Palpate lymph nodes bilaterally.The examiner may be positioned in front of or behind the patient and examine the lymph nodes with the pads of his index and middle fingers.This should be done slowly and carefully to make certain that there aren’t any abnormalities present.It is better if the examiner moves the skin over the underlying tissue rather than move his fingers over the surface of the skin.The examiner may have the patient position his head with his neck slightly flexed forward.The examiner palpates all nodes bilaterally.
For palpation of lymph nodes,be sure to keep the skin and muscles relaxed.If the lymph nodes are enlarged , note their location,size,number,hardness,mobility ,tenderness,adhesion,fusion,swelling ,fistula or scars.
Chapter 4 Physical Examination of the Chest
The chest indicates the region that lies under the neck and above the abdomen. Chest wall is composed of sternum, ribs, and vertebras. The anterior part is a little shorter than the posterior part. Chest examination includes many components: chest shape, chest wall, breasts, vessels, mediastinum, bronchus, lung, pleura, heart, and lymph nodes, etc.
In addition to general physical examination, the following check methods have been widely used in clinical work: X-ray topography, lung function test, blood-gas analysis, aetiology, histology, and relevant bio-chemical tests. These methods can provide early stages of abnormality and pathogens, even give out exact diagnosis on pathology and pathogenesis, but, many changes in palpation, percussion and auscultation for all kinds of rales, can not be detected through these methods so they can’t completely replace the basic physical examinations till now. The basic physical examination has long been used clinically, which doesn’t need high-quality equippment, handy for use to provide important information and signs for the diagnosis of the chest diseases. Of course, a correct diagnosis depends not only on the basic physical examination, but also other supplementary examinations and the ill history should be emphasized in synthetical consideration.
Traditional physical examination of the chest includes four methods, inspection, palpation, percussion and auscultation. The examination should be performed in warm circumstance with well light. 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, and be examined thoroughly with the sequence of inspection, palpation, percussion and auscultation. In general, the anterior and the lateral part is examined first, then the posterior part, this may overcome the tendency that only percussion and auscultation be cared but inspection and palpation be overlooked and avoid omission of any significant sign.
A.. Landmark on chest wall
The chest contains important organs such as lung and heart. Examination of chest aims to determine the physiologic and pathophysiologic situations of these organs. The position of each organ inside the chest can be determined by examining the surface of the chest. To mark the underlying organ, and detect the position and range of the abnormalities, it is quite important to make well aquaintance with the natural landmarks and artificial lines, with which the underlying structure and abnormalities can be exactly located on the chest wall.
Suprasternal notch: Above the manubrium sterni. In normal condition trachea is in this notch.
Manubrium sterni: a piece of hexagon bone at the top of the sternum. Its upper part connects bilaterally to the sternal end of each clavicula, while its base part connects to the sternum.
Sternal angle: Also termed Louis angle. It is formed by the protrusion of the conjunction composed of sternum and manabrium sterni. It connects bilaterally to each of the right and left second costal cartilage. It acts as an important landmark for counting rib and interspace, and indicates the bifurcation of the trachea, the upper level of the atria of heart, the demarcation of upper and lower part of mediastinum, and the fifth thoracic vertebra as well.
Suprabdominal angle: also termed infrasternal angle, denotes the angle formed by the bilateral rib rows (composed of the seventh to tenth costal cartilage joining bilaterally) which meet at the lower end of the sternum. It corresponds to the dome part of the diaphragm. Normally this angle is approximately 70°- 110°,narrower in slender and wider in dumpy persons, and it also widens slightly during deep inspiration. The underlying region contains the left lobe of liver, stomach and pancreas.
Xiphoid process: the protrusive triangular part of the lower end of the sternum with its base connects to the sternum. The length of xiphoid process in normal subject varies widely.
Rib: a total of 12 pairs. Each connects to the corresponding thoracic vertebra with its posterior end. The ribs run obliquely to the lateral and then to the anterior direction, with smaller oblique angle above and larger angle lower. Each of the 1-10 rib connects to the relevant cartilage and the sternum, constructing the bony framework of the chest. The eleventh and the twelfthrib do not connect to the sternum and thus are called free ribs.
