Thorax
examination
Rayan al abdullatif
Why thorax examination
matters?
Introduction
Thorax examination is essential for evaluating lung function and detecting respiratory
abnormalities. It follows a structured approach to ensure accurate assessment and
diagnosis.
The thorax houses vital organs such as the lungs, heart, and major blood vessels.
A thorax examination helps assess respiratory function and detect abnormalities
It consists of four key assessment methods:
Inspection (visual assessment)
Palpation (feeling for abnormalities)
Percussion (tapping to assess underlying structures)
Auscultation (listening to breath sounds)
Objectives
By the end of this presentation, you should be able to:
1. Understand the importance of a thorax examination.
2. Learn how to perform each assessment method correctly.
3. Recognize normal vs. abnormal findings in the chest.
4. Understand how this examination aids in diagnosing respiratory diseases.
Assessment Methods
• A step-by-step approach is essential for accuracy.
• Always compare the right and left sides of the chest.
Follow this sequence:
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
Inspection
Inspection is the visual examination of the chest to detect abnormalities in shape, movement,
and breathing patterns.
Steps to Assess the Patient
1. Position the patient in a sitting, upright position in a well-light room.
2. Observe for chest symmetry - Both sides should rise equally during breathing.
3. Check for breathing effort and rate - Look for signs of rapid or irregular breathing.
4. Observe skin color - Cyanosis (bluish skin) may indicate oxygen deficiency.
5. Look for the use of accessory muscles - Straining in the neck or shoulders may
indicate respiratory distress.
6. Assess tracheal position - It should be midline; a shift may suggest a lung problem.
Inspection
Angle of Louis (Sternal Angle)
• A bony ridge located at the junction of the manubrium and sternal body.
• Serves as a landmark for identifying rib 2 and important thoracic
structures (e.g., tracheal bifurcation).
Chest Movement:
• Normally, both sides of the chest should expand equally during breathing.
• Asymmetry may indicate lung collapse (atelectasis), pneumothorax, or pleural effusion.
• Paradoxical movement (e.g., flail chest) suggests rib fractures or severe trauma.
Inspection
Thorax Configuration (Chest Shape)
Normal and abnormal thoracic shapes can indicate underlying respiratory or
musculoskeletal issues.
• Normal Chest – Symmetrical with a slightly oval shape.
• Kyphosis – Excessive curvature of the thoracic spine, causing a hunched posture.
• Scoliosis – Lateral curvature of the spine, leading to asymmetry in chest expansion.
• Kyphoscoliosis – Combination of kyphosis and scoliosis, leading to severe chest wall
deformities that may impair breathing.
Palpation
Palpation is the use of hands to assess chest movement, vibrations, and any
abnormalities in the thorax.
Procedure:
• Place hands on both sides of the chest to assess chest
expansion and symmetry.
• Feel for tenderness, swelling, or any abnormal lumps.
• Check for tactile fremitus by placing your hands on the chest
while the patient says “99.” Increased fremitus may indicate lung
consolidation, while decreased fremitus may suggest pleural
effusion or pneumothorax.
Palpation
Steps to Assess the Patient
1. Assess Chest Expansion:
Place both hands on the lower ribs with thumbs touching at the midline.
Ask the patient to take a deep breath.
Observe the movement of your hands--both sides should expand equally.
Unequal expansion may indicate lung collapse, pneumonia, or pleural effusion.
2. Assess Tactile Fremitus:
Ask the patient to say "99" while placing your hands on different areas of the chest.
Increased vibrations suggest pneumonia or lung consolidation.
Decreased vibrations may indicate pneumothorax or pleural effusion.
3. Check for Tenderness or Pain:
• Gently press on the chest wall
. Pain could indicate rib fractures or inflammation.
4. Assess for Subcutaneous Emphysema:
• Feel for a crackling sensation under the skin, which suggests trapped air due to trauma or pneumothorax.
