Local chest examination

Local chest examination

1. Local chest examination Dr. Abeer Abdulkareem Ibrahim

2. R WIIPPPPEe P osition the patient on the bed . P ain(ask if the patient if he has any pain ). 8. P rivacy . 9. E xplain the examination . 10. E xpose adequately . R ight side . W ash or W arm hands . I ntroduce yourself . I dentity of patient ( Name /DOB) . P ermission (gain consent ) .

3. P - Position the patient. In this examination the patient should be supine and reclined at sitting position or 45 degrees. E - Expose the necessary parts of the patient. Ideally the patient should be undressed from the waist up , taking care to ensure the patient is not cold . preparation

4. Respiratory General Appearance Evidence of respiratory distress (Includes all of the following steps.) Observe rate, rhythm, depth, and effort of breathing Assess patient’s color, looking for cyanosis Listen to patient’s breathing for audible wheezing Look for use of accessory muscles (Look at neck and supraclavicular area.) Note any retraction of the intercostal muscles during inspiration (Check lower interspaces anteriorly and posteriorly.) Stand in front of the patient and OBSERVE

5. Local Examination framework

6. Local Examination framework

7. Inspection of the chest Shape of the chest (normal or there is deformity) Scars Apical pulsation and intercostal spaces Movement of the chest ASK THE PATIENT to take deep breath and observe chest wall, ( symmetrical or a symmetrical movement) Breathing pattern (abdominothoracic in male thoracoabdominal in female)

8. Pectus excavatum Scar P ectus carinatum( pigeon chest) Normal chest wall

9. Palpation Tenderness Trachea Apex beat Chest expansion Tactile vocal fremitus

10. Palpation 2-Trachea 4-5 cm of the upper trachea can be felt in the neck above the sternal notch. Pushed –pneumothorax -pleural effusion Pulled -fibrosis -collapse

11. 3-Apex beat Located at the 5th intercostal space / midclavicular line Palpate the apex beat with your fingers (placed horizontally across the chest)

12. 4-Chest expansion Place your hands on the patient’s chest, inferior to the nipples Wrap your fingers around either side of the chest Bring your thumbs together in the midline, so that they touch Ask patient to take a deep breath Observe movement of your thumbs, they should move apart equally If one of your thumbs moves less, this suggests reduced expansion on that side Abnormal Chest expansion: Less than 2 cm Reduced expansion can be caused by lung collapse / pneumonia

13. 5-Tactile vocal fremitus This is the vibration felt on the chest as the patient speaks. Each part of the chest is tested. Place the medial edge (ulnar) of your hand horizontally against the chest. Ask the patient to say “99” or “1, 1, 1.” You should feel the vibration against your hand. Abnormal finding: ↑ Vibration in consolidation ↓ In pneumothorax, collapse, COPD and pleural effusion (It gives the same information as vocal resonance testing so it is now rarely tested)

14. Palpation of the trachea

15. Percussion Place your non-dominant hand on the chest wall Your middle finger should overlie the area you want to percuss ( between ribs) With your dominant hand’s middle finger, strike the middle phalanx of your non-dominant hand’s middle finger Percussion technique Supraclavicular (lung apices) Infraclavicular Chest wall  Axilla Percuss the following areas, comparing side to side: Resonant – this is a normal finding Dullness –  fluid / tumor Types of percussion note

16. Introduction to Auscultation Auscultation is the term for listening to the internal sounds of the body Auscultation is performed for the purposes of examining: The circulatory system The respiratory system The gastrointestinal system (bowel sounds).

17. STETHOSCOPE

18. The bell is designed to hear low pitched sounds The diaphragm is designed to hear high pitched sounds. How are these worn? These should be worn …….. !!!!! facing forward .

19. Incorrect Positioning Proper insertion

20. Chest Auscultation Listen one full respiration at each spot Compare one side to the other Listen for the breath sounds and any added sounds. (“keep going, in and out”) will help. Ladder pattern

21. Auscultation involves Listening to the sounds generated by breathing Listening for any adventitious (added) sounds Listening to the sounds of the patient’s spoken as they are transmitted through the chest wall. (vocal resonance)

22. 1- Breath sounds (lung sound) Produced by airflow in the large airways and larynx and altered by passage through the small airways before reaching the stethoscope. Reduced sound: Local : Effusion, tumor, pneumothorax, pneumonia. Global : Asthma Vesicular breathing:

23. Bronchial breathing: caused by ↑ density of matter in the peripheral lung, allowing sound from the larynx to the stethoscope unchanged, has a hollow, blowing quality, heard equally in inspiration and expiration, often with a brief pause between. A similar sound can be heard by listening over the trachea in the neck. Bronchial breathing is heard over consolidation, lung abscess at the chest wall, and with dense fibrosis.

24. Sound like the pop of cereal. They are heard in inspiration. Crackles are often a normal finding at the lung bases , they will clear after asking the patient to cough Causes include fluid or infection . Musical sounds caused by narrowed airways. It is heard easier in expiration Crackles ( crepitations , rales): Wheeze (rhonchi): 2- Added sounds

25. 3- Vocal resonance Auscultatory equivalent of vocal fremitus Ask the patient to say “99” or 1, 1, 1” and listen over the same areas as before.

26. Inspection: Shape of the chest or deformity Movement of the chest (symmetrical or asymmetrical) and Breathing pattern Scars Apical pulsation. Intercostal space Palpation: Position of trachea Apex beat Chest expansion Local rib tenderness Vocal fremitus Percussion: Percussion note Percussion technique Auscultation: Breath sound Added sound (rhonchi, crepitation) Vocal sound