Thorax examination

Orientation on the thorax
 
Observation
- Shape variations of the thorax
- Breathing
 
Palpation
 
Percussion
 
Auscultation
- Alveolar breathing
- Airway breathing
- Side phenomena
- Bronchophony
 
Most common physical medical findings in airway disorders
Acute bronchitis
Lung emphysema
Pleural exudate
Types of exudates
Pneumothorax
Crupous pneumonia
Atelectasis
Bronchopneumonia
Asthmatic attack
 
Breast examination

is performed by the means of observation, palpation, percussion, and auscultation.
 
Orientation on the thorax
 
   Front:
1. Anterior medial line - in the middle of the sternum.
2. Sternal line - around the edge of the sternum.
3. Parasternal line - between the sternal and medioclavicular lines.
4. Medioclavicular line - in the middle of the clavicle.
   Side (5):
Anterior axillar line - around the lateral edge of m. pectoralis major.
Middle axillar line - in the middle of the axilla.
Posterior axillar line - around the lateral edge of m. latissimus dorsi.
   Back:
(6) Scapular line - horizontal line through the inferior angle of the scapula.
(7) Paravertebral line - around the edge of the vertebral column.
(8) Back medial line - in the middle of the vertebral column following spinous processes.
 

 


 

Orientation links
on the thorax

Observation
 
A normal thorax is symmetrical, widening evenly with breathing.
 
It is necessary to notice possible breathlessness, cyanosis, or painful breathing before starting the physical examination.
 
Shape variations of the thorax:
 
   Pyknic - the front-back diameter is longer, ribs stand horizontally.
   Asthenic - is long and flat.
   Funnel shaped - the inferior part of the sternum is intracted.
   Barrel-shaped - is short, fixed in the inspirational state, with a longer front-to-back diameter, occurs in emphysema or chronic obstructive bronchopulmonary disease.
   Kyphoscoliotic - is asymmetrical, with gibbus, dextro- or sinistroscoliosis, occurs in rickets during childhood.
   Avian (bird-like) - is characterised by swollen cartilaginous ends of the ribs after rickets.
   Retraction of hemithorax - may occur in atelectasis, because of adhesions, or after thoracoplasty.
   Thoracal arching - occurs with a massive pneumothorax or pleural exudate.
 
During examination, it is possible to notice kyphosis or kyphoscoliosis. Post-operative scars after thoracotomy (lung and heart surgery) should also be noted.
 
Breathing
 
Eupnoea means normal breathing with a frequency of 16 - 18 breaths per minute.
 
   Tachypnoea - manifests by increased breathing frequency e.g. in anger, pain, fever, or in bronchopulmonary and cardiac disorders.
   Bradypnoea - means decreased breathing frequency, e.g. in alcohol poisoning or intracranial hypertension.
   Apnoea - means halted breathing, may be temporary or permanent (death).
   Hyperpnoea - means deepened breathing, e.g. fever, severe anaemia, or acidosis, also called Kussmaul respiration (decompensated diabetes mellitus, uraemia).
   Periodical breathing (Cheyne-Stokes breathing) is characterised by an increasing frequency and deepth of breathing, followed by decreased frequency and depth of breathing and apnoea. The Whole cycle repeats. It occurs with severe cerebral apoplexy. If it occurs during sleep, it can be a marker of the beginning left heart insufficiency.
 
Palpation
 
Of the thoracic wall is used mainly for detection: of thoracic vibrations, a pleural frictional murmur, a quality of thoracic wall, tenderness, and resistance.
 
Thoracic vibrations (fremitus pectoralis) are normally symmetrical on both halves of the thorax.
 
   Increased vibrations - are found over an infiltrated lung tissue (pneumonia, bronchopneumonia - better conductivity of the tissue).
   Weakened or missing vibrations - occur with fluidothorax or pneumothorax (insulating layer decreases conduction of the vibrations) and emphysema.
 
A pleural frictional murmur can be palpable in patients with severe dry pleuritis.


 

Kyphoscoliosis,
gibbus
 

Fresh scar after
sternotomy
 

Older scar after
sternotomy

 

Percussion
 
In healthy person it is full, bright, comparable on both halves of the thorax.
 
   Shortened - appears with a loss of air supply (pneumonia, atelectasis), with fluidothorax (the shape is parabolic with the top located in axilla).
   Hypersonic - is connected with excessive air supply (emphysema) or with pneumothorax, when it can be also tympanic.
 
Auscultation
 
Under physiological circumstances, clear alveolar breathing is present over the lungs, without any side phenomena. Tubal breathing can only be heard over the upper sternum and between the scapulae.
 
Alveolar breathing
 
   Sharpened
diffusely - during increased breathing, e.g. acidotic breathing (decompensated diabetes mellitus, uraemia).
unilaterally - compensatory manifestation (broad infiltration, compression by fluidothorax).
   Weakened - present with emphysema, atelectasis, pleural exudate, and pneumothorax.
   With prolonged expiration - occurs in airway obstruction (chronic obstructive bronchopulmonary disease, bronchial asthma)
   Mixed - can be present in bronchopneumonia.
 
Tubal breathing
 
If heard outside the major airways, it is a pathological finding. It is caused by exudation to alveoli (pneumonia) or by their compression (exudate).
 
