Chest examination Chest symptoms 1 Cough 2 Expectoration

Chest examination

Chest symptoms 1 - Cough 2 - Expectoration 3 - Hemoptysis 4 - Chest pain 5 -Wheeze 6 - Dyspnea 7 - Cyanosis 8 - Symptoms of toxemia (night fever , night sweating , loss of appetite , loss of body weight )

Local examination

Inspection n 1) Shape of the chest: rounded or oval 2) Chest movement: abdominal or thoracic , equal on both sides , No retraction 3)Respiratory rate, rhythm and depth

Palpation n n 1) position of the apex 2) Position of the trachea: central 3) Symmetry& chest expansion: equal on both sides of the chest 4) Swelling: absent 5) Tactile vocal fremitus: equal on both sides of the chest

Percussion n Line by line , side by side , space by comparison Auscultation 1) Breath sound: vesicular , equal on both sides 2) Vocal resonance: equal on both sides 3) Adventitious sounds(ronchi, crepitation, rub): absent

Inspection n 1)Shape of the chest: before 2 years: rounded after 2 years: oval 2)Chest movement: a)before 5 years: mainly abdominal b)after 5 years: mainly thoracic c)equal on both sides or not: unequal movement suggest unilateral lung pathology

d)Retractions: normally absent in upper airway obstruction as in croup: suprasternal retraction in lower airway obstruction: retraction are seen in lower intercostal space, subcostal area 3) Respiratory rate, rhythm and depth: Neonate: <60 c/m, one year: <50 1 -5 year: <40 , >5 year: <30 c/m n

Kussmaul breathing : rapid deep respiration seen in metabolic acidosis Cheyne-Stokes respiration : shallow respiration alternating with period of apnea occur in cerebral edema

Palpation n n 1) position of cardiac apex: by palm of the hand (lowermost outermost pulsation) 2) position of trachea: with the index and ring finger on the sternal attachment of the sternomastoids, feel with the middle finger on the suprasternal notch for the position of the trachea normally the trachea is central pulling the trachea to the diseased side(e. g: collapse, fibrosis)or pushing it to the healthy side(pneumothorax, pleural effusion)

n n n 3) Symmetry and chest expansion: by placing your hands on the patient back with the thumbs together on the midline, ask the patient to breath deeply Normally the palms move equally 4) Swelling : normally absent 5) Tactile vocal fremitus: the palm of the right hand should be applied flat on the different zones of the chest while the child is asked to repeat the word(- ﺃﺮﺑﻌﺔ )ﺃﺮﺑﻌﺔ and compare both sides Normally the hand detect vibrations of equal intensity on both sides of the chest

n 6)Ronchus fremitus(palpable ronchi): Palpable vibrations felt by the palm of the hand in moderate-sever obstruction of the bronchi

Percussion n n n From above to bottom , line by line , space by comparison between both sides Use light percussion for the lung Resonant: normal lung Hyper-resonance: normal at (kronigs isthmus), lungs of small infants, emphysema, pneumothorax Dullness: consolidation, collapse Stony dullness: pleural effusion

Auscultation n n 1) Air entry on both sides : in any disease Types of breath sounds A) Bronchial: heard over tracheobronchial tree , pulmonary consolidation e. g: lobar pneumonia and pulmonary TB B) Vesicular: normal over the lung C) Vesicular with prolonged expiration(harsh vesicular ) : heard in bronchial obstruction e. g: bronchial asthma

n n n 2) Vocal resonance(VR): ask the child to repeat( ﺃﺮﺑﻌﺔ - )ﺃﺮﺑﻌﺔ or cry and auscultate the chest vocal resonance in: 1)pulmonary consolidation 2)pulmonary cavitation vocal resonance in 1) foreign body obstruction 2)pleural effusion n n 3) pneumothorax 3)Adventitious sound: A)Crepitation: interrupted inspiratory bubbling sounds produced by passage of air through fluids(secretions) in airways and alveoli:

n n 1) fine crepitation: in heart failure 2) medium sized crepitation: in bronchopneumonia 3)coarse crepitation: in pulmonary edema B)Ronchi: continous musical usually expiratory sounds accompained with prolonged expiration and produced by narrowing of airways:

n n n 1)sibilant(high pitched): caused by obstruction of small bronchioles 2)sonorous(low pitched): caused by obstruction of larger bronchi C)Pleural rub: it is friction sound heared with respiration, indicating friction on movement between the two layers of pleura, heared in cases of pleural diseases

Pectus exacavatum

Palpation to detect position trachea

Assessing chest expansion in expiration (left) and inspiration (right). Percussion over the anterior chest. Direct percussion of the clavicles for disease in the lung apices

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