Chest Physical Examination IMS

Chest Physical Examination
Francesco Tarantini, MD PhD

Luca Novelli, MD
Caterina Conti, MD
Respiratory Unit, Papa Giovanni XXIII Hospital
Bergamo
School of Medicine and Surgery

Let’s go back to anatomy…
Anatomic Landmarks
1. NIPPLES and STERNUM
2. Manubriosternal junction (ANGLE OF LOUIS) the
point at which the 2° rib articulates with the
sternum
3. Intercostal spaces and RIBS are counted from this
reference point
4. SUPRASTERNAL NOTCH
5. VERTEBRA PROMINENS (Spinous process of C7)
Diaphragm 6. CLAVICLES
Chest Lines Midclavicular line Midsternal line
Right
Anterioraxillary line
Posterioraxillary line
Left
Anterioraxillary line Midlaxillary line
Physical Examination
4 steps:
1. INSPECTION/OBSERVATION
2. PALPATION
3. PERCUSSION
4. AUSCULTATION
+ Vital Signs evaluation

Inspection & Observation
Exposure is a key point

…you can’t describe
what you can’t see!
Inspection & Observation
Spine and Thorax
Watch the patient in standing position and look:
 Shape of spine
 Stand behind patient, inviting to bend at waist
 Scoliosis (curvature to one side and higher shoulder)
 Kyphosis (abnormally excessive convex curvature of the
spine)
Chest wall abnormality may affect pulmonary function

Linear diaphragm as hyperinflation due to
Chronic Ostructive Pulmonary Disease (COPD) and Obesity
BLUE BLOATER - PINK PUFFER
CLUBBING enlargement of the terminal phalanges of the fingers and/or toes is
associated with emphysema, lung cancer, congenital heart disease, cirrhosis, or cystic
fibrosis
Spasm of arteries cause episodes of
reduced blood flow triggered by cold or
emotional stress
It could be secondary to a connective

tissue and thyroid disorder
Other characteristics of
the hands to describe
Subcutaneous emphysema
• Gas or air is in the layer under the skin
• Subcutaneous  beneath the skin
• Emphysema  trapped air
• usually occurs on the chest, neck and
face, where it is able to travel from the
chest cavity along the fascia.
• Characteristic crackling feel to the
touch, a sensation that has been
described as similar to touching snow
(or Rice Krispies!)  subcutaneous
crepitation.
Dyspnea
A subjective experience of breathing discomfort that consists of
qualitatively distinct sensations that vary in intensity
…Symptom or Sign?
Investigate Dyspnea features:
- Acute or Chronic
- Night and Daytime
- At rest and/or exertional
- With or without respiratory sounds
- With or without chest pain
- Changing by position
Dyspnea
(as a Sign)
Modiefied
DYSPNEA VISUAL SCALE (VAS)

 Is there breathing difficulty (DYSPNEA) during efforts
 High frequency of breathing TACHYPNEA
 Are there audible noises (WHEEZING)?
 Inability to speak for dyspnea?
 Pursed lips
 Lips colour: Blue (CYANOSIS) or cherry-red lips in CO toxicity
 Use of accessory muscles of neck (sternocleidomastoids, scalenes),
inter-costals for breathing (RESPIRATORY DISTRESS)
 Position requested by the patient to breath better
Palpation
• Patient in gown  chest

accessible & exposed
• Explore painful &/or
abnormally appearing areas
• Chest expansion – position
hands as below, have patient
inhale deeply  hands lift
out laterally
Palpation – Assessing Fremitus
• Fremitus = normal vibratory
sensation w/palpating hand
when patient speaks
• Place ulnar aspect (pinky side) of
hand firmly against chest wall
• Ask patient to say “99”
• You’ll feel transmitted vibratory
sensation  fremitus!
• Assess posteriorly & anteriorly
(i.e. lower & upper lobes)
• * Not Performed in the absence
of abnormal findings *
Lung Pathology - Simplified
• Lung  sponge,
pleural cavity 
plastic container
• Infiltrate (e.g.
pneumonia)  fluid
within lung tissue
• Effusion  fluid in
pleural space
(outside of lung)
Fremitus - Pathophysiology
• Fremitus:
– Increased w/consolidation (e.g. pneumonia)
– Decreased in absence of air filled lung tissue (e.g.
effusion).
Percussion
• Normal lung filled