Side breathing noises
 
   Dry noises - whistling, squeaking, or crackling; arising from vibrations of the viscous secretions during both inspiration and expiration. They occur with acute and chronic bronchitis and bronchial asthma. The findings vary in connection with cough.
   Wet noises - occur in presence of a liquid or semi-liquid content in the airways.
   Non-accentual - generated in the bronchi, present with acute and chronic bronchitis, bronchiectasia, or lung oedema.
   Accentual - their occurence is associated with infiltration or compression of the surrounding tissue (better conductivity), they are present with bronchopneumonia.
   Crepitation (crepitus) can be heard physiologically on the lung bases.
It is caused during inspiration by separating of the walls of collapsed alveoli and disappear with the alveolar expansion. Their persistence is pathological, caused by exudation to the alveoli. They occur in case of pneumonia - crepitus indux, redux.
   Pleural frictional murmur - squeaky sound caused by the friction of inflamed pleural layers. It is detected in case of dry pleuritis.
 
Pectoral voice (bronchophony)
Can be heard evenly over the lungs:
 
   Weakened - arises from disorders of the air supply (atelectasis), exudate or pneumothorax.
   Strengthened - is found in cases of lung infiltration (pneumonia, lung infarction).
 
The most common physical findings in airway disorders
 
(examination description keeps the order of observation, palpation, percussion, and auscultation).
 
Acute bronchitis (a young man)
 
No breathlessness.
Distant bronchitic phenomena (can be heard in case of a large finding).
Fremitus pectoralis normal on both sides.
Percussion full and bright.
Alveolar breathing, in both phases there are either dry or wet phenomena present (it depends on intraluminal content).
Bronchophony unchanged.
 

 

Emphysema
 
Barrel-shaped thorax.
Fremitus pectoralis weakened.
Percussion hypersonic.
Breathing alveolar, weakened. If there is a chronic bronchitis present, the dry or wet phenomena are often heard.
Bronchophony weakened.
 

 


Emphysema

Pleural exudate
 
Presence of fluid between the two pleural layers. It can be detected when the volume exceeds 500 ml.
 
Usually without breathlessness, but it depends on the size of the exudate.
Fremitus pectoralis weakened in the area of exudate.
Percussion shortened or even obscured, exudate borders have parabolic shape with the top in axilla. Near the upper edge the percussion is hypersonic or even tympanal (skodaic resonance).
Bronchophony weakened.
 
Types of exudates according to aetiology:
 
   Transudate - low amount of proteins, specific weight up to 1013 g/l, amount of proteins less then 30 g/l, occurs most frequently in case of cardiac insufficiency.
   Exudate - high amount of proteins, specific weight gretaer than 1013 g/l, amount of proteins gretaer than 30 g/l, occurs in case of TBC, tumours, pleuropneumonia, or collagenoses.
   Empyema - means presence of pus in the pleural cavity.
   Haemothorax - presence of blood in the pleural cavity (trauma).
   Chylothorax - presence of lymph in the pleural cavity in case of a damaged thoracic duct.
 

 


Pleural exudate

Pneumothorax
 
presence of air in the pleural cavity (trauma, rupture of emphysematous bulla, iatrogenic origin).
 
Breathlessness depends on the size and cause of the pneumothorax.
Limited breathing movements of the affected thorax half.
Fremitus pectoralis weakened or missing.
Percussion hypersonic.
Breathing weakened or missing if the lung is completely collapsed.
Bronchophony weakened.
 

 


Pneumothorax

Atelectasis
 
means loss of air supply to alveoli, bronchi, bronchioles, or the whole lung. The extend of affection depends on its cause.
 
In case of larger atelectasis breathlessness and cyanosis is present.
Fremitus pectoralis weakened.
Percussion shortened.
Breathing shortened.
Bronchophony weakened.
 

 

Pneumonia (croupous)
 
The finding described below is seen only rarely in clinical practice, because of current antibiotic treatment.
 
Breathlessness (may be manifested).
Fremitus pectoralis strengthened.
Percussion shortened.
Initially, crepitations are audible (crepitus indux), later tubal breathing (phase of hepatisation), crepitations again (crepitus redux during resorbence), progressive weakening of tubal breathing.
Bronchophony strengthened.
 

 

Bronchopneumonia
 
Breathlessness (may be present; it depends on the age and volume of affection).
Fremitus pectoralis strengthened.
Crepitations and accentual noises can be audible.
Bronchophony is strengthened over the affection.
 
Asthmatic attack
 
Orthopneic position, inspiratory position of thorax, severe expiratory breathlessness, distress, and non-productive cough.
Fremitus pectoralis weakened.
Percussion hypersonic, lowered lung borders.
Audible distant bronchitic phenomena.
Prolonged expiration with numerous whistles and squeaks. They can often be heard also during inspiration.
Bronchophony is diffusely weakened.
 
Examination of breasts
 
Observation
 
   Symmetry and size of the breasts.
   Appearance of the skin - reddening, retraction, and ridging.
   Appearance of the nipples - impaction, purulent secretion (inflammation), or secretion containing blood (tumour).
 
Palpation: local change of consistency – focus, its shape, size, border, and mobility:
 
   Oval with clear demarcation – suspected cysts.
   Irregular, without clear demarcation and immoveable – suspect tumours.

 

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