At times it is difficult to be certain where the normal variations and definite pathologic changes begin.

  27. INSPECTION Normal thorax The anteroposterior diameter of the thorax in the normal adult is definitely less than the transverse diameter.

  28. INSPECTION what to observe • 1.First: the general nutrition and musculoskeletal development 2.Next: the skin and breasts • 3.vein and subcutaneous emphysema

  29. INSPECTION • 4.the anteroposterior diameter of the thorax persons with pulmonary emphysema --barrel chest • 5.the general slope of the ribs normal : 45 º degree angle patients with emphysema :the ribs are nearly horizontal ; this angle becomes abnormally wide

  30. INSPECTION • 6.retraction or bulging of interspaces • Retraction of the interspaces:obstruction of the respiratory tract • Bulging of interspaces :a massive pleural effusion,tension pneumothorax

  31. INSPECTION • 7.the rate and depth of quiet breathing • in the adult at rest the normal respiratory rate is approximately 16 to 18 breaths per minute and is quite regular in depth and rhythm • increase in the respiratory rate :fever

  32. INSPECTION • 8.Alterations in shape of the thorax • In the normal subject,the two sides of the chest move synchronously and expand equally • Unilateral retraction of the thorax :a thickened fibrotic pleura • Pigeon chest • Funnel chest

  33. INSPECTION • 9.Types of respiration • (1)Dyspnea :difficulty or effort in breathing ; participation of the accessory respiratory muscles • Inspiratory dyspnea :obstruction of the trachea or major bronchi (tumor,laryngitis) • Expiratory dyspnea :obstruction in the bronchioles and smaller bronchi (asthma)

  34. INSPECTION • 9.Types of respiration • (2)Bradypnea : abnormal slowing of respiration • (3)Apnea : temporary cessation of breathing • (4)Tachypnea : increased respiratory rate • (5)Hyperpnea : an increase in thedepth of respiration • (6)Hyperventilation :an abnormal increase in both rate and depth of respiration(it is seen in diabetic acidosis and highly emotional states)

  35. INSPECTION • 9.Types of respiration • (7)Pleuritic or restrained breathing :the inspiratory phase is suddenly interrupted as a result of pain associated with acute pleuritis ; The respirations are quite shallow but more rapid than normal

  36. INSPECTION • 9.Types of respiration • (8)tidal respiration :is characterized by periods of rapidly increasing rate and depth of respiration, which within a matter of a few more respiratory cycles becomes shallower and shallower until respiration ceases.This is followed by a period of apnea,which may last a few seconds to as long as 30 seconds.periodic respiration may be present in many relatively severe disease states.

  37. INSPECTION • 9.Types of respiration • (9)Sighing respiration :occurs when the normal respiratory rhythm is interrupted by a deep inspiration,which is followed by a prolonged expiration and ordinarily is accompanied by audible sighing. it is rarely associated with organic disease;instead it is almost always a manifestation of emotional tension.

  38. INSPECTION • 9.Types of respiration • (10)Ataxic breathing: is characterized by unpredictable irregularity . Breaths may be shallow or deep,and stop for short periods.

  39. PALPATION Thoracic expansion • Variations in expansion are more readily detectable on the anterior surface where there is greater range of motion. • The examiner's hands should be placed over the lower anterolateral aspect of the chest. • Expansion should be tested during both quiet and deep inspiration.

  40. PALPATION Thoracic expansion • Expansion may be limited as the result of acute pleurisy,fibrous thickening of the pleura (fibrothorax),fractured ribs,or other trauma to the chest wall.

  41. PALPATION Fremitus • Vocal fremitus :Vocal fremitus is a palpable vibration of the thoracic wall produced by phonation .

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