Chest Examination Palpation - New Valley University PDF

Chest examination Palpation Professor of Internal Medicine Dr. NABILA FAIEK Palpation of the front of the chest ▪ The examiner should be at the right side of the bed. ▪ Examine the front of the chest with the patient supine with arms at the sides (slightly abducte...

Chest examination Palpation Professor of Internal Medicine Dr. NABILA FAIEK Palpation of the front of the chest ▪ The examiner should be at the right side of the bed. ▪ Examine the front of the chest with the patient supine with arms at the sides (slightly abducted). ▪ Exposure – expose from waist upwards but remember to preserve dignity of patient. If female (e.g. cover with towel). Exposure of the front of the chest Palpation of the back of the chest ▪ Examine back while the patient is sitting. The patient’s arms should be folded across the chest with hands resting, if possible, on the opposite shoulders. ▪ Examine back from a midline position behind the patient. Palpation of the chest (Items) ▪ Local tenderness ▪ Confirmation of inspection Respiratory movement Pulsations Dilated veins: direction of filling ▪ Position of the trachea ▪ Tactile vocal fremitus (TVF) ▪ Palpable adventitious sounds: palpable rhonchi (rhonchus fremitus) palpable pleural rub Palpable crepitus Causes of Local tenderness: ▪Myositis ▪ fracture rib ▪ Liver abscess in the right lower chest due to liver.  Respiratory movement Front of the chest: ▪ Upper part: Place your hands, palm down either side of the manubrium, with your thumbs equidistant from the midline and raised slightly with your fingers on the chest, wrapped around the thorax. Ask the patient to take deep breaths in and observe your hands simultaneously rising with each inspiration. Lower part: Place the fingertips of both hands on either side of the lower ribcage(below nipple), Extend your fingers around the sides so that the tips of the thumbs meet in the midline.Ask the patient to take deep breath. Observe movement of your thumbs, they should move apart equally. If one of your thumbs moves less, this suggests reduced expansion on that side. Assess the respiratory movement from the front lower part A :Expiration B: inspiration  Respiratory movement Back of the chest: Repeat the procedure to check the patient’s posterior chest while the patient in the setting position (Upper part , lower part ) ▪ Causes of restricted mobility of one side Pleural effusion Pneumothorax Collapse Fibrosis Pneumonia Space occupying lesion ▪ Confirmation of Pulsations Epigastric pulsation ( Enlargement of right ventricle , aorta in thin person, hepatic pulsation from tricuspid regurgitation) Apical pulsation: Use palmar surface of your hand and then the tip of the finger to localize Left Parasternal pulsation Left 2nd space pulsation Right 2nd space pulsation Suprasternal pulsation Position: in the 5th left intercostal space(just inside )half inch medial to the mid clavicular line ▪ Causes of shift (pushing) the apical pulsations to the opposite side Pleural effusion Pneumothorax Space occupying lesion ▪ Causes of pulling the apical pulsations to the same side Collapse Fibrosis Epigastric pulsations Put your hand in the epigastrium using 3 fingers (index , middle, ring) ▪ From Above: Enlargement of right ventricle (Pulsation in ring finger) ▪ From below: aorta in thin person(Pulsation in middle finger) ▪ From right: hepatic pulsation in tricuspid regurgitation(Pulsation in index finger) ▪ Palpate the right 2nd space pulsation and left 2nd space pulsation by the palmar surface of your hand.  Suprasternal pulsation ▪ Palpate the suprasternal notch with your index finger. ▪ Normal: There will be no palpable pulse ▪ Causes of palpable pulsations: Hyperdynamic circulation Aortic Arch aneurysm ▪ Dilated veins Long segment of vein (one inch or more) is selected for examination. Stand on the right hand side of the patient and place the index finger of both hands side by side over the vein—the left above the right one. Now start milking the vein by movement of two index fingers in opposite direction. The two ends of the bloodless vein is blocked with the pressure given by two index fingers. The left index finger is now removed and the rapidity of venous filling from above is noted. The same procedure is repeated after removal of the right index finger. The rapidity of venous filling indicates the direction of blood flow. ▪ Dilated veins SVC obstruction :( filling from above downward) IVC obstruction :( filling from below upward) Position of the trachea ▪ Ask the patient to relax the sternomastoid muscles by dropping the chin,. Gently place the tip of your right index finger into the suprasternal notch and palpate the trachea, the distance between it and the sternomastoids on each side should be the same.. ▪ This can be uncomfortable; be gentle and explain what you are doing. ▪ Normally the trachea is central. ▪ Causes of shift (pushing) the trachea to the opposite side Pleural effusion Pneumothorax Space occupying lesion ▪ Causes of pulling the trachea to the same side Collapse Fibrosis  Tactile vocal fremitus (TVF) ▪ Palpable vibrations initiated at the vocal cords by voice , transmitted through the airways and palpated on chest wall. ▪ Place palm of one hand(right) horizontally against the chest make sure that your fingers do not touch the chest. Ask the patient to say “44” in Arabic or “Ninety nine ” in English (Ulnar side of the hand could be used specially in the interscapular area and supraclavicular area). ▪ You should feel the vibration against your hand. ▪ Normally equal on both sides. ▪ Compare the both sides.( region by region) ▪ Front: Compare areas: Supraclavicular 1 Infraclavicular 2 Mammary 3 Inframammary 4 ▪ Axilla: Upper 5 Lower 6 ▪ Back: Compare areas: suprascapular 1 Interscapular 2 Infrascapular 3 4 ▪ Causes of increased TVF Consolidation Cavity surrounded by consolidation ▪ Causes of decreased TVF Pleural effusion Pneumothorax Collapse due to bronchial obstruction ▪ Palpable adventitious sounds: Palpable rhonchi (rhonchus fremitus) Palpable pleural rub Palpable crepitus Palpation of the Back of the chest (Items) ▪ Local tenderness Confirmation of inspection Respiratory movement ▪ Tactile vocal fremitus (TVF) ▪ Palpable adventitious sounds: palpable rhonchi (rhonchus fremitus) palpable pleural rub Palpable crepitus