诊断学英文课件：Physical examination of the chest

Physical examination of the chestChest examinationChest examination The basic physical examination has long been used clinically. It doesnt need high-quality equippment, handy for use to provide important information and signs for the diagnosis of the chest diseases. Chest examinationChest examination The chest indicates the region that lies under the neck and above the abdomen. Chest wall is composed of sternum, ribs, and vertebras. Traditional physical examination of Traditional physical examination of the chestthe chest inspection palpation percussion Auscultation olfactoryTraditional physical examination of Traditional physical examination of the chestthe chest The patient should expose the chest to the full, in sitting or supine position according to the need for the examination or the ill condition.Traditional physical Traditional physical examination of the chest examination of the chest In general, the anterior and the lateral part is examined first, then the posterior part, The outline The outline The first section : Landmarks on chest wallThe second section: Chest wall, chest framwork, and breast (Extrathoracic organs examined) inspection, palpation.The third section: Lung and pleura (Intrathoracic organs examined) inspection, palpation, percussion and auscultation. I Bone landmarks（ natural landmarks ） II Vertical line landmarks（ artificial lines ） III Natural fossa and anatomic region ( ( natural landmarks ） IV The boundary of lung and pleura ( (artificial lines ）The first section Landmarks on chest wall I Bone landmarksI Bone landmarks Suprasternal notch Manubrium sterni Sternal angle (Also termed Louis angle ) Suprabdominal angle Xiphoid process: Rib: a total of 12 pairs. Intercostal space (interspace) Scapula Spinous process Costolspinal angle Suprasternal notchManubrium sterniSternal angleXiphoid processRibsScapulaIntercostal spaceBody of stermuncostal cartilageclaviculaBone landmarkBone landmarksvsuprasternal notchv manubrium stermiBone landmarksvsternal angle （ Louis angle. ）* * It connects bilaterally to each of the right and left second costal cartilage. an important landmark for counting rib and interspace. the bifurcation of the trachea, the upper level of the atria of heart, the demarcation of upper lower part of mediastinum, the fourth thoracic vertebraBone landmarksvSuprabdominal angle: ( infrasternal angle) denotes the angle formed by the bilateral rib rows which meet at the lower end of the sternum. Bone landmarksvXiphoid process :the protrusive triangular part of the lower end of the sternum with its base connects to the sternum. vRib:a total of 12 pairsv free ribs.Bone landmarksvIntercostal space (interspace) :医大二院呼吸内科医大二院呼吸内科 张晓晔张晓晔Bone landmarks Scapula inferior angle. acts as the mark of the seventh or the eighth rib, or corresponds to the eighth thoracic vertebra.thoracentisis pleural effusionBone landmarks Spinous process: marks the posterior midline. The seventh cervical spinal process the hallmark for counting the thoracic vertebrae Bone landmarks Costolspinal angle: constructed by the twelfth rib and the spine. II Vertical line landmarksII Vertical line landmarks（ artificial lines ） nine artificial linesnine artificial lines II Vertical line landmarksII Vertical line landmarksv1.anterior midline1.anterior midline v2.midclavicular line2.midclavicular line (L, R) v3.sternal line3.sternal line (L, R) v4.parasternal line 4.parasternal line (L, R) the anterior partVertical line landmarks Anterior midline: namely midsternal line, a vertical line through the middle of the sternum running from its top at the middle point of the upper ridge of the manubrium sterniMidclavicular line: vertical line drawn through the middle point of each clavicula.Vertical line landmarksVertical line landmarks Sternal line : vertical line runs along the vertical edges of the sternum and parallels to the anterior midline. Parasternal line : Vertical line at the middle of sternal line and midclavicular line.II Vertical line landmarksparasternal linesternal linemidclavicular lineanterior midlinev5.anterior axillary5.anterior axillary (L, R) v6.posterior axillary line6.posterior axillary line (L, R) v7.midaxillary line7.midaxillary line (L, R) the lateral part II Vertical line landmarksII Vertical line landmarksVertical line landmarks Anterior axillary line (L, R): vertical line drawn downward through the anterior axillary fold along the anteriolateral aspect of the chest. Posterior axillary line (L, R): vertical line drawn through the posterior axillary fold along the posteriolateral wall of the chest. Midaxillary line (L, R): running downward vertically from the apex of the axillary and between anterior axillary line and posterior axillary line.Vertical line landmarks Scapular line (L, R): vertical line drawn through the inferior angle as the arm hanging naturely, parallels to the spine. Posterior midline (L, R): namely midspinal line, running vertically downward through