Percussion
Percussion is a technique where the examiner taps on the chest wall to assess the underlying structures
and detect abnormalities in lung tissue.
Procedure:
• Use the middle finger of one hand to tap over the middle
finger of the other hand placed on the chest.
• Compare the sounds produced on different parts of the
chest.
• Normal finding: Resonant sounds over healthy lung tissue.
• Abnormal findings:
• Dull sounds: May indicate consolidation (e.g., pneumonia) or
pleural effusion.
• Hyperresonant sounds: Suggest air trapping, such as in
pneumothorax or emphysema.
Percussion
Steps to Assess the Patient
1. Position the patient sitting upright
2. Place the middle finger of one hand firmly on the chest wall.
3. Use the other hand's middle finger to tap on the placed finger.
4. Compare both sides of the chest to detect differences in sound.
5. Move from top to bottom and side to side.
Percussion
Normal vs. Abnormal Findings
• Resonant sound → Normal, air-filled lungs.
• Dull sound → Fluid or solid tissue (pneumonia, pleural effusion, tumor).
• Hyperresonant sound → Excess air (pneumothorax, emphysema).
• Flat sound → Bone or large pleural effusion.
Auscultation
Auscultation is the process of listening to lung sounds using a stethoscope to assess
airflow and identify abnormal breath sounds.
Procedure:
• Use the diaphragm of the stethoscope to listen to breath sounds.
• Ask the patient to breathe deeply through their mouth.
• Compare lung sounds on both sides in a systematic pattern.
Auscultation
Steps to Assess the Patient
1. Ensure a quiet environment.
2. Position the patient upright.
3. Use the diaphragm of the stethoscope and place it firmly
on the chest.
4. Ask the patient to breathe deeply through their mouth.
5. Listen to breath sounds in a systematic pattern:
Start from the upper chest and move downward.
Compare both sides of the chest.
Auscultation
Identify normal vs. abnormal sounds:
Vesicular sounds -> Normal breath sounds.
Crackles (rales) - Fluid in the lungs (pneumonia,
pulmonary edema).
Wheezing -> Narrowed airways (asthma, COPD).
Stridor -> Upper airway obstruction.
Absent breath sounds - Pneumothorax or lung collapse.
Recommendations for a Proper
Thorax Examination
Ensure good lighting.
Keep the patient relaxed and comfortable.
Compare both sides of the chest.
Follow a systematic approach.
Practice frequently to develop skills.
Summary
A thorax examination consists of inspection, palpation, percussion, and
auscultation.
Each step provides valuable diagnostic clues.
Recognizing normal vs. abnormal findings is essential for accurate
diagnosis.
A structured, step-by-step approach improves examination accuracy.
References
1. Guyton, A. C., & Hall, J. E. (2021). Textbook of Medical Physiology (14th ed.). Elsevier.
2. West, J. B. (2020). Respiratory Physiology: The Essentials (11th ed.). Wolters Kluwer.
3. Bates, B. (2021). Bates’ Guide to Physical Examination and History Taking (13th ed.).
Lippincott Williams & Wilkins.
4. Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2020). Mosby’s Guide to
Physical Examination (9th ed.). Mosby.
5. McGee, S. (2018). Evidence-Based Physical Diagnosis (4th ed.). Elsevier.
6. American Thoracic Society. (2023). Clinical Practice Guidelines for Lung Examination.
American Journal of Respiratory and Critical Care Medicine, 207(5), 520-534.
7. Epstein, S. K. (2001). Evaluation of the Patient with Dyspnea. New England Journal of
Medicine, 344(9), 732-741.
8. Sapira, J. D. (2000). The Art and Science of Bedside Diagnosis (2nd ed.). Lippincott
Williams & Wilkins.
9. Standring, S. (2015). Gray’s Anatomy: The Anatomical Basis of Clinical Practice (41st
ed.). Elsevier.
10. University of California, San Diego. (n.d.). Lung Sounds.