w/air
• Tapping generates
drum-like sound 
resonance
• When no longer over
lung, percussion 
dull (decreased
resonance)
• Work in “alley”
Percussion - Technique
• Patient crosses arms in front,

grasping opposite shoulder
(pulls scapula out of way)
• Place middle finger flat against
back, other fingers off
• Strike distal interphalangeal joint
w/middle finger of other hand -
strike 2-3 times at each spot
Percussion
• Use loose, floppy wrist action –
percussing finger  hammer
• Start at top of one side  then move
across to same level, other side  R to L
(as shown)
• at Bottom of lungs, detect
diaphragmatic excursion  difference
between diaphragmatic level at full
inspiration v expiration (~5-6cm)
• Percuss upper lobes (anterior)
• Cut nails to limit pain to the patient
Percussion
• Difficult to master technique & detect tone

changes - expect to be frustrated!
• Practice – on friends, yourself (find your
stomach, tap on your cheeks, on your thigh,
etc)
• Detect fluid level in container
• Find studs in wall
Percussion:
Normal, Dull/Decreased or Hyper/Increased Resonance
 Causes of Dullness:
 Fluid outside of lung
(effusion)
 Fluid or soft tissue filling
parenchyma (e.g.
pneumonia, tumor)
 Causes of hyper- resonance:

 COPD  air trapping
 Pneumothorax (air filling
pleural space)
Auscultation
• Normal breathing creates sound  appreciated via

stethoscope over chest  “vesicular breath sounds”
or “normal breath sounds”
• Note sounds w/both expiration & inspiration –
inspiration typically more apparent
• Pay attention to:
 quality
 inspiration versus expiration
 Location
 intensity
Lobes Of Lung
• Posterior View • Anterior View
Where you listen dictates what you’ll hear!

Lobes Of Lung
• Posterior View • Anterior View
Lobes Of Lung
• Right Lateral View • Left Lateral View
Where you listen dictates what you’ll hear!

Lobes Of Lung
• Right Lateral View • Left Lateral View
Trachea
Auscultation (listening
w/Stethoscope)
• Use a Stethoscope Technique
• Patient crosses arms,
grasping opposite shoulders
• Areas To Auscult
 Posteriorly (lower lobes) ~ 6-8 places
- Alternate R  L as move down
(comparison) - ask patient to take
deep breaths trough mouth
 Right middle lobe – listen in ~ 2 spots
– lateral/anterior
 Anteriorly - Upper lobes – listen ~ 3
spots each side
 Over trachea
Pathologic Lung Sounds
• Crackles (Rales): “Scratchy” sounds associated w/fluid in

alveoli & airways (e.g. pulmonary edema, pneumonia); finer
crackles w/fibrosis
• Ronchi: “Gurgling” type noise, caused by fluid in large &
medium sized airways (e.g. bronchitis, pneumonia)
• Wheezing: Whistling type noise, loudest on expiration, caused
by air forced thru narrowed airways (e.g. asthma) – expiratory
phase prolonged (E>>>I)
• Stridor: Inspiratory whistling type sound due to tracheal
narrowing  heard best over trachea
• Bronchial Breath Sounds: Heard normally when

listening over the trachea. If consolidation (e.g.
severe pneumonia) upper airway sounds transmitted
to periphery & apparent upon auscultation over
affected area.
• Absence of Sound: In chronic severe emphysema,
often small tidal volumes & thus little air movement.
Also w/very severe asthma attack, effusions,
pneumothorax
• Egophony: in setting of suspected

consolidation, ask patient to say “eee” while
auscultating. Normally, sounds like “eee”..
Listening over consolidated area generates a nasally
“aaay” sound.
Not a common finding (but interesting)
Lung Sound Simulation
 R.A.L.E. Repository
http://www.rale.ca/Recordings.htm
 Bohadan A, et al. Fundamentals of Auscultation. NEJM 2014;

