Physical examination of the chest. Inspection. Chest pain.

Physical examination of the chest.
Inspection. Chest pain.
Inspection
Landmark on chest wall.
Physical examination of the
chest
Traditional physical examination of the chest includes four
methods.
Inspection
Palpation
Percussion
Auscultation
- warm circumstance, well light
- sitting or supine position (according to the need for the examination
or the ill condition)
Breath movement: healthy subject is steady and regular.
Inspiration: active movement, leading to the expansion of the
lung (air flowing into the lung).
Expiration: passive movement, depending on the elastical
recoil of the lung and chest---air in the lung is exhaled.
Males and children: diaphragmatic respiration.
Female: thoracic respiration
Respiratory rate: 16-20/min (in newborn and children higher).
Tachypnoe: >24/min (fever, pain, anemia, hyperthyreoidism
and heart failure), bradypnoe<12/min (overdose anesthetics
or sedatives or elevated intracranial pressure).
Chest wall deformities
Pectus excavatum
Sternum sunken into the chest
Pectus carinatum
sternum protruding from the chest
Pectus excavatum
Scoliosis
Kyphosis
Kyphoscoliosis
Inspection
Nutrition, skin, lymph nodes, development of skeleton muscles
- Vein: normally the vein on chest wall is not obviuos.
(if v. cava or their branches are blocked---veins
become
full form varicose)
Chest wall deformities
IMPORTANT:
Affects the percussion
Affects the breath and circulation
Palpation
Retraction of hemithorax
Obstruction of free air flowing into the respiratory
tract (atelectasis, pulmonary fibrosis, extensive
thickening fibrotic pleura)
Bulging of hemithorax
Massive pleural effusion, tension pneumothorax,
severe emphysema
Palpation
Subcutaneous emphysema: air enters and stores in
subcutaneous tissue (pressing the skin produce
„crepitation” or grasping snow).
Tenderness: normally ther is no tenderness on chest wall
(intercostal neuritis, costal cartilagitis, soft tissue
inflammation, rib fractures, pain on sternum occurs in
leukemia, myelodysplasia).
Respiratory expansion-check whether expansion is equal
(place your thumbs along each costal margin, and your
hands along the lateral rib cage).
Tactile fremitus-the patient says „ninety-nine”, whilst
physician sense with ulnar aspect of hand for changes in
sound conduction.
Pleural friction fremitus (inspiration and expiration too)
Examination of the breast
Inspection: symmetry (enlargement of one breast may denote
congenital deformation, cyst formation, inflammation, or tumor).
Superficial appearance: skin erythema, ulceration, pigmentation and
scars (inflammation, breats cancer).
Nipple: size, location, symmetry, inversion and secretion (tumor).
Skin retraction (trauma, inflammation, tumor).
Palpation: sitting position, patient’s arms at side first then overhead or
pressed on both hips. Supine position: shoulders can be elevated by a
small pillow putted under them to allow the breasts.
Palpation: from the upper lateral quadrant with a procedure of
clockwise direction for thorough examination (superficially and deeply
palpation)
If a MASS exist, it should be characterized as the following
features:
Location
Size (length, width and thickness)
Contour (regular or irregular, margin is dull or acute)
Consistency (soft, cystic, moderatly firm or extremely hard)
Tenderness (if tender, what degree)
Mobility (movable or fixed)
Chest pain
Pleuralgic pain, or nerve compression pain
Many causes of chest pain arise from the pleura (parietal
pleura (pain sensory nerve)).
Conditions of the lung are less likely to cause chest pain
unless they involve the pleura. (This is certainly true of
pneumonia and neoplasm).
Pleuritis: stich (mordant pain), it worsen with breath (tyni
breath).
Pleura-, lung tumor --- intercostal nerve or plexus
brachialis
Chest pain
Modality
Location
Emission (to left shoulder: angina or AMI, to back:
aorta dissection)
Temporal modality (acute or chronic)
Connection with other factors (eating, high blood
pressure, breath)
Suggestibility (drugs)
Other factors (fever, weight loss etc.)
Exams
ECG
Blood cell count
Sedimentation rate (pneumonia, infarction)
Sputum smear and culture (pneumonia)
Serum cardiac troponin levels [myocardial infarction
(MI)]
d-Dimer testing (pulmonary embolism)
Gastro-esophagoscopy (reflux esophagitis)
X-ray (pneumonia, pleuritis, radiculopathy)
Echocardiograph (pericarditis)
24-hour Holter monitoring (coronary insufficiency)
Gallbladder ultrasound