Thorax Examination

Inspection
 Shape & symmetry of the chest
AP Ø > lateral Ø → barrel shape, hyperinflation,
asthma, emphysema.
Pigeon Chest (pectus carinatum) → localised
prominence (outward bowing of the sternum &
costal cartilage) → chronic childhood respiratory
illness, rickets.
Funnel chest (pectus excavatum) → localised
depression of the lower end of sternum →
aesthetic, restricted lung capacity.
Kyphoscoliosis, scarrs, deformity
 Palpation
 Chest Expansion → thumbs should move
symmetricaly apart at least 5 cm.
 Apex beat
→ displacement towards side of the lesion :
collapse of the lower lobe, localised
pulmonary fibrosis.
→ away from the side of the lession : pleural
effusion, tension pneumothorax
 → impalpable in hyperexpanded lung
(chronic airflow limitation).
 Vocal fremitus : “ninety-nine”, front & back,
two comparable positions, ~ vocal
resonance.
 Ribs : Pain ; rib fracture, tumor deposition,
bone disease.
Percussion
 Symmetrical areas of the anterior, posterior,
axillary regions. In supraclavicular fossa → apex
of the lung.
 Resonant : normal, dull : consolidation, extremelly
dull/stony dull : fluid fill area (pleural effusion),
hyperresonant : pneumothorax
 Liver dullness (upper level) : normally, the fifth rib
in right MCL. If resonant → emphysema or
asthma.
 Cardiac dullness : decreased in emphysema.
Auscultation
 Normal (vesicular) breath sounds : louder &
longer on inspiration than on expiration, there
are no gap. Air turbulence in the large airways
filtered through the normal lung to the chestwall.
 Bronchial breath sound :
without filtered, hollow-blowing quality, gap
between inspiration & expiration, higher intensity
& pitch exp sound, consolidation conducts the
sound.
 Amphoric sound (very hollow) : air passes
over the top of a hollow jar. Large cavity.
 Intensity of the breath sound :
reduce: emphysema, pleural effusion,
pneumothorax, large neoplasm, pulmonary
collaps.
 Added (advetitious) sounds:
continuous → wheezing, continuous
oscilation of opposing airway walls → airway
narrowing. Louder on expiration, inspiratory
wheeze → severe airway narrowing.
asthma (high pitched) or chronic (low pitched)
→ bronchial muscle spasm, mucosal oedema
& excessive secretions.
localised wheeze → lung Ca.
 Interrupted non- musical sounds →
Crackles
low pitch → rales, high pitch → crepitation.
loss of stability of peripheral airways wich collapse
on expiration. High inspr pressure → rapid air
entry into distal airways → abrupt opening of
alveoli & small / medium sized bronchi containing
secretion.
early inspiratory: disease of small airways.
late / pan inspratory : alveoli, coarse crackles:
pools of retained secretions
 Pleural Friction Rub :
thickened, roughened pleural surface rub →
pleurisy, malignant of pleura, spontaneous
pneumothorax ( pleurodynia).
 Vocal resonance :
Consolidated lung → tend to transmit high
frequencies.
whispering pectoriloque : whispered speech
is distincly heard.
 Comparison of the chest signs in common respiratory disorders
Disorder Mediastinal Chest wall Percussion Breath Added sounds
displacement movement sounds

Consolidation none Reduced over Dull Bronchial Crackles

affected area

Collapse Ipsilateral shift Decreased over Dull Absent or Absent

affected area reduced

Pleural Effusion Heart displaced to Reduced over Stony dull Absent over Absent,
opposite side affected area fluid; may be pleural rub
bronchial at maybe found
upper border above
effusion
Pneumothorax Tracheal Decreased over Resonant Absent or Absent
deviation to affected area greatly
opposite side if reduced
under tension

Bronchial none Decreased Normal or Normal or Wheeze

asthma symmetrically decreased reduced

Interstitial none Decreased Normal Normal Fine

pulmonary symmetrically inspiratory
fibrosis (minimal) crackles over
affected lobes
 Thorax :
 Inspection: static : D > S, dinamic : D < S
scarr ?
 Palpation : Stem/vocal fremitus : D < S
Pain ?, Crepitation ?

 Percussion : DS
DS
DS
 Auscultation : - V Rh: -- Wh: - -
- V -- --
- V -- --