Breast Examination

Yvette Ethel Mondano-Yap, MD, FPCP, DPSN

 The Thorax and the Lungs

Yvette Ethel Mondano-Yap, MD, FPCP, DPSN

Chest Examination

consists of
inspection
palpation
percussion and
auscultation
Chest Examination
Inspection process initiates and continues
throughout the patient encounter.
Palpation, confirmed by percussion, assesses
for tenderness and degree of chest
expansion.
Auscultation, a more sensitive process,
confirms earlier findings and may help to
identify specific pathologic processes not
previously recognized.
Locating Findings on the Chest
Chest abnormalities maybe described in 2 dimensions:
1. along the vertical axis
2. around the circumference of the chest
To make vertical locations,
count the ribs and the
interspaces. The sternal angle
(angle of Louis) is the best
guide.

Note: The costal cartilages of

the first 7 ribs articulate with
the sternum; the 8th, 9th and
10th ribs articulate with
cartilages just above them and
the 11th and 12th ribs are
floating ribs.
Vertical locations…

… Use the 12th rib posteriorly as

another starting point.

… Use the inferior tip of the

scapula – it usually lies at the
level of the 7th rib or
insterspace

… Use the most protruding

spinous process of the
vertebrae when the neck is
flexed forward – usually the
vertebra of C7.
Around the circumference of the chest

- Use a series of vertical lines:

midsternal and vertebral
midclavicular line
anterior and posterior axillary lines
midaxillary line
scapula line
Locations on the Chest
• Supraclavicular – above the clavicles
• Infraclavicular - below the clavicles
• Insterscapular - between the scapulae
• Infrascapular - below the scapula
• Bases of the lungs – the lowermost portion
• Upper, middle and lower lung fields
Lungs, Fissures and Lobes
Lungs, Fissures and Lobes
Each lung is attached by its root and pulmonary ligament to the
heart and trachea but is otherwise free in the thoracic
cavity. Each lung has an apex, three surfaces (costal,
medial, and diaphragmatic), and three borders (anterior,
inferior, and posterior).
The portion of the upper lobe of the left lung that lies
between the cardiac notch and the oblique fissure is known
as the lingula, and it corresponds to the middle lobe of the
right lung.
In men, the right lung weighs approx. 625 g, the left 570 g.
The lungs contain 300,000,000 alveoli and their respiratory
surface is about 70 sq m. Respirations per minute are 12 to
20 in an adult.
The Trachea and the Airways

• The left lung is longer, narrower,

and has a smaller volume than
the right lung.
• The bronchi themselves divide
many times before branching
into smaller airways called
bronchioles.
• At the end of each bronchiole
are thousands of small air sacs
called alveoli.
• Within the alveolar walls is a
dense network of tiny blood
vessels called capillaries.
The Pleurae

… is a thin, glistening, slippery

serous membrane, inflammation
of which is called pleurisy.
… lines the thoracic wall and
diaphragm, where it is known as
the parietal pleura. It is
reflected onto the lung, where it
is called the visceral pleura.
… the pleural space/cavity is the
potential space between visceral
and parietal pleurae.
Blood supply, lymphatic drainage and
innervation

• The lungs are innervated by parasympathetic fibers via the

vagus nerve and sympathetic fibers from the anterior and
posterior pulmonary plexuses to the smooth muscle in the
walls of the bronchial tree.

• The bronchial arteries and veins circulate blood to the

bronchial tree. The pulmonary arteries and veins circulate
the blood involved in gas exchange.

• Superficial and deep lymphatic vessels drain toward the

hilus and end in pulmonary and bronchopulmonary nodes.
These in turn drain into the tracheobronchial nodes.
 The Thorax and the Lungs

Yvette Ethel Mondano-Yap, MD, FPCP, DPSN

Breathing

A. Establishment of Basic Pattern: regulated by

neuronal mechanisms
1. Medullary Structures
a. Dorsal Respiratory Group - (Inspiratory Center)
b. Ventral Respiratory Group - (Expiratory Center)

2. Pontine Structures
a. Pneumotaxic Center: A role in respiratory patterns
b. Apneustic Center: to amplify inhalation – Breathe in
deeply and get little expiration of gas – Expiration is
impeded but inspiration is not – It amplifies inspiration
Breathing

Quiet Breathing:

Inspiration. The diaphragm is

the predominant muscle of
respiration. Others involved are
parasternals and scalenes
Expiration is predominantly a
passive phenomenon.
Breathing

During exercise and in certain

diseases:
I
Inspiration:
1. External intercostals raise the lower ribs up
and out, increasing the lateral and AP dimensions of
the thorax.
2. Scalene muscles and sternomastoids
serving to raise and push out the upper ribs and the
sternum.