the posterior spinal process, or along the middle of spine.the posteriorl partIII Natural fossa and anatomic regionvaxillary fossaaxillary fossavsuprasternal fossasuprasternal fossavsupraclavicular fossasupraclavicular fossavinfraclavicular fossainfraclavicular fossa腋窝腋窝supraclavicular fossasuprasternal fossainfraclavicular fossaaxillary fossa 四区1. suprascapular regionsuprascapular region2. scapular region scapular region 3. interascapular interascapular regionregion4.infrascapular region4.infrascapular region In summary In summary 1.Four angles2.Four fossa2.Four fossa3.Four 3.Four regionregion4.Nine line4.Nine lineIn summaryIn summary Four angles:Sternal angle: Suprabdominal angle ; Costolspinal angle ; inferior scapula angle ;Four fossaFour fossa: :axillaryfossa;suprasternalfossa;axillaryfossa;suprasternalfossa;supraclavicular fossa;infraclavicular fossasupraclavicular fossa;infraclavicular fossaIn summaryIn summary Four Four region:region:suprascapular region; scapular region;interascapular suprascapular region; scapular region;interascapular region;region;infrascapular regioninfrascapular regionNine line:Nine line:.anterior midline.anterior midline ;.midclavicular line.midclavicular line ; ;.sternal line.sternal line ; ;.parasternal line;.parasternal line; . .Anterior axillary line ;.Posterior axillary line; .Midaxillary line;. Scapular line ;. Posterior midline 胸部的体表标志.rm Landmarks on chest wall IV The boundary of lung and pleura IV The boundary of lung and pleura Trachea bifurcates into the left and the right primary bronchus at the sternal angle level. The right primarybronchus is wider, shorter and steeper. The left one is slender and oblique. The right lung :the upper, middle, and lower lobe. The left lung :the upper and lower lobesTwo lungs resemble in shape, except for that the anterior part of the left lung is occupied by the heart.The lobe of the lungsIV The boundary of lung and pleuraIV The boundary of lung and pleura Lung apex Upper boundary of the lung Outer boundary of the lung Inner boundary of the lung Lower boundary Boundaries between lobes Lung apex: protrudes about 3 cm above the upper edge of the clavicula with its apex point near the sternal end of the clavicula, approaches the level of the first thoracic vertibra.Lung apexIts projection on the anterior Its projection on the anterior chest wall forms an chest wall forms an upward upward arcarc. . It begins at It begins at sternal-clavicular sternal-clavicular junctionjunction. .It It ends at the border point of ends at the border point of middle and inner one third of middle and inner one third of the claviculathe clavicula. .Upper boundary of the lungruns downward runs downward from the upper from the upper boundary, quite boundary, quite approaches the approaches the inner surface of inner surface of lateral chest wall.lateral chest wall.Outer boundary of the lung It runs down from the sternal-clavicuar junction.The two sides nearly meet each other at the sternal angle. separates at the fourth costal cartilage level. The right boundary continues almost vertically downward, turns rightward at the sixth costal cartilage to meet the lower boundary. The left boundary turns leftward to the anterior end of the fourth rib, along the anterior ends of 4-6 ribs downward, then turns left again to meet the lower boundary.Inner boundary of the lungThe anterior part begins fromThe anterior part begins from the sixth rib.the sixth rib.It It runs downward and laterally runs downward and laterally to to the midclavicuar line at the the midclavicuar line at the level of the sixth interspacelevel of the sixth interspace and and to the midaxillary line at to the midaxillary line at the level of the eighth the level of the eighth interspace.interspace. The posterior part of the lower The posterior part of the lower boundary approaches boundary approaches horizontal at the tenth rib level horizontal at the tenth rib level by the inferior angle line.by the inferior angle line.Lower boundary of the lungoblique fissureoblique fissure Both begin from the Both begin from the third thoracic vertebra third thoracic vertebra at posterior midlineat posterior midline, , run outward and run outward and downward, meet the downward, meet the fourth rib at fourth rib at posterioraxillary lineposterioraxillary line, , then run downward then run downward anteriorly, end anteriorly, end at the at the sixth chondrocostal sixth chondrocostal junctionjunction. . oblique fissureBoundaries between lobeshorizontal horizontal fissurefissurebegins from the begins from the forth rib at forth rib at posterior posterior axillaryaxillary line, line, ends at the right ends at the right edge of sternum edge of sternum at at the level of the level of the third the third interspace.interspace.horizontal fissureBoundaries between lobesvisceral pleuraparietal pleurapleural cavity sinus phrenicocostalis胸壁 肺The boundary of The boundary of pleurapleuravisceral pleura :the pleura covering the surface