The Examination of the Lungs.—For the purposes of examination, the body, especially the chest and abdomen, must be stripped. The light should be good. Its source, as to whether it falls directly, obliquely or vertically, upon the patient, must often be varied. Many physiologic and pathologic conditions can be seen only with oblique illumination. It is therefore desirable to have the patient first face the window, later turn his side toward it. In the latter position most of the shadows become intensified.
<Callout type="tip" title="Pro Technique">Accurate, useful and skilled inspection is in reality often the most difficult to acquire and the last in which the practitioner becomes proficient.</Callout>
The following points are especially to be noted: General appearance, posture, gait, facial expression, nutrition, color. Absolute symmetry is unknown. As a general rule the right side of the body is better developed than the left. The right chest is about 17 inches larger in circumference than the left. The spine curves toward the right, the right arm is longer and the corresponding shoulder is often narrower and lower.
The Skin.—(a) The color (pallor, cyanosis, jaundice, pigmentation, mottling, ete.); (b) the character (texture, moisture, edema, eruptions, gloss, subcutaneous fat, wasting, distended blood-vessels).
The Muscles.—Development, wasting, tremors, symmetry.
The Face.—Intelligence, expression, symmetry, spasm, paralysis, edema, myxedema.
The Hair—Dryness, sparsity, distribution, dyes, parasites, local discoloration, the presence of vermin.
The Eyes.—Prominence of the eyeballs, the pupils (size, color symmetry, equality, reaction to light, ete.), conjunctiva (color, ecchymosis, discharges).
The Mouth.—Teeth, gums, tongue, pharynx, tonsils, lips (pyorrhea, cyanosis, herpes, ulcerations, moisture, deposits, drooping, rhagades).
The Ears.—Shape, discharges, tophi, scars.
The Nose.—Discharges, obstruction, motion of the nostrils (dyspnea), dilated venule: The Neck.—Pulsations—arterial and venous, swelling thyroidal enlargement, scars.
<Callout type="warning" title="Safety Hazard">A patient stripped to the waist should not be subjected to the discomfort of a cold examining room.</Callout>
The Hands.—Cyanosis, curved or ridged nails, clubbed fingers, joints, deposits (tophi, Heberden’s nodes), shape, symmetry, nutrition, capillary pulse. The Abdomen.—Shape, distention, varicos edema, eruptions.
The Legs and Feet.—Edema, clubbing of the toes, deformities, varicosities, cyanosis, scars, pigmentation, adenitis ties, asymmetry, pulsation.
<Callout type="important" title="Critical Rule">Inspection requires no special technique; the only requirement is that one should keep in mind constantly that every abnormality, however slight it may appear, is worthy of consideration.</Callout>
The Examination of the Chest This method of physical examination is too frequently omitted, or made so hastily and cursorily that little or no information is obtained. Inspection, properly done, yields more valuable information than any other procedure at our disposal, with the exception of auscultation; and furthermore, it has this to commend it, namely, that no special training is required, and the beginner, providing he is taught to use his eyes intelligently, is as capable of seeing defects as the experienced observer. This is in marked contrast to the training necessary to educate the ear to differentiate sounds, particularly those produced by percussion, the latter method often requiring years of practice.
In order that inspection should yield the best results, it is absolutely essential that the patient be stripped to the waist. The unpleasantness and inconvenience to a patient of undressing for this purpose, the time occupied in so doing, the trouble it gives, and a sense of delicacy in women are no longer to be considered the serious obstacles Laennec which has not been believed them to be. An examination of a patient entirely exposed is in the vast majority of instances worse than no examination at all.
For some years we have used the following method. A piece of linen or fine muslin a yard long is cut from one corner to the center and the free edges hemmed (see Figs. 4 and 5). This is thrown over the shoulders. In examining the anterior aspect of the chest the cape is loosened over the shoulder. When the area below the breast is examined the cape still affords protection. In examining the back, the cape may be pushed up exposing the entire back as no objection is ever offered to this method. It must be borne in mind that a patient stripped to the waist not be subjected to the discomfort of a cold examining room.