Active expiration:
1. Abdominal wall muscles (including the rectus
abdominus, internal and external obliques, and
transversus abdominus), which drive intra-
abdominal pressure up when they contract.
2. Internal intercostals assist with active
expiration by pulling the ribs down and in, thus
decreasing thoracic volume.
Respiratory Membrane

• a. Type I: Most of
the alveolus cells
and are the basic s
structural cells
• b. Type II:
Produces pulmonary
surfactant
• c. macrophages
Pulmonary Surfactant

- a complex substance
containing phospholipids and
a number of apoproteins
- produced by the Type II
alveolar cells
- is differentially reduces
surface tension, more at
lower volumes and less at
higher volumes, leading to
alveolar stability and
reducing the likelihood of
alveolar collapse
Changes With Aging

- Capacity to exercise decreases

- Chest wall becomes stiffer and harder to move
- Respiratory muscles weaken
- Lungs’ elastic recoil decreases
- Speed of breathing gradually decreases
- Skeletal changes e.g. kyphosis and barrel chest
 The Thorax and the Lungs

Yvette Ethel Mondano-Yap, MD, FPCP, DPSN

Common or Concerning Symptoms
1. Chest pain
Sources:
2. Myocardium
3. Pericardium
4. Aorta
5. Trachea and large bronchi
6. Parietal pleura
7. Chest wall, including musculosketal system
and skin
8. Esophagus
9. Extrathoracic structures such as neck, GB,
stomach
Common or Concerning Symptoms

2. Dyspnea - nonpainful but uncomfortable awareness

of breathing that is inappropriate to the level of
exertion. Ask PQRST.
3. Wheezing - musical respiratory sounds
4. Cough - reflex response. Ask if with sputum, volom,
color, odor and consistency.
5. Blood-streaked sputum – coughing up blood
from the lungs
Health Promotion And Counselling

Tobacco cessation
Four “As”:
3. Ask about smoking at each visit.
4. Advise patients regularly to stop smoking in clear
personalized message.
5. Assist patients to set stop dates and provide
educational materials for self-help.
6. Arrange for follow-up visits to monitor and support
progress.
 Techniques of Examination:
With patient sitting, examine the posterior thorax
and lungs with the arms folded across the chest
with hands resting on the opposite shoulders.

With patient supine, examine the anterior thorax

and lungs.

For patients unable to sit up without aid, ask help. If

not, roll the patient to 1 side and then to the
other.
- PROCCED in an orderly fashion- IPaPA
 History
• Pre-existing conditions
• Family Health History
• Immunizations status
• Allergies
• Current Therapies tried
• Last Medications
Assessment

80% is Visualization
• Inspection

• • Color
• • Level of Consciousness
• • Respiratory Rate-
• • Symmetry of Chest
• • Quality of Respirations
• • Respiratory Patterns age appropriate
• • Work of breathing
• • Chest Wall Deformities
respiratory patterns

• Bradypnea - abnormally slow respirations

• Hyperpnea – deep respirations
• Tachypnea - abnormally fast respirations
• Apnea - the cessation of breathing resulting from lack
of respiratory effort
• Kussmaul Breathing - increased rate, deep respiration
usually associated with metabolic acidosis
• Cheyne Stokes - Respiratory rate and volume
progressively increase until they reach a climax,
then they cease entirely for 10-50 sec.
• Obstructive-Mild to Severe
chest wall deformities

• • Pectus excavatum (funnel chest,

abnormally depressed)
• • Pectus carinatum (pigeon chest,
abnormal prominence of the
sternum)
• • Thoracic kyphoscoliosis (hump back)
• • Barrel Chest (CF, COPD)
• Palpation:
In health, the chest and lung transmit a vibration,
called fremitus, during speech.
Fremitus abnormalities may be felt in chronic
obstructive lung diseases or obesity, in which the
vibration is diminished, and in pneumonia, in which
it is increased over the infected lobe.
Palpation Findings

• Palpation for nodules and observed abnormalities

Soft/Hard/Neurofibromatoses
Sinus tracts
• Palpation for tenderness:
Costochondral junction
Chest pain
• Position of trachea
• Assess ventilatory excursion:
Symmetry
Synchrony
Expansion
• Tactile Fremitus
• Assess observed abnormalities:
Gynecomastia
Spider hemangiomas
• Examine the Lymph Nodes
e.g Axillary, Supraclavicular, Cervical LN
• Palpate the Trachea
- to locate the trachea and verify that it is in the midline.
- may be displaced by masses in the neck.
- the trachea gives an indication of the position of the
mediastinum within the chest

The best way is to place the index and the middle fingers either
side of the trachea and judge whether the distances between it and
the sternocleidomastoids are equal on both sides.
• Chest Expansion tests
- to test if both sides of the chest move equally with
respiration.