of the lungparietal pleura :the pleura covering the inner surface of the chest wall, the diaphragm, and the mediastinum.The boundary of The boundary of pleurapleura pleural cavity The visceral part and the parietal part of pleura turn over each other successively, make up the right and the left thoracic cavity two wholly closed spaces.thoracic cavity. sinus phrenicocostalis:At each side, the costal part and the diaphragmatic part of the parietal pleura beneath the lower boundary of lung turns over and compose a place about 2-3 interspace height. sinus phrenicocostalis 肺的体表投影.rmThe second section:The second section:Chest wall1.Vein: Normally the vein on chest wall is not obvious. Chest wall2. Subcutaneous emphysema: Indicates the condition when air enters and stores in subcutaneous tissue. Chest wall 3.Tenderness: In intercostal neuritis, costal cartilagitis, chest wall soft tissue inflammation and rib fractures, the involved portion may be tender. 4.Interspace: retraction or bulging of interspace. Retraction of the interspace during inspiration indicates the obstruction of free air flowing into the respiratory tract. Bulging of interspaces may be seen in patients with massive pleural effusion, tension pneumothorax, or severe emphysema.the result of tumor,In adultIn adult a ratio of 1:1.5 a ratio of 1:1.5 In elder and childhood In elder and childhood a ratio of 1:1a ratio of 1:1Chest framworkChest framwork 1. Flat chest: This can be seen in slender adult, and in patients with chronic hectic diseases as well, such as tuberculosis. 2. Barrel chest: The AP diameter is increased to as large as, or even greater than the transverse diameter, resulting in cylindric thorax. This situation can be seen in severe emphysema patient, or elderly or obese subject.Normal Barrel chestChest framwork 3. Rachitic chest佝偻病胸佝偻病胸: a deformed chest caused by rachitis, seen mostly in childhood.funnel chestpigeon chestrachitic rosaryrachitic rosaryThoracic deformity Flat chest 扁平胸扁平胸 tuberculosis肺结核肺结核 in slender adult1 the anterioposterior(AP) diameter : : transverse diameter Normal Barrel chest COPDelderly or obese subject.Rachitic chest pigeon chest 4. Unilateral deformation of the thorax: Bulging of hemithorax is noted most in massive effusion, pneumothorax, or unilateral severe compensatory emphysema. Unilateral flat or retraction of the thorax is usually seen in atelectasis, pulmonary fibrosis, extensive thickening fibrotic pleura, etc.Chest framwork 5. Local bulge of chest wall: Seen in obvious heart enlargement, massive pericardial effusion, aortic aneurysm and tumors inside or on the chest wall. Besides, bulging can also be noted in costal cartilagitis and rib fracture.Spinal deformity 6. Thoracic deformation caused by deformed spine: Severe kyphoscoliosis, kyphosis(驼驼背背), or protrusion of spine, can lead to asymmetric thorax, with widened or narrowed interspaces. In severe cases of spine deformation, the deformed thorax may cause respiratory and circulatory dysfunction. This is common in spinal tuberculosis.ScoliosiskyphosisThe second section:The second section: The breastInspection Symmetry: two breasts are generally symmetrical in healthy female in erect sitting position. Obvious enlargement of one breast may denote congenital deformation, cyst formation, inflammation, or tumor. Shrinkage of one breast usually indicates maldevelopment.Superficial appearance: Skin erythema of the breast may indicate local inflammation, or breast cancer The former is commonly associated with local swelling, hotness, and pain.whereas the latter presents scarlet skin without pain, this provides a differentiation. ulceration, pigmentation and scars on the breast skin should be mentioned. “ orange peel” or “ pig skin”. Nipple:Nipple:The size, location, symmetry of two sides and whether or not inversion of the nipple must be noted. Nipple retraction if it appears recently, it may implies malignancy. Secretion appearing at the nipple indicates abnormality along ductal system. Bleeding benign infraductal papilloma breast carcinoma. Clear nipple secretion becomes purple, green, or yellow chronic cystic mastitis. Skin retractionSkin retractionBreast skin retraction may be due to trauma or inflammation.It should be mentioned that if there isnt any definite evidence of acute breast inflammation, skin retraction often indicates the presence of a malignant tumor. Especially when advanced appearance of carcinoma such as tumor mass, skin fixation or ulceration does not appear, Axilla fossa and Axilla fossa and supraclavicular fossasupraclavicular fossa: Thorough inspection of the breasts includes observation of the most important lymphatic drainage areas. Detailed observation must be conducted to find if there are any bulging, redness, mass, ulceration, fistula or scars. PalpationThe palpation should begin from the healthy breast, then the ill one. The examiner should place his palm and fingers flatly on the breast, press gently with the palmar aspect of fingertips, with a rotary or to-and-fro motion. Palpation Palpation Take the nipple as the central point, a horizontal line and a vertical line through the central point departs the breast into four quadrants. The left breast should be palpated from the upper lateral quadrant, with a procedure of clockwise direction. the right breast with anti-clockwise direction. 