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LEARNING OBJECTIVES

Learning Objectives

  • The student will be able to conduct a basic chest exam on standardized or real patients using modalities of inspection, palpation, percussion, and auscultation.

  • The student will be able to make valid diagnostic inferences from the findings of a basic chest exam, including interpretation and application of likelihood ratios.

Physical examination of the patient's chest adds valuable information to direct clinicians toward a correct diagnosis when symptoms suggest a lung disease or disorder. This chapter summarizes first the key elements of a basic chest exam, using the four modalities of inspection, palpation, percussion, and auscultation. It then gives guidance on interpreting those findings, using estimates of the discriminatory power of certain results, or their absence, by means of positive likelihood ratios (+LR) or negative likelihood ratios (−LR). It is important to note that students must practice the chest exam on standardized patients and real patients. Such practice should be augmented with breath sound simulators, a valuable way to become familiar with abnormal lung and adventitious sounds that standardized patients usually do not have.

GENERAL CONSIDERATIONS

Although this chapter focuses on the basic chest exam, assessing all vital signs is crucial in patients who present with symptoms that suggest a lung disease or disorder. Here, four modalities are discussed in succession. In practice, most physicians first evaluate the patient for any signs of respiratory distress including use of accessory muscles of respiration, then examine the posterior chest and lung fields using all four modalities, and finally examine the anterior chest wall and lung fields using all modalities. The posterior chest wall is best examined with the patient sitting erect on an exam table or hospital bed. Even frail, bedridden patients can generally be safely held in a sitting position by assistants, while the physician examines the posterior chest and lung fields. Some experts recommend examining the anterior chest wall with the patient sitting, while others prefer that the patient be supine for the anterior chest exam, so that a female patient's breasts may be gently displaced.

The lungs are nearly symmetrical structures, and except for the lower anterior chest wall where the heart intervenes, each side serves as a natural control to the other. Indeed, a proper chest exam carefully evaluates any side-to-side asymmetries. The exam should not be made through a hospital gown, since this can alter the findings of all four modalities. Physicians can learn to respect patient modesty while completing a thorough exam.

INSPECTION

There are four questions to be answered during the inspection phase of the chest exam:

  1. Is the patient using the accessory muscles of respiration?

  2. Is the trachea deviated from a midline position?

  3. Are there any chest wall structural abnormalities such as kyphosis or scoliosis?

  4. Is chest expansion of the two hemithoraces symmetric, ...

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