Intercostal space (interspace): The space between two adjacent ribs, used to mark the position of any lesion. Beneath the first rib is the first interspace, beneath the second rib the second interspace, and so forth. Most ribs are palpable over the chest wall except for the first one because its anterior portion is overlapped by the clavicula and usually unpalpable.
Scapula: lies between the second and the eighth rib on the posterior chest wall. The hillock and shoulder ridge of the scapula is palpated easily. Its inferior end is called inferior angle. When the patient is in standing position with his arms hanging naturally, the inferior angle acts as the mark of the seventh or the eighth rib, or corresponds to the eighth thoracic vertebra.
Spinous process: marks the posterior midline. The seventh cervical spinal process at the base of the neck is most prominent, usually serves as the hallmark for counting the thoracic vertebrae which start just following it.
Costolspinal angle: constructed by the twelfth rib and the spine. The kidney and ureter lies in the region in front of this angle.
II Vertical 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 sterni and running down vertically through the middle of the xiphoid process.
Midclavicular line (left, right): vertical line drawn through the middle point of each clavicula, e.g. the vertical line running through the middle point of the clavicula between its shoulder end and sternal end.
Sternal line (L, R): vertical line runs along the vertical edges of the sternum and parallels to the anterior midline.
Parasternal line (L, R): Vertical line at the middle of sternal line and midclavicular line.
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.
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.
III Natural fossa and anatomic region
Axillary fossa (L, R): the depressed region formed from the inside aspect of the upper arm connecting to the chest wall.
Suprasternal fossa: a depressed region above the manubrium sterni, behind it lies the trachea in normal condition.
Infraclavicular fossa (L, R): a depressed region beneath the claviculae with its lower margin at the third rib, corresponds to the lower part of each lung apex.
Suprascapular region (L, R): the region above the scapular hillock with the upper lateral margin at the ridge of the trapezius, corresponds to the lower part of the lung apex.
Infrascapular region (L, R): the region that between the line through two inferior angles and the horizontal line through the twelfth thoracic vertebra. The posteriormidline departs it into two parts.
Interscapular region (L, R): The region between the inside ridges of both scapulae, is departed by the posteriormidline into two parts.`
IV The boundary of lung and pleura
Trachea runs down along the anterior part of the neck into the thorax at the front of esophagus, bifurcates into the left and the right primary bronchus at the sternal angle level, then enters into the left and right lungs, respectively. The right primary bronchus is wider, shorter and steeper, while the left one is slender and oblique. Right primary bronchus departs into three branches, enter the upper, middle, and lower lobe of the right lung, respectively. Left primary bronchus bifurcates and enters the upper and lower lobes, respectively. Two lungs resemble in shape, except for that the anterior part of the left lung is occupied by the heart. Each lobe has a topographic position on chest wall. To know the topographic position is of importance for location diagnosis of lung diseases.
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.
Upper boundary of the lung: its projection on the anterior chest wall forms an upward arc. It begins at sternal-clavicular junction, runs upward and outward to the level of the first thoracic vertebra, then downward and outwardly, ends at the border point of middle and inner one third of the clavicula.
Outer boundary of the lung: runs downward from the upper boundary, quite approaches the inner surface of lateral chest wall.
Inner boundary of the lung: runs down from the sternal-clavicuar junction, the two sides nearly meet each other at the sternal angle, then runs down along each side of the anterior midline, then separates at the fourth costal cartilage level. The right boundary continues almost vertically downward, turns rightward at the sixth costal cartilage, runs down 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.
Lower boundary: two sides of the lower boundary are in analogy position. The anterior part begins from the sixth rib, runs downward and laterally to the midclavicuar line at the level of the sixth interspace, and to the midaxillary line at the level of the eighth interspace. The posterior part of the lower boundary approaches horizontal at the tenth rib level by the inferior angle line.
Boundaries between lobes: called fissure. Lobes of the two lungs are separated by visceral pleura between lobes. The fissure between the upper lobe and the middle and lower lobes of the right lung, and that between the upper and lower lobe of the left lung, is called oblique or diagonal fissure. Both begin from the third thoracic vertebra at posterior midline, run outward and downward, meet the fourth rib at posterioraxillary line, then run downward anteriorly, end at the sixth chondrocostal junction. The anterior upper aspect of the right lower lobe attaches to the lower aspect of the middle lobe. The boundary between the upper and middle lobe is horizontal, called horizontal fissure, begins from the forth rib at posterior axillary line, ends at the right edge of sternum at the level of the third interspace.