Best technique is to hook your fingers as far around the chest

as possible and bring the thumbs together, but they should
not be parallel with each other. The thumbs should be off
the chest wall and, thus, free to move. Ask the patient to
breath in, and watch your thumbs as they move apart. Look
for the symmetry of motion between the two sides.

Mediastinal Displacement
Away from lesion: .
Pneumothorax
Large Pleural Effusion
Towards Lesion:
Collapsed Lung.
Localised Fibrosis
• Tactile Fremitus
• Ask the patient to say "ninety-nine" several
times in a normal voice. ++
• Palpate using the ball of your hand.
• You should feel the vibrations transmitted
through the airways to the lung.
Tactile Fremitus

• Increased fremitus indicates fluid in the

lung or consolidation of the underlying lung
tissue.
• Decreased fremitus indicates sound
transmission obstructed by
chronic obstructive pulmonary disease (COPD)
fluid outside the lung (pleural effusion)
air outside the lung (pneumothorax)
• Palpate the Lymph nodes.
The idea is to feel all the 'walls' of the axilla: the
superior, medial, lateral and posterior. Use your
left hand to palpate the patient's right axilla and
use your right hand to palpate the patient's left
axilla. It should be noted that lung disease rarely
involves the Axillary lymph nodes.

Also palpate the supraclavicular and cervical LN

The purpose of percussion in the
respiratory examination is to detect
whether the underlying lung tissues are
air filled, fluid filled, or solid.

• Percussion: Tapping on the chest wall

over healthy lung results in a hollow
resonant sound.
• STEPS
• Hyperextend the middle finger of the left hand. This finger is
known as the pleximeter finger.
• Place it on the chest, running in the space between two adjacent
ribs. It is important that the pleximeter finger is placed flat
against the chest wall.
• Separate the fingers as wide as possible and make sure the thumb,
the index, ring and little fingers are not touching the chest.
• The right middle finger (the plexor finger) is used to strike the
pleximeter finger. It is important that the tip of the plexor finger
(and not the finger pad) is used to strike the DIP joint of the
pleximeter finger. Following the strike, the plexor finger should be
removed as quickly as possible to avoid damping the vibrations.
• The chest should be percussed in 5 areas on each
side, again comparing the right and left sides at
each step.
• It is usual to strike the pleximeter finger 2 or 3
times in quick succession before pausing to move
on the next area.
• Posterior Chest
• Percuss from side to side and top to bottom using the pattern
shown in the illustration. Omit the areas covered by the scapulae.
• Compare one side to the other looking for asymmetry.
• Note the location and quality of the percussion sounds you hear.
• Find the level of the diaphragmatic dullness on both sides.

Diaphragmatic Excursion
• Find the level of the diaphragmatic dullness on both sides.
• Ask the patient to inspire deeply.
• The level of dullness (diaphragmatic excursion) should go down 3-
5cm symmetrically
• Percussion Findings
Abnormal lungs may be: hyperresonant, dull, or
stony dull. Dullness is expected over the liver and
over the heart. Obese patients may show reduced
resonance, but this is equal on both sides.
Percussion Notes and Their Meaning
Intensity Pitch Duration Location
Flat soft high short thigh
e.g. Large Pleural Effusion
Dull medium medium medium liver
e.g. Lobar Pneumonia
Resonance loud low long normal lung
e.g. Healthy Lung or Bronchitis
Hyperresonant VL lower longer -
e.g. Emphysema, Pneumothorax
Tympany loud high - gastric bubble
e.g. Large pneumothorax
• Auscultation

• most important examining technique

to assess airflow through the
tracheobronchial tree
• it helps to assess the condition of
the surrounding lungs and pleural
space.
Auscultation involves

• Listening to the sounds generated by breathing

• Listening for any adventitious (added) sounds
• If abnormalities are suspected, listening to the
sounds of the patient’s spoken or whispered
voice as they are transmitted through the chest
wall (transmitted voice sounds)
Procedure

• Start with listening to the apices of the lung.

Then listen over the chest using the diaphragm,
and then listen to the lateral part of chest. You
should listen in 5 areas on each side of the chest,
comparing right and left sides at each step.