1： upper lateral ；2：Under lateral ；3： under inner；4： upper inner.Consistency and elasticityConsistency and elasticity : Increase in firmness and lost of elasticity suggests infiltration of the subcutaneous tissue by the presence of an inflammation or neoplasm. When subareolar carcinoma exist, the elasticity of the skin of involved region is usually lost.Tenderness The presence of tenderness in a position of the breast usually indicates an underling inflammatory process. tenderness is seldom in present with malignant lesions.MassMass: Location: Size,number: Contour: Consistency Tenderness: Mobility: Common breast lesions: 1) Acute mastitis: The breast is red, swollen, hot and painful, inflammation is usually restricted in one quadrant of one breast. This disease occurs commonly in lactation women. 2) Breast tumors: Breast carcinoma is lack of inflammatory appearance, most are solidate and adherent to subcutaneous tissue, the local skin appear as orange peel, nipple is usually retracted. in female of middleaged or older, usually associated with axillary lymphatic metastasis. Benign lesions are soft, clear of margin, and somehow movable, usually seen as cystic mastoplastia, intracanalicular fibroma, etc.The third section: The third section: Lung and pleuraLung and pleura Inspection palpation percussion auscultationInspectionBreath movement Respiratory rate Rhythm of the breath Breath movementBreath movement Breath movement The breath movement in healthy subject at rest is steady and regular. The average tidal volume in adult with quiet breath at rest is about 500 ml. Breath movementBreath movement 1)The respiratory movement is accomplished through the contraction and relaxation of the diaphragm and intercostal muscles. 2) In normal condition: Inspiration is an active movement, Expiration is a passive movement. 3)3)Respiration in healthy males and children tends to be predominantly diaphragmatic:abdominal respiration. Whereas in female:thoracic respiration.Breath movementBreath movement In patients with partial obstruction of the upper breathing tract cause the depression of supersternal fossa, superclavical fossa and interspaces, termed “ three depression sign”. On such occasions inspiration is prolonged, hence called inspiratory dyspnea. In patients with lower respiratory tract is obstructed, exhalation with exertion may lead to bulging of the interspaces. This is associated with prolonged expiration, called expiratory dyspnea. It usually occurs in asthma and obstructive emphysema.Respiratory rate In the normal adult at rest, the respiratory rate is 12 to 20 per minute. The ratio of respiratory rate to pulse rate is 1:4. The respiratory rate in newborn is about 44 per minute, and decreases gradually upon growing up.Respiratory rate 1) tachypnea: Indicates the increased respiratory rate that over 24 per minute, usually seen in fever, pain, anemia, hyperthyroidism and heart failure. Respiratory rate 2)bradypnea: Indicates the decreased respiratory rate that less than 12 per minute. The respiration becomes superficial, seen in over dose of anesthetics or sedatives and elevated intracranial pressure.Respiratory rate 3) Change of the breath depths: Hypopnea呼吸浅慢 could be seen in respiratory palsy, ascites and fatness, etc. And also could be seen in pneumonia, pleurisy, pleural effusion and pneumothorax. Respiratory rate3) Change of the breath depths Hyperpnea (In physiological conditions ) could be found during strenuous exercises. It can also appear when one is excited or nervous, because of over ventilation. Kussmaul breath(IN pathological conditions ) : This kind of deep and slow breath is named as Kussmaul breath, seen in diabetic ketoacidosis and uremic acidosis. Rhythm of the breath Normal adult respiration is basically regular and smooth in testing status. The rhythm of the breath usually changes in diseases. 1. Tidal breathing 潮式呼吸 2. Ataxic breathing 间停呼吸 Also called Biots breahting. 3.Inhibitory breath 4. sighing respirationRhythm of the breath 1. Tidal breathing Also called as cheyne-stokes respiration. Respiration waxes and wanes cyclically so that periods of deep breathing alternate with periods of apnea(no breathing). The periods of the tidal breath can last from 30s to 2min. The periods of apnea can persist 5-30s.Rhythm of the breath 2. Ataxic breathing 间停呼吸 Also called Biots breahting. Ataxic breathing is characterized by unpredictable irregularity. Breaths may be shallow or deep, and stop for short periods Causes include heart failure, uremia, drug induced respiratory depression and brain damage(typically on both sides of the cerebral hemispheres or dienceph