The Posture of the Patient.—As to the posture of the patient, the sitting position is the one of choice. The patient should be instructed to sit with his back straight and not, on the one hand, to sit too rigidly, or, on the other, to assume a slouching position. The standing position may be selected if the examiner prefers it, but it is not as convenient and if the examination takes much time is tiring both for the patient and the examiner. Inspection of the chest in patients who are confined to bed and acutely ill is never as satisfactory as in those who can sit or stand up.
Further- more, is available for the method. Another difficulty is that in private houses the light frequently comes from one side only, so that half of the chest is in a shadow which seriously interferes with a good view. In very ill patients this method of physical examination, in common with the other procedures, suffers from a lack of thoroughness which is often unavoidable.
If the examination of the patient in the recumbent attitude is unavoidable, care must be taken to see that the body rests on an even plane; otherwise the results may he affected very materially (see p. 202). To fix a standard of what constitutes a normal chest which shall serve as a criterion by which to estimate either the existence of or the degree, of abnormal variations, is not possible. Individuals entirely free from thoracic disease present the greatest variations in the conformation of their chests.
The Conformation of the Normal Chest.—Providing that the chest does not present some one of the recognized deformities, it is assumed to be normal if it is symmetrical, not only generally but in its different parts. The shoulders should be on the same level and the line from the neck to the point of the shoulder slightly convex.
In men the clavicles are usually more or less prominent and the supraclavicular spaces a little depressed. In women the clavicles are not uncommonly hidden by adipose tissue and there are no depressions above the clavicles. Beneath the clavicles the chest wall is slightly convex. The intercostal spaces are slightly below the surface unless the individual is well covered with fat.
Owing to the progressively increasing obliquity of the ribs from behind forward the intercostal interspaces are broader in front than behind. In the majority of individuals a projection of the sternum is visible at the level of the second costal cartilages. This projection or angle is of variable degree and is formed by the articulation of the upper and middle portions of the sternum. It is known as the Angulus Sterni or Angle of Louis. In certain thoracic conditions, particularly emphysema, the bulging forward of the upper ribs tends to accentuate this angle.
The lower part of the sternum just above the ensiform cartilage is normally slightly depressed. Viewed from behind the angles of the scapula should be on the same level (corresponding to the spine of the eighth dorsal vertebra) and closely approximated to the chest wall. The spine should be straight and slightly concave from above downward.
Slight deviations of the spine are not uncommon, however, and may or may not be an indication of thoracic disease. They are frequently due to faulty posture.
Key Takeaways
- Inspection is a critical part of physical diagnosis and can yield valuable information about the patient’s condition.
- The chest should be examined from multiple angles, including anterior, posterior, and profile views.
- Proper lighting and positioning are essential for accurate inspection.
Practical Tips
- Always ensure that the patient is comfortable during the examination to avoid unnecessary discomfort or stress.
- Practice observing subtle changes in skin color, texture, and moisture to improve your diagnostic skills.
- Use a cape when examining patients to maintain their modesty while ensuring proper lighting.
Warnings & Risks
- Avoid undressing the patient unnecessarily as it can cause discomfort and embarrassment.
- Be aware that certain deformities or postures may affect the accuracy of the examination.
- Do not rely solely on inspection; combine it with other diagnostic methods for a comprehensive assessment.
Modern Application
While the techniques described in this chapter are rooted in early 20th-century medical practices, many of the principles of physical diagnosis remain relevant today. Modern survival preparedness can benefit from these foundational skills, especially when dealing with limited resources or remote locations where advanced diagnostic tools may not be available.
Frequently Asked Questions
Q: What is the importance of proper lighting during a chest examination?
Proper lighting is crucial as many physiologic and pathologic conditions can only be seen with oblique illumination. The source of light should vary to ensure that both sides of the chest are well lit, preventing errors in diagnosis.
Q: How does the sitting position affect the examination?
The sitting position is preferred as it allows for a more natural posture and reduces discomfort for the patient compared to standing or lying down. It also makes the examination less tiring for both the examiner and the patient.
Q: What are some common deformities of the chest that should be noted during inspection?
Common deformities include scoliosis, kyphosis, lordosis, and asymmetry in the size or expansion of the two sides of the chest. These can affect the accuracy of the examination and may indicate underlying thoracic disease.