Pleura: the pleura covering the surface of the lung is termed visceral pleura, and that covering the inner surface of the chest wall, the diaphragm, and the mediastinum, is called parietal pleura. 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. Intrathoracic pressure is negative, which makes the two layer of pleura adhere closely together, forming a latent cavity. In the cavity there is a little plasma, which lessons the rub between pleura during respiration. 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, called sinus phrenicocostalis. Because of its lowest position, even at deep inspiration, it can't be brimmed by the expanded lung.
In examining chest wall, the examiner should pay attention to the following aspects in addition to the nutrition, skin, lymph nodes, and the development of skeleton muscle:
1. Vein: Normally the vein on chest wall is not obvious. When superior or inferior vena cava and their branches are blocked, collateral circulation will be built up, veins on chest wall become full form varicose. The blood flow in the varicose vein is downward when superior vein is obstructed, and upward when inferior vein obstructed.
2. Subcutaneous emphysema: Indicates the condition when air enters and stores in subcutaneous tissue. Pressing the skin with fingers will lead to motion of stored air in the subcutaneous tissues, and produce crepitation, a sensation like rolling a lock of hair between the thumb and fingers or grasping snow. When pressing the stethoscope on the involved skin, the sound can be heard that resemble to rolling hair, called crepitus. Subcutaneous emphysema at chest is commonly the result of injuries of lung, trachea or pleura, free air escapes from injured part into subcutaneous tissues. Occasionally subcutaneous emphysema can be caused by local infection of bacillus aerogenes. In severe cases air may spread to neck, abdomen and other position of subcutaneous tissues.
3.Tenderness: Normally there is no tenderness on chest wall. In intercostal neuritis, costal cartilagitis, chest wall soft tissue inflammation and rib fractures, the involved portion may be tender. Tenderness and pain on percussion on sternum usually exist in leukemia patients when myelodysplasia occurs.
4.Interspace: It must be mentioned whether there is any 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. In addition, the corresponding interspace bulging may be noted in the thoracic wall as the result of tumor, aortic aneurysm, or marked cardiac enlargement in infancy and childhood.
II Chest framwork
In normal subjects, there is some variation in size and shape of the thorax. In general, the two halves of the thorax are grossly symmetric, present elliptical shape. Shoulders are at nearly horizontal level. The clavicula is a little prominent and there is a little depression of both the supraclavicular and infraclavicular areas. Though, in right-handed person, the greater pectoral muscle at the right side is usually more developed than that of the left side. The opposite would apply for those who are left-handed. In adult, the anterioposterior(AP) diameter of the thorax is shorter than the transverse diameter, present a ratio of 1:1.5. In elder and childhood, the AP diameter is a little shorter than or nearly equals to the transverse diameter, makes the thorax cylindric.
1. Flat chest: The thorax framework is flat, the AP diameter is less than half of the transverse diameter. 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. The oblique degree of the rib becomes small, the rib angle with spine is larger than 45°. Interspace becomes wider and full. The infrasternal angle becomes wider with less respiratory variation. This situation can be seen in severe emphysema patient, or elderly or obese subject.
3. Rachitic chest: a deformed chest caused by rachitis, seen mostly in childhood. Along each side of the sternum, chondrocostal junctions usually bulge like rosary, termed rachitic rosary. The lower anterior part of ribs turns outward, the part of chest wall attaching with diaphragm depress, form a sulciform band, called Harrison groove. The xiphoid process is depressed, making the thorax funnel-like, called funnel chest. If the AP diameter is a little longer than the transverse diameter, the vertical span is smaller, the lower part of the sternum bulges, and the adjacent ribs depress, the resultant deformed chest is called 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.
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, the former usually has tenderness on the bulged cartilage, the latter often reveals severe pain as the chest wall being pressed, in addition to bone fremitus of the broken ends of ribs.
6. Thoracic deformation caused by deformed spine: Severe kyphoscoliosis, kyphosis, or protrusion of spine, can lead to asymmetric thorax, with widened or narrowed interspaces. The relation between the landmark and the position of underling organ changes. In severe cases of spine deformation, the deformed thorax may cause respiratory and circulatory dysfunction. This is common in spinal tuberculosis.
