Thorax Examination

Pulmonology Departement
FKUB

General Examination

Respiratory rate ( tachypnoea: > 15/mnt )

Breathing patterns
Cheyne-Stokes : cyclically , RR, depth, RR ,
ending in apnoea or hypopnoea
Kussmaul : hiperventilation with deep, sighing
respiration
Use of accessory muscles

Stridor

Harsh, rasping or croaking inspiratory noise

Foreign body or tumour partially occluding
the larynx, trachea or a main bronchus

Hoarseness
Cyanosis
Blood pressure
Hands : clubbing, discoloration of the
fingers & nails, tremor

Neck

Jugular venous pressure (JVP)

Neck nodes

Inspection

Shape & symmetry of the chest

AP > lateral 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
displacement

Chest wall
movement

Percussion

Breath sounds

Added sounds

Consolidation

none

Reduced over
affected area

Dull

Bronchial

Crackles

Collapse

Ipsilateral shift

Decreased over
affected area

Dull

Absent or
reduced

Absent

Pleural Effusion

Heart displaced to
opposite side

Reduced over
affected area

Stony dull

Absent over
fluid; may be
bronchial at
upper border

Absent,
pleural rub
maybe found
above
effusion

Pneumothorax

Tracheal
deviation to
opposite side if
under tension

Decreased over
affected area

Resonant

Absent or
greatly
reduced

Absent

Bronchial
asthma

none

Decreased
symmetrically

Normal or
decreased

Normal or
reduced

Wheeze

Interstitial
pulmonary
fibrosis

none

Decreased
symmetrically
(minimal)

Normal

Normal

Fine
inspiratory
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
- V
- V

Rh:

----

Wh: - ---

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