Chest

Findings on Chest Examination

Component	Inspection	Palpation	Percussion	Auscultation
General	Scars PPM Thoracotomy Sternotomy
Respiratory	Chest form Hyper-expansion Pectus excavatum Pectus carinatum Barrel-shaped chest Flail chest	Chest expansion Subcutaneous emphysema	Resonance	Breath sounds Normal breath sounds Crepitations Rales Wheeze
Cardiovascular	Sternotomy CPR bruising Epicardial pacing wires	Heave/thrills Apex beat Sternotomy stability PPM		Heart sounds Cardiac wheeze
Neurological
Endocrine and Metabolic
Renal
Gastrointestinal	Jaundice Gynaecomastia
Haematological
Integumentary
Trauma	Seatbelt sign
Infective
Malignant
Toxic
Immune
Congenital
Obstetric

Features

Respiratory

• Chest form
  • Barrel chest
    Suggests hyperexpansion from COPD.
  • Scoliosis/kyphoscoliosis
    Restrictive lung disease due to ↓ chest volume and ↓ chest wall compliance.
  • Funnel chest
    Restrictive lung disease.
    
• Subcutaneous emphysema
  Subcutaneous air, palpable in large volumes. Causes include:
  • Pneumothoraces
  • Bronchial injury
  • Hollow viscus injury
    Rarely.

Normal Breath Sounds

Sound	Location	Timing	Nature
Tracheal breathing	Sternum/manubrium	Inspiration Expiration
Bronchial breathing	Parasternal	Inspiration Expiration	Loud High Pitched
Vesicular	Peripheries	Inspiration Early expiration	Soft Low-pitched

Bronchial breathing may be physiological or pathological, depending on the location.

Abnormal Breath Sounds

Sound	Location	Timing	Nature	Aetiology
Bronchial breathing	Peripheries	Inspiration Expiration	Harsh Loud	Consolidation of alveoli small airways between the chest wall and patent airways. Occurs as normal breath sounds are transmitted more readily through consolidated lung.
Absent	Anywhere	Inspiration Expiration	Soft or absent	↓ Airflow to affected side, which may indicate: Hypoventilation ↓ VT Endobronchial intubation Dynamic hyperinflation Emphysema Atelectasis Pleural disease Pleural effusion Pneumothoraces Obesity
Crackles	Peripheries	Early inspiration	High-pitched Clicking Crackling	Popping open of collapsed airways in early inspiration: COPD Bronchopneumonia Bronchitis
		Pan-inspiratory Late inspiration	Fine crepitations	Interstitial lung disease
		Pan-inspiratory Late inspiration		Alveolar consolidation Pulmonary oedema Pneumonia Alveolar haemorrhage
Ronchi	Peripheries	Inspiration Expiration	Coarse snoring Gurgling	Vibrating liquid or secretions in airway
Wheeze		Expiration		Two forms: Monophonic Localised obstruction: Tumour Foreign body Sputum plug Polyphonic Generalised, variable obstruction: Asthma COPD
Pleural rub	Anywhere	Inspiration Expiration	Coarse brushing	Pleural inflammation

• Resonance
  The sound produced by chest wall percussion can be divided into:
  • Normal
  • Hyper-resonant
    Higher-pitched, “hollow” sound, indicating air (classically bullae or pneumothoraces).
  • Dull
    Lower-pitched, shorter sound, indicating effusion.

Percussion is performed with a finger of the non-dominant hand on the chest wall, and firmly tapping the distal segment with a finger on the other hand.

Remember to remove the percussing finder from the struck finder immediately - leaving the two fingers in contact ↓ the pitch of the produced note.

Cardiovascular

• Apex Beat
  Palpation of the apical impulse, generated by the heart pushing into the chest wall during isovolumetric contraction.
  • The normal apex beat is:
    • Brief
    • “Tapping”
    • Felt over a small area
  • With LV dilatation, the apex beat:
    • Moves laterally and caudally
    • Can be felt over a larger area of the heart
    • Becomes “heaving”
  • With LV hypertrophy:
    • The location is unchanged
    • Becomes stronger
      Described as “thrusting”.
  • With a hyperdynamic circulation:
    • May be seen as a sternal heave

Normal Heart Sounds

Sound	Timing	Aetiology	Considerations
S1	End-diastole/initial systole	Closure of mitral and tricuspid valves	Indirect measure of force of ventricular contraction
S2	End-systole	Closure of aortic and pulmonary valves

Abnormal Heart Sounds

Sound	Timing	Aetiology	Considerations
S3	End-diastole/initial systole Immediately following S2.	Rapid deceleration in diastolic filling due to diastolic dysfunction: Aortic stenosis LVH	Best heard over apical impulse Lower pitched May only be heard with bell.
S4	Pre-systole	Vigorous atrial contraction

Murmurs are additional heart sounds that occur due to pathologically turbulent blood flow.

Interpretation of Cardiac Murmurs

Timing	Lesions
Pansystolic	MR TR VSD
Ejection and midsystolic	AS Aortic sclerosis PS ASD RVOTO Fallot’s.
Late systolic	MV prolapse HOCM Aortic coarctation
Mid-late diastolic	MS TS AR Myxoma
Continuous	PDA Aortic-pulmonary shunt VSD

• Cardiac wheeze
  Bibasal expiratory wheeze secondary to ↑ extravascular lung water in dependent regions, leading to small airway compression.

Gastrointestinal

• Gynaecomastia
  ↓ Oestrogen clearance in men with chronic liver disease.

Gynaecomastia

Trauma

• Seatbelt sign
  Chest (and/or abdominal) wall bruising associated with a 3-point restraint. Indicates a high-energy mechanism and a high risk of internal injury.

Seatbelt sign

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References

1. Foot C, Steel L, Vidhani K, Lister B, MacPartlin M, Blackwell N. Examination Intensive Care Medicine. Elsevier Australia; 2011. (Examination series).