• Identify patterns of breath sounds by their

intensity, their pitch and the relative duration of
their inspiratory and expiratory phases.
Breath sounds
• produced by vibrations due to turbulent
airflow through out the airways. These
sounds are transmitted through the
smaller airways and lungs to the chest wall.
• the intensity of the sounds increase during
inspiration and then fade away during the
first third of expiration.
Breath Sounds
• Vesicular Breath Sounds - These are soft and low-pitched sounds
that are heard over most of the lungs. They are heard through
inspiration and continue without pause through to expiration, but
fade away about one third of the way through expiration.

• Bronchovesicular Breath Sounds - These are slightly louder and of

higher pitch than vesicular sounds. The inspiratory and expiratory
sounds are about equal in length. They may be head normally in the
1st and 2nd interspaces and between the scapulae.

• Bronchial Breath Sounds - These are loud and high-pitched sounds,

whose expiratory phase lasts longer that the inspiratory phase.
Heard over the manubrium, if heard at all. Also result from
enhanced transmission of higher frequency sounds through solid
lung tissue as in consolidation or fibrosis.

• Tracheal sounds – very loud, harsh sounds, inspiratory and

expiratory sounds are about equal, heard over the trachea in the
neck.
Notes on Breath Sounds…

• If bronchovesicular or bronchial sounds are heard

distant from those listed, then you should suspect
that air-filled lung has been replaced by fluid-
filled or solid lung tissue.

• Breath sounds may be decreased when airflow is

decreased (as by obstructive lung disease or
muscular weakness) or when transmission of sound
is poor ( as in pleural effusion, pneumothorax or
emphysema).

• A silent gap between inspiratory and expiratory

sounds suggests bronchial breath sounds.
Adventitious (Added) sounds
Discontinuous Sounds (Crackles/Rales/Crepitations)
Fine crackles occur in inspiration and are soft, high-pitched,
brief sounds (5-10msec).
- be imitated by rubbing some hair between your fingers
near your ear.
- occur due to the 'popping' opening of small airways that
were closed prematurely at the end of the previous
expiration.

Coarse crackles are somewhat louder, lower in pitch and not quite so
brief (20-30msec)
- occur when there is fluid in the larger bronchi.

•  
Crackles…

• Listen for the following characteristics:

• Loudness, pitch and duration
• Number ( few to many)
• Timing in the respiratory cycle
• Location in the chest wall
• Persistence of their pattern from breath to
breath
• Any change after a cough or a change in patient’s
position
Crackles
May be due to abnormalities of the lungs or of the airways.
If they occur early on in inspiration reflect bronchiectasis or chronic
bronchitis. If they occur later in inspiration, then they may be due
to restrictive conditions of the lungs such as pneumonia, fibrosis
or pulmonary edema.

• Typically if it is associated with Pulmonary Oedema and Fibrosing

Alveolitis affect both lung bases equally, whereas in pneumonia and
in mild bronchiectasis the crackles are localised.

• Bear in mind that normal individuals may have a few basal crackles
after maximal expiration. Can also be heard in dependent portions
of the lungs after prolonged recumbency. These often clear on
coughing.

• Early inspiratory crackles are heard most often in chronic

bronchitis and emphysema, are fairly coarse, and change with
coughing.
Adventitious sounds

Continuous Sounds longer than crackles (>250msec), musical

Wheezes – high-pitched, with hissing or shrill quality

- predominantly expiratory sounds that reflect localised
narrowing of the airways. Asthma and Chronic bronchitis
are the most common causes. Occasionally, they may occur with
pulmonary oedema.

Stridor is an inspiratory wheeze associated with upper airway

obstruction (croup) caused by a foreign body or possibly a tumour.

Rhonchi - relatively low-pitched, ften have a "snoring" or "gurgling"

quality. Any extra sound that is not a crackle or a wheeze is
probably a rhonchi which suggests secretions in large airways.
Adventitious sounds
• Pleural Rub –
- squeaky to- and fro-rubbing sound
- occurs when inflamed surfaces of the pleura rub together.

Causes include pleurisy (a virus or bacterium infects the

pleurae), pneumonia and pulmonary embolism, etc. They
usually occur in inspiration and in expiration.
• VOCAL RESONANCE

Auscultation of the chest while the patient speaks can

provide extra information about the patient’s lungs. Ask the
patient to say "99" every time you change your stethoscope
position over the patients chest wall. Vocal resonance is
increased over solid areas of lung with open airways - for
example, consolidation; and decreased by pleural fluid.

This part of the physical exam has largely been replaced by

the chest x-ray.
Voice Transmission Tests

• Bronchophony
Ask the patient to say "ninety-nine" several times in a normal
voice.
Auscultate several symmetrical areas over each lung.
The sounds you hear should be muffled and indistinct. Louder,
clearer sounds are called bronchophony.

