Chest Exam / Lung Topography

1. Chest Exam / Lung Topography

2. Physical examination employs the use of inspection, palpation, percussion, and auscultation to determine patients’ clinical status and their response to therapy • Each examination is modified according to the purpose of the examination • Physical examination skills develop over time with practice

3. Examination of the Headand Neck • Identify the patient’s facial expression, looking for evidence of pain or acute distress • Look for evidence of cyanosis around the lips and oral mucosa • Patients may use pursed-lip breathing when COPD is present

4. Eyes • The eyes are inspected for pupillary response to light when neurologic defects are suspected • Dilated and fixed pupils suggest brain death in some patients • The eyelids may droop (ptosis), indicating damage to the third cranial nerve

5. Neck • The trachea should be midline • If it is deviated to one side, a unilateral lung problem is probably present • Atelectasis • pneumothorax • The status of the jugular veins in the neck is important • Patients with cor pulmonale have JVD • Use of accessory muscles in the neck suggests obstructive lung disease

6. Lung Topography • Anterior chest is defined by the midsternal and midclavicular lines

7. Lung Topography • Lateral chest is defined by midaxillary, anterior axillary and posterior axillary lines

8. Lung Topography • Posterior chest is defined by the midspinal and midscapular lines

9. Thoracic Cage Landmarks

10. Thoracic Cage Landmarks • On the posterior chest, C7 is seen as the most prominent spinous process at the base of the neck

11. Thoracic Cage Landmarks • The angle of Louis, or sternal angle, is located on the anterior chest. • Formed by the ridge between the manubrium and the gladiolus

12. Lung Fissures • The oblique fissure • starts at rib six on the anterior chest at the midclavicular line • It runs up and laterally crosses the midaxillary line at fifth rib and across the posterior chest, ending at T3 • horizontal fissure • passes from the fourth rib at the midsternal line laterally to the fifth rib in the midaxillary line

13. Tracheal Bifurcation • At T4 on posterior chest • At sternal angle on anterior chest

14. Tracheal Bifurcation

15. Diaphragm • The diaphragm is a dome-shaped muscle • The top of the dome rests at about the fifth rib anteriorly and at T9 on the posterior chest normally

16. Lung Borders • On the anterior chest the upper border of the lung extends 2 to 4 cm above the medial third of the clavicles. The inferior border of the lung is at rib six normally

17. Lung Borders • On the lateral chest the lower margin of the lung is at rib eight

18. Lung Borders • On the posterior chest the superior border of the lung extends to T1. The inferior border varies with breathing but is usually at about T10

19. Examination of the Thorax • Look • Feel • Listen

20. Look For • A barrel chest or evaluate the A-P diameter • An in crease A-P diameter is consistent with COPD

21. Look For • Kyphoscoliosis is present when the spine is bent laterally and from front to back • Can causea restrictive lung problem

22. Look For • Pectus carinatum is seen as an abnormal sternal protrusion

23. Look For • Pectus excavatum is seen as depression of the sternum

24. Look For • Breathing pattern is important to identify when lung disease is present • Rapid and shallow breathing is consistent with restrictive disease • A prolonged expiratory time is consistent with obstructive lung disease • Retractions are seen as inward depression of the skin around the rib cage with inspiration • This suggests a high work of breathing (WOB) • Abdominal paradox is seen as inward movement of the abdomen with inspiration • This suggests diaphragm paralysis or fatigue • Hoover’s sign is seen as inward movement of the lateral chest with inspiration. It is a sign of severe COPD.

25. Feel For (Palpation) • Vocal fremitus is assessed to identify pathologic changes in the lung. • Increased vocal fremitus is consistent with pneumonia and atelectasis. • Decreased vocal fremitus is consistent with lung hyperinflation, pleural disorders, and obesity.

26. Palpation

27. Palpation • Use palpation to assess for uniform chest excursion

28. Percussion • Percussion is done to determine the condition of the underlying lung. • Increased resonance is heard with pneumothorax and lung hyperinflation. • Decreased resonance is heard with pneumonia and atelectasis.