Chest examination sheet

By the end of the topic, you should know fundamentals of chest history taking & become
capable of taking a chest history case.
Importance of History Taking
Taking a patient history is an essential element in establishing a diagnosis and is used to get
a deeper understanding of the patient’s symptoms. The purpose of a systematic health
history is to obtain important and detailed knowledge about the patient, their lifestyle, social
supports, medical history, and health concerns, with the history of presenting illness as the
focus. This enables the practitioner to gather important information about the patient is
underlying medical conditions and the reason they have attended, which will be valuable in
formulating a diagnosis.
General approach:
 Introduce yourself.
 Never forget patient names
 Confidentiality & respect patient privacy.
 Try to see things from patient point of view. Understand patient underneath mental
status, anxiety, irritation or depression.
 Always exhibit neutral position.
 Listening.
 Questioning simple/clear/avoid medical terms/open, interrupting, direct questions &
summarizing.

Sheet

A. Clinical history B. Examination C. Investigation

general Local
(Inspection-Palpation-
Percussion-Auscultation)
 A. Chest case history taking
1. Personal history
2. Chief complaint
3. present history of illness
4. Past history
5. Family history
6. Chest symptoms.

1) Personal history:
 Name: Familiarity & documentation.
 Age: Diseases common among certain age groups.
 Sex: Diseases common related to the type of sex.
 Race: Diseases common among certain races.
 Occupation: Diseases common among certain occupations.
 Residence: Diseases common among certain place of residency.
 Marital status & off springs
 Habits of medical importance: eg, smoking, addiction, Alcohol.
Smoking index: Number of cigarettes/day X Number of Years
 Mild (100-200)
 Moderate (200-400)
 Heavy (< 400)

2) Chief complaint:
The main reason that pushed the patient to seek for visiting a physician (or) for help.
Patient own words (avoid medical terms).
Short/specific. In one clear sentence.

3) Present history of illness:

1. Onset

Acute

 Dramatic- seconds.
 Sudden- min/hrs.
  Rapid- days.

Gradual
 wks./months

2. Course
 Progressive
 Regressive
 Intermittent
 Stationary

3. Duration
 Days, weeks, months, ….

4) Past history:
Why do we ask for history?
 To determine the etiology of illness.
 To avoid giving any future medications that will worsen the condition. To
determine any medical co morbidities or medications that might predispose to
illness.
 To assess for treatment modalities that might contraindicate with the current
condition of the patient.

Past History (Medical & Surgical)

 Similar chest condition.
 Tuberculosis.
 Bilharziasis.
 Previous hospitalization.
 Previous surgery.
 Blood transfusion.
 Drug allergy.
 Co-morbid condition: DM, HTN, Renal or hepatic disease
5) Family history:
 Similar familial chest condition, eg, Bronchial asthma.
 A particular disorder might be described as “running in a family” if more than one
person in the family has the condition.

6) Chest symptoms:
Cardinal Chest Symptoms:
 Cough
 Expectoration
 Hemoptysis
 Dyspnea
 Chest Pain
 Cyanosis
 Clubbing

1) Cough
 Sudden Explosive Expiration
 Can be either Reflex or Voluntarily
 From the bronchi, the dividing tubes become progressively