• Whispered Pectoriloquy
Ask the patient to whisper "ninety-nine" several times.
Auscultate several symmetrical areas over each lung.
You should hear only faint sounds or nothing at all. If you hear the
sounds clearly this is referred to as whispered pectoriloquy.

• Egophony
Ask the patient to say "ee" continuously.
Auscultate several symmetrical areas over each lung.
You should hear a muffled "ee" sound. If you hear an "ay" sound
this is referred to as "E -> A" or egophony.
• Peripheral Cyanosis This is where the peripheries, such as
the fingertips, adopt a bluish tinge, and occurs due to
reduced circulation to the limbs. The peripheries are also
usually cold. This may be due to: . Cold weather. Raynaud's
Phenomenon. Peripheral Vascular Disease. May also occur in
Heart Failure, when there is reduced perfusion to the
extremities
• Central Cyanosis The most common causes: . Severe Airflow
Limitation. Pulmonary Fibrosis. Left Ventricular Failure
• Look inside the mouth for evidence of central cyanosis. Ask
the patient to open their mouth as wide as possible, and
stick their tongue up to the roof of their mouth. Look at
the under-surface of the tongue for any bluish tinge, which
will signal central cyanosis.
• Look for Clubbing. This is where there is an increase in the soft tissues of
the nail bed and fingertip. There are many ways to detect clubbing, each
looking for its different stages. It recommended that, in OSCE's, all of
these be done, to make it obvious that you looking for clubbing. Causes of
Clubbing

• Rock the Nail from side to side on the nail bed. This will detect any
bogginess (softening of the nail bed), which is the first stage of clubbing.
• Squat down beside the bed, so that you are looking side-on at the finger,
and your eyes are level with the nail. This allows you to look at the angle
between the nail and the nail bed (the nail-bed angle). This is normally
concave, and about 160o. But, if the fingers are clubbed, it may be
obliterated i.e. flat (180o) or even convex.
• Look for the Diamond Sign. Ask the patient to place their index fingers
together, with their nails facing each other and touching. Normally, the
concave nail-bed angle on each finger will create a 'diamond' area in
between the fingers. This will be obliterated in clubbing
• Causes of Clubbing
• enlarge
• Respiratory
• . Bronchial Carcinoma (most common)
• . Pleural / Mediastinal tumours, e.g. Mesothelioma
• . Chronic Suppurative Lung Disease e.g. CF, Bronchiectasis, Abscesses
• . Lung Fibrosis
• Cardiac
• . Congenital Cyanotic Heart Disease e.g. Fallot's Tetralogy
• . Subacute Infective Endocarditis
• Gastrointestinal
• . Cirrhosis
• . IBD
• . Coeliac Disease
• Look for Tar Staining, which
indicates that the patient is a
smoker. Smoking is an important risk
factor for bronchial carcinoma and
COPD, as well as other non-
respiratory conditions
• Ask the patient to hold out their arms in
front of themselves, parallel to the bed,
with the wrists extended fully (i.e. the
palms should face forward). Ask them to
close their eyes, and hold that pose for
about 10 seconds. If they have any Carbon
dioxide retention (or, indeed, if they have
liver disease) a tremor will be elicited.
This is known as CO2 Flap and is
indistinguishable from Liver Flap.
 Chronic Bronchitis
Process
-Excessive mucus production in
bronchi, followed by chronic
obstruction of airways
 Chronic Bronchitis
Timing
-Chronic productive cough followed by
slowly progressive dyspnea

Factors that Aggrevate

-Exertion, inhaled irritants,
respiratory infections
 Chronic Bronchitis
Factors that Relieve
-Expectoration; rest, though dyspnea may
become persistent

Associated Symptoms
-Chronic productive cough, recurrent
respiratory infections; wheezing may
develop
 Chronic Bronchitis
Setting
-History of smoking, air pollutants,
recurrent respiratory infections
 Chronic Bronchitis
Physical Exam:
Inspection
-patient complains of symptoms for more than 2-6
months
-patient has labored breathing
-may use 2nd accessory respiratory muscles
-cough is deep seated with elevation of shoulders;
sputum is mucoid to purulent , may be blood
streaked or even bloody
-patient looks fine, doesn’t look ill at all
 Chronic Bronchitis
Palpation
-equal vocal fremitus, slightly louder on
the right
-course rhonchi
-both bases disappear after coughing
and expelling sputum
 Chronic Bronchitis
Percussion
-mild-no change, percussion notes are
resonant, loud in intensity, low in pitch,
long in duration as seen in a normal lung
Auscultation
-moist rales over lung bases that do not
clear on coughing