Normally the breast is not obvious in childhood and man, with the nipple located in the fourth interspace at midclavicular line. In normal female the breast begins to develop during adolescence, assumes hemispherical. The nipple also develops to cylidric shape.
Breast examination should be conducted in systemic sequence rather than only the position complained by patient, lest any misdiagnosis. Besides breast, the lymphatic drainage sites must be examined as well. When examined, the patient should stripped to waist for adequate exposure of the chest, and plenty of light is essential. The patient is usually in sitting or supine position. Normally the first step is inspection, then palpation.
Symmetry: two breasts are generally symmetrical in healthy female in erect sitting position. Mild asymmetry can also be seen as the result of difference in development of two breasts. 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 involving the superficial lymphatic tube and causing carcinous lymphadenitis. The former is commonly associated with local swelling, hotness, and pain, whereas the latter presents scarlet skin without pain, this provides a differentiation. When breast tumor is present, the superficial vessels are usually visible. Moreover, ulceration, pigmentation and scars on the breast skin should be mentioned.
Edema of the breast makes the hair follicles and follicular openings easily seen, which may be obvious in breast carcinoma and inflammation. The edema associated with carcinoma is caused by mechanical blockage of cancer cells in the lymphatic channels beneath the skin, termed lymphoedema. In this situation, the hair follicles and follicular opening depress obviously, so that theinvolved skin looks like “ orange peel” or “ pig skin”. Inflammatory edema is caused by inflammatory irritation, which increases the capillary permeability, results in the extravation of plasma into the intercellular space, usually associated with skin redness. Notations should be given as to the exact location and range of the edema on the breast skin.
During pregnancy and lactation period, the breast will enlarge obviously, protrude and prollapse, with larger areola and more pigmental. The axillae becomes full, superficial vein in breast skin can also be seen. In some instances the breast tissue extends to the apex of the axillae, because of the hypertrophy of the breast tissue in preparation for lactation.
Nipple: The size, location, symmetry of two sides and whether or not inversion of the nipple must be noted. Nipple retraction since childhood indicates mal-development; if it appears recently, it may implies malignancy. Secretion appearing at the nipple indicates abnormality along ductal system. The secretion may be serous, purple, yellowish, greenish or sanguineous. Bleeding is most often caused by the presence of benign infraductal papilloma, but also by the presence of breast carcinoma. Clear nipple secretion becomes purple, green, or yellow, usually indicates chronic cystic mastitis. During pregnancy the nipples become larger and more mobile. In condition with hypoadrenocorticism, there may be obvious pigmentation on areola.
Skin retraction: Breast skin retraction may be due to trauma or inflammation which cause local fat necrosis and fibroblastic proliferation, leading to shortening of the ligamentous fibers between the superficial layer and the deep layer in the involved area. It should be mentioned that if there isn't 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, the mild degree of skin retraction may be the physical sign of early stage of breast carcinoma.
In order to find skin or nipple retraction, the patient should be instructed to do such upper limb movements that cause the contraction of anterior chest muscles to stretch the breast ligament, such as raising arms over head, pressing palms together, or exerting pressure on both hips with her hands.
Axilla fossa and supraclavicular fossa: Thorough inspection of the breasts includes observation of the most important lymphatic drainage areas. Detailed observation of the axillary and supraclavicular regions must be conducted to find if there are any bulging, redness, mass, ulceration, fistula or scars.
The upper margin of the breast is at the second or the third rib, its lower margin at the sixth or seventh rib, the inner margin at the sternal ridge, and the outer margin ends at anterioaxillary line.
When the breast is palpated, the patient may take sitting position, with her arms at side first, then overhead or pressed on both hips. In supine position, the shoulders can be elevated by a small pillow putted under them to allow the breasts rest more symmetrically on the chest wall for more detailed and convenient examination. Take the nipple as the central point, a horizontal line and a vertical line through the central point departs the breast into four quadrants. This makes it convenient to locate the lesion.
The 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. The left breast should be palpated from the upper lateral quadrant, with a procedure of clockwise direction for thorough examination, each quadrant is palpated superficially and then deeply, and the nipple is palpated finally. The same procedure is adopted for palpation of the right breast with anti-clockwise direction. Attention must be paid to any redness, swell, hotness, tenderness and lump while palpation being performed, as well as induration, mis-elasticity and secretion.