Anterior Chest Exam

INTERPERSONAL SKILLS AND PROFESSIONALISM Appropriate attire Introduce self o Student doctor o Shake hands Sweaty palms could indicate: Nervousness Thyroid problem Large hands could indicate: acromegaly

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Explain procedure o I am going to be examining your chest, lungs, and extremities today. I will inspecting these areas visually, I will also be feeling & tapping with my hands, and listening with my stethoscope Obtain permission from pt Wash hands Expose pts chest and extremities o Take off shoes

GENERAL EXAM OF RESPIRATORY SYSTEM Pt placed supine Comment on pts general appearance o Young, white, female in apparent good health Comment on rate, rhythm & effort of respiration o Take pulse 30 sec X 2 & count breaths in epigastric rgn (1220 WNL) o Rhythm = regular o Respiration is regular and effortless. Rate is 15 WNL Comment on use of accessory muscles of respiration o SCM, scalenes, abdominal mm Comment on presence of dyspnea, nasal flaring, pursed lipped breathing o Dyspnea labored or difficult breathing o Nasal flaring

w/fever indicates pneumonia w/bilateral pedal edema indicates CHF o Pursed lipped breathing indicates emphysema Comment on pallor, flushing, cyanosis o Pallor: pale anemia o Flushing: Red o Cyanosis: Blue Peripheral fingers and/or toes Due to sluggish blood flow Cold weather exposure, Raynauds disease Central Lips, tongue, fingers & toes Due to impaired lung oxygenation Pulmonary infection, edema, asthma, chronic bronchitis, methemoglobinemia Comment on nail clubbing or pitting o Look at fingers from side, then top o Clubbing Indicates: Fallots tetralogy (cyanotic congenital heart disease), lung abscess, pulmonary TB, lung cancer, Crohns, sub-acute bacterial endocarditis (SBE) CVS, GI, Resp o Pitting Indicates: psoriasis Can also be seen in: reiters syndrome, sarcoidosis, repetitive trauma (typists) Comment on peripheral edema above both ankles o Warning!!! This may cause pain! o Hands from med malleolus, Thumb joint on tibia, press in o Bilateral pitting edema CHF (congestive heart failure), cirrhosis, renal failure o Unilateral pitting edema Deep vein thrombosis (DVT) Comment on halitosis, acetone, musty, fecal breath o Get 6 from pt, have pt say hamburger

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Halitosis: gingivitis Acetone: ketone acidosis diabetes Musty: liver overproduction of ammonia Fecal: fistula Abnormal tube-like connection

INSPECT ANTERIOR CHEST Expose chest inc clavicle area Stand at pts feet Comment on chest size, shape & symmetry o Normal size, shape, & symmetry Comment on barrel chest, pectus excavatum/carinatum, flail chest o Barrel Chest: A-P and lateral diameter the same, over inflated lungs Indicates asthma, emphysema o Pectus excavatum May be seen in rickets, marfans disease pts o Pectus carinatum (pigeon chest) May be seen in rickets, marfans disease pts o Flail chest usually the result of a trauma. 2 or more ribs broken in 2 or more places. That segment of the thorax becomes disassociated with the remainder causing the affected segment to move opposite in respiration Comment on rachitic rosary, intercostal space retraction or bulging o Rachitic rosary smooth bead-like swellings of costochondral jnxn Seen in rickets pts o Intercostal space retraction intercostal spaces pulled in, more evident in lower chest Indicates: sever airway obstruction o Intercostal space bulging intercostal spaces pushed out

Indicates: pleural effusion (fluid in plural cavity), empyema (pus in plural cavity) Comment on slope of ribs, motion and local lag o Have pt take deep breath o Note direction of ribs, should go EO direction o Local lag: impairment of resp mvmt Comment on skin lesions, scars & vascular abnormalities o Skin lesions Chery angioma Kaposis sarcoma Due to HHV type 8 Common in HIV pts Herpes Zoster Will present w intercostal neuralgia before rash appears Caused by HHV type 3-double stranded DNA virus-varicella zoster Comment on dilated veins on chest, abdomen or legs o Turn pts leg out to see back of calves for veins o Dilated superficial v in upper arm and chest SVC obstruction Distended v bilaterally above diaphragm Assoc w intrathoracic lymphoma or lung cancer o Mondors disease (superficial thrombophlebitis) Distended veins on one breast

PALPATE ANTERIOR CHEST Warm hands Determine if tracheal shift or tug o Middle finger over trachea feel pulse Normal: bottom to top Tracheal tug: pulsation top to bottom Indicates aortic arch aneurism Assess upper half & lower half chest expansion o Fingers on clavicle, have pt breath Hands should rise equally

o Fingers on ribs, close thumbs, have pt breath Thumbs should separate o Asymmetric mvmnt indicates lung pathology Pneumonia Pneumothorax Lung abscess Pleural effusion Comment on expansion of chest bilaterally o upper and lower equal on both sides Palpate trapezius, lung apices, ribs & intercostal spaces o Swellings bone tumor fracture Tietze syndrome Costochondral junction swollen & tender o Tenderness Bone tumor Fracture Osteomyelitis Inflammation of bone due to an infection Tietze syndrome Costochondral junction swollen & tender Costochondritis Costochondral junction tender (not swollen) Comment on Masses, tenderness, abnormal sensations o Masses Tumors o Tenderness Cellulitis Tender points: fibromyalgia Trigger points: myofascial pain syndrome o Abnormal sensations Crackling under skin: subcutaneous emphysema Traumatic pneumothorax Ruptured esophagus

Check for tactile fremitus over apex, 2,3,4,5 intercostal space bilaterally o Have Pt say 99 for each point o Use knife edge of hands o Check tactile fremitus over 6 intercostal space (mid-axillary line) Comment on tactile fremitus: asymmetrical, increased, decreased, normal o Increased Consolidation has occurred Pneumonia TB Pulmonary fibrosis o Decreased Vibrations cannot translate (air) Pleural effusion Pneumothorax

PERCUSS ANTERIOR CHEST

10/15/2011 9:03:00 AM

10/15/2011 9:03:00 AM