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It is necessary for the patient to be stripped to the waist. Usually, the patient
lies in a recumbent or semi-recumbent position with arms abducted, when the
anterior and lateral aspects of the chest are being examined, and sit upright with
arms folded across the chest, when the posterior aspect of the chest is being
examined. When the patient cannot sit, the posterior chest may be examined by
turning the patient on his lateral sides. Always compare between identical points
or areas on both sides of the chest.
The right lung is composed of three lobes (the upper, middle and lower
lobes) separated from each other by the minor and major interlobar fissures,
while the left lung is composed of two lobes only (the upper and lower lobes)
separated by the major interlobar fissure only. The right lung is composed of 10
bronchopulmonary segments: the upper lobe has three segments (anterior, apical
and posterior), the middle lobe has two segments (medial and lateral) and the
lower lobe has five segments (apical, anterior, posterior, medial and lateral),
while the left lung is composed of 8 bronchopulmonary segments only: the
upper lobe has two segments (anterior and apicoposterior), the lingula has two
segments (superior and inferior) and the lower lobe has four segments (apical,
anterior, posterior, and lateral).
the apex. On the left side: The landmarks are the same with the exception
that the lung border turns away from sternum at 4th till the 6th costal cartilage
(to the parasternal line) where it turns laterally, due to the heart, which lies in
contact with chest wall in this area.
2- Pleurae: The pleura lies so close to the lungs at the apices and along the
inner margins, so following the same surface markings, but the at the lower
borders of the lungs the pleura extends farther (reaching the level of 8th rib in
the midclavicular line, level of the 10th rib in the midaxillary line and level of
12th thoracic vertebra in paravertebral line).
Anterior
Posterior
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Surface anatomy of the lungs and pleurae from anterior and posterior
3- Kronig’s isthmus:
a- Anterior: Medial 2/3 of the clavicle.
b- Posterior: Medial 1/3 of spine of scapula.
c- Medial: A line joining sternoclavicular joint with the 7th cervical spine
posteriorly.
d- Lateral: A line joining point A (junction of medial 2/3 of clavicle with
outer 1/3) and point B (junction of medial 1/3 of spine of scapula with
lateral 2/3).
4- Lung fissures:
a- The oblique fissure (both lungs): a line drawn from the 3rd thoracic spine
posteriorly slanting downwards and laterally to cut the 5th rib in the
midaxillary line and ends at the 6th costal cartilage anteriorly 3 inches
from middle line. It also divides the axilla into upper and lower axillary
areas.
b- The transverse fissure (right lung only): a line drawn laterally from the
costal cartilage of the 4th rib to meet the oblique fissure at the 5th rib in
midaxillary line.
6- Bare area of Heart: An area over the anterior chest wall extending from
the 4th to the 6th costal cartilages and from the left sternal border to the left
parasternal line.
7- Heart:
a- Left 5th intercostal space, 3.5 inches from median plane.
b- Left 2nd costal cartilage, 1.5 inches from median plane.
c- Right 3rd costal cartilage, 1.0 inches from median plane.
d- Right 6th costal cartilage, 0.5 inches from median plane.
INSPECTION
Chest is inspected from the head or from the foot. If the patient is too ill to sit
up, the back is examined by rolling the patient on each side in turn.
1- Shape of the chest:
The healthy chest is an ellipse in cross section (the anteroposterior to
transverse diameters in the ratio of 5:7), bilaterally symmetrical with smooth
contours, the ribs are oblique and the subcostal angle is about 70-110o. Chest
diameters are measured by the pelvimeter. Abnormal shapes of chest that
may be present are:
a- Barrel chest: The anteroposterior diameter is increased, ribs are
horizontally placed with wide intercostals spaces, spine becomes concave
forwards, sternum is much more arched and the subcostal angle is obtuse.
This deformity is present in emphysema.
b- Funnel chest: An exaggeration of normal depression seen at end of the
sternum, often congenital but may be acquired in shoemakers (pectus
excavatum). It is due to fibrous replacement of the anterior portion of the
diaphragm. It is usually asymptomatic, but when there is marked degree
of depression of the sternum, the heart may be compressed and apex
shifted to left with reduction in the lungs ventilatory capacity.
c- Rachitic chest: A groove in the region of costochondral junctions during
inspiration (Harrison’s sulcus) with swellings of costochondral junctions
(Rachitic rosary).
d- Pigeon’s chest: The sternum becomes prominent and the chest acquires a
triangular form (pectus carinatum). The congenital form is due to
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PALPATION
1- Form of the chest: Diameters of the chest are measured by the pelvimeter.
The sternum and ribs should be palpated for any masses. It is important to
examine the vertebral column by passing your fingers (the thumb and index
fingers) along the lateral borders of the spine from above downwards to see if
there is kyphosis, scoliosis or kyphoscoliosis. Scoliosis may be acquired
(secondary to lung or pleural diseases where the curve of spine is towards the
diseased side) or congenital (curve of spine is towards the healthy side).
2- Trachea:
a- Position of the trachea is determined by thrusting the tip of the index
finger gently into the suprasternal notch and noticing the resistance on
each side of the trachea, the side with least resistance indicates that the
trachea is shifted to the other side.
b- Normally, trachea is central in its cervical part and slightly shifted to the
right in its intrathoracic part, this shift is not felt clinically.
c- A downward movement of the trachea and larynx during inspiration,
detected by thumb and index fingers on the sides of the thyroid cartilage,
is felt in COPD patients due to contractions of the low flat diaphragm.
d- Tracheal tug (downward pull on the trachea and larynx during systole) is
felt in cases of aortic aneurysm.
3- Local tenderness:
• Search for local tenderness by superficial palpation of the chest while
looking at the patient’s face to see if there is pain at special areas.
• Subcutaneous emphysema is recognized by the crackling sensation.
4- Tactile vocal fremitus (TVF):
a- This sign detects vibrations transmitted to the hand from the larynx.
While putting palm of the same hand on the chest in identical areas on
the both sides in turn, the patient is asked to say 44 in Arabic.
b- Pathologically, vocal fremitus is diminished when a bronchus is blocked
as in tumors and in pleural effusion or pneumothorax, which damps
down vibrations.
c- Increased vocal fremitus occurs when vibrations are better conducted as
in cases of:
10
(1) (2)
Suprascapular areas Subscapular areas
Estimation of chest movement posteriorly
7- Pulsations:
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PERCUSSION
b- Pneumoperitoneum.
c- Cirrhotic shrunken liver.
d- Splenectomy.
e- Dilatation of the stomach.
Anterior Posterior
Areas of percussion
Anterior Posterior
Tidal percussion
AUSCULTATION
1- Normal breath sounds are generated by turbulence of air in the
large airways. They are composed of two elements: the bronchial and the
vesicular elements.
2- Normally, expiration is longer than inspiration, with
inspiration/expiration ratio of 1:1.33, but clinically inspiration is heard longer
than expiration because flow of air is turbulent (active process) while it is
laminar in expiration (passive process).
3- Auscultation determines:
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Anterior Posterior
17
Areas of auscultation
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