370: 744-51. Click on: Interactive Graphic - Fundamentals of
lung sound auscultation.
http://www.nejm.org/doi/full/10.1056/NEJMra1302901
TO SUM UP: Few pathognomonic findings
• Effusion • Consolidation
• Auscultation  • Auscultation 
decreased/absent bronchial breath
breath sounds sounds
• Percussion  dull • Percussion  dull
• Fremitus  • Fremitus 
decreased increased
• Egophony  absent • Egophony  present
Summary of Skills
Observe & Inspect
□ Nails, fingers, hands, arms
□ Respiratory rate
Lungs and Thorax

General observation & Inspection
□ Patient position, distress, accessory muscle use
□ Spine and Chest shape
Palpation
□ Chest excursion
□ Fremitus
Percussion
□ Alternating R & L lung fields posteriorly top bottom
□ R antero-lateral (RML), & Bilateral anteriorly (BUL)
□ Determines diaphragmatic excursion
Auscultation
ANAMNESI
• Fisiologica
• Familiare
• Lavorativa e sociale
• Propriamente detta
• Patologica
• Remota
• Prossima e motivo dell’osservazione clinica
• Farmacologica ed Allergica
Familiare
• Situazione familiare, nucleo familiare
• Patologie in anamnesi nella famiglia ed esclusione di morbosità a trasmissione
ereditaria/genetica
Lavorativa/sociale
• Indagare la storia lavorativa con particolare riferimento alle esposizione ambientali, al carico
di lavoro e rischio di tecnopatie.
• Indagare sempre la sintomatologia riferita ha correlazione temporale e spaziale rispetto al
lavoro svolto
• Contesto familiare ed abitativo, salubrità degli ambienti
• Scolarità o svolgimento del servizio militare/adesione a screening di popolazione
Propriamente detta
• Indagare alvo, diuresi, alimentazione, ritmo sonno-veglia, deambulazione, stato mnesico
• Autonomia nelle mansioni quotidiane (IADL o ADL)
• Abitudini voluttuarie (fumo [pacchi/anno], alcool [Litri o Bicchieri/die], sostanze psicoattive)
ADL
Basic Activity of Daily Living
Patologica remota
• Natalità a termine o meno/Parto eutocico o

distocico
• Comuni estantemi dell’infanzia
• Anamnesi Chirurgica
• Anamnesi Medica (principali patologie
croniche o pregresse riferite e relativo stato di
follow-up) – In genere meglio ordine
temporale (oppure per organi/apparati)
Patologica Prossima
• Breve epicrisi della clinica e della sintomatologia clinica riferita dal
paziente che ha richiesto l’osservazione medica
• Indagare bene la durata, l’esordio, le modifiche ed i trattamenti eseguiti
oltre agli esami diagnostici effettuati
Farmacologica ed Allergica
• Terapia cronica eseguita
• Indagare sempre intolleranze a farmaci o alimenti o inalanti al fine di
determinare correlazione temporale con sintomi e clinica (es. rinite
allergica)
Thanks for your attention

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Chest Physical Examination

Francesco Tarantini, MD PhD

School of Medicine and Surgery

+ Vital Signs evaluation

Exposure is a key point

Watch the patient in standing position and look:

Chest wall abnormality may affect pulmonary function

It could be secondary to a connective

Investigate Dyspnea features:

DYSPNEA VISUAL SCALE (VAS)

• Patient in gown  chest

• Normal lung filled

• Patient crosses arms in front,

• Difficult to master technique & detect tone

 Causes of hyper- resonance:

• Normal breathing creates sound  appreciated via

• Posterior View • Anterior View

Where you listen dictates what you’ll hear!

Where you listen dictates what you’ll hear!

• Crackles (Rales): “Scratchy” sounds associated w/fluid in

• Bronchial Breath Sounds: Heard normally when

• Egophony: in setting of suspected

 Bohadan A, et al. Fundamentals of Auscultation. NEJM 2014;

Lungs and Thorax

□ Spine and Chest shape

□ R antero-lateral (RML), & Bilateral anteriorly (BUL)

□ Determines diaphragmatic excursion

• Natalità a termine o meno/Parto eutocico o

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