Physical examinatio+cxr

Respiratory system 1
In The name of God

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Physical Examination
of the Chest

‫ﻣﻌﺎﯾﻨﮫ ﻓﯿﺰﯾﮑﯽ ﺳﯿﺴﺘﻢ ﺗﻨﻔﺲ‬


Diagram of Thoracic Area


Chest Topography:
Anterior Chest


Chest Topography:
Lateral Chest


Chest Topography:
Posterior Chest


Respiratory tract anatomy

fig 13-1
8


Lung Anatomy
• Right Lung
– Superior lobe
– Middle lobe
– Inferior lobe
• Left Lung
– Superior lobe
– Inferior lobe


Fissures:


Location of Lobes


Lung Anterior


Lung Posterior


Lung Left Side


Lung Right Side


Physical Exam Techniques
• Observation
• Palpation
• Percussion
• Auscultation


Observation:
Breathing Patterns
• Apnea
• Tachypnea/Bradypnea
• Biot’s
• Cheynes-Stokes
• Kussmaul


Observation:
Thoracic Contour


Observation: Thoracic Contour
(cont.)
• Pectus Excavatum
• Pectus Carinatum
• Kyphosis
• Scoliosis
• Kyphoscoliosis
• Symmetry of chest movement


Barrel Chest


Scoliosis


Kyphosis

Slide 18-22


Observation: Clubbing


Palpation: Tracheal Alignment


Tracheal Alignment
Abnormalities
• Pneumothorax – shifts to unaffected side
• Pleural Effusion – shifts to unaffected side
• Fibrosis or Atelectasis – shifts towards
affected side
• Pulmonary consolidation – no shift


Palpation : Chest Excursion


Palpation: Vocal Fremitus
• BILATERAL comparison
of vocal vibrations
• Increased with alveolar
consolidation
• Decreased with increased
distance between lung and
chest wall
– Pneumothorax, Pleural
effusion


Percussion
• Assess density of
underlying tissue


Percussion Notes
• Resonance – normal
• Dullness – increased density
– Atelectasis, alveolar filling/consolidation,
pleural effusion, fibrosis
• Hyperresonance – decreased density
– Hyperinflation (COPD), Pneumothorax


Lets all listen in


Auscultation: Listening to breath
sounds with a stethoscope


Normal Breath Sounds and Their
Locations


Abnormal Breath Sounds:
Diminished or Absent

• Increased distance between aerated lung and
chest wall:
– Pneumothorax, Pleural effusion, Atelectasis,
Obesity around thorax
• Decreased or absent airflow
– Airflow obstruction (eg asthma), Hyperinflation
(COPD), Malpositioned ET Tube


Bronchial or Bronchovesicular
in abnormal part of the lung

• Lung has become more solid and less
aerated in these areas
• Consolidation, eg, pneumonia, or
Atelectasis


Adventitious Sounds

• Wheeze – continuous musical sounds heard
mostly during expiration
– May be also heard on inspiration
• Caused by a sudden change in airway
caliber
– Edema, spasm, secretions, foreign body


Adventitious Sounds

• Crackles – discontinuous sound heard
mostly on inspiration
• Caused by small airways and alveoli
popping open or from secretions in very
large airways


Condition Chest Fremitus Percussion Breath
Excursion Sounds
Atelectasis

Pneumothorax

Pleural Effusion
COPD

Pulmonary
Consolidation
Fibrosis
Pulmonary
Edema


Techniques - Projection
•P-A (relation of x-ray beam to patient)


Techniques - Projection (continued)
•Lateral


•Lateral Decubitus


•Oblique


The Normal Chest X-ray
• PA View:
1. Aortic arch
2. Pulmonary trunk
3. Left atrial appendage
4. Left ventricle
5. Right ventricle
6. Superior vena cava
7. Right hemidiaphragm
8. Left hemidiaphragm
9. Horizontal fissure


Lung Anatomy
• Trachea
• Carina
• Right and Left Pulmonary
Bronchi
• Secondary Bronchi
• Tertiary Bronchi
• Bronchioles
• Alveolar Duct
• Alveoli


Anatomy


Rotation


Rotation (continued)


Penetration


Inspiration/Expiration


Technical Details
•Type
•Rotation
•Inspiration/expiration
•Penetration


Summary of Density
• Air
• Water
• Bone
• Tissue

Tissu
e


Densities
The big two densities are:

(1) WHITE - Bone
(2) BLACK - Air

The others are:

(3) DARK GREY- Fat
(4) GREY- Soft tissue/water

And if anything Man-made is on the film, it is:

(5) BRIGHT WHITE - Man-made


Pitfalls to Chest X-ray
Interpretation
• Poor inspiration
• Over or under penetration
• Rotation
• Forgetting the path of the x-ray beam


Systematic Approach
• Soft Tissues
– Breast shadows
– Supraclavicular areas
– Axillae
– Tissues along side of
breasts


Systematic Approach
• Diaphragm and
Pleural Surfaces
– Diaphragm
• Dome-shaped
• Costophrenic angles
– Normal pleural is not
visible
– Interlobar fissures


Mediastinum


Hilum


Hilum

Made of:

1. Pulmonary Art.+Veins
2. The Bronchi

Left Hilus higher (max 1-2,5 cm)

Identical: size, shape, density


Ribs


Lung Anatomy on Chest X-ray
• The right upper lobe
(RUL) occupies the upper
1/3 of the right lung.
• Posteriorly, the RUL is
adjacent to the first three
to five ribs.
• Anteriorly, the RUL
extends inferiorly as far as
the 4th right anterior rib


• The right middle lobe
is typically the
smallest of the three,
and appears triangular
in shape, being
narrowest near the
hilum


• The right lower lobe is the
largest of all three lobes,
separated from the others by
the major fissure.
• Posteriorly, the RLL extend
as far superiorly as the 6th
thoracic vertebral body, and
extends inferiorly to the
diaphragm.
• Review of the lateral plain
film surprisingly shows the
superior extent of the RLL.


• These lobes can be separated
from one another by two
fissures.
• The minor fissure separates
the RUL from the RML, and
thus represents the visceral
pleural surfaces of both of
these lobes.
• Oriented obliquely, the
major fissure extends
posteriorly and superiorly
approximately to the level of
the fourth vertebral body.


• The lobar architecture
of the left lung is
slightly different than
the right.
• Because there is no
defined left minor
fissure, there are only
two lobes on the left;
the left upper


• These two lobes are
separated by a major
fissure, identical to that
seen on the right side,
although often slightly
more inferior in location.
• The portion of the left
lung that corresponds
anatomically to the right
middle lobe is
incorporated into the left
upper lobe.


The Silhouette Sign
• An intra-thoracic radio-
opacity, if in anatomic
contact with a border of
heart or aorta, will obscure
that border. An intra-
thoracic lesion not
anatomically contiguous
with a border or a normal
structure will not
obliterate that border.


Pathology


RUL pneumonia

RML pneumonia

RLL pneumonia

LUL pneumonia

LLL pneumonia

Consolidation on CT

Hilar m l

The Enlarged Hila
Causes:

1. Adenopathies (neoplasia, infection)

2. Primary Tumor

3. Vascular

4. Sarcoidosis


Multiple Masses

Hilar Lymphadenopathy - BL

Pleural Effusion

Pulmonary Fibrosis

Heart failure

Pneumothorax

RUL collapse

Emphysema

Cervical Rib

Cavitating lesion

Hiatus hernia

Chest Tube, NG Tube, Pulm. artery cath

Physical examinatio+cxr

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Physical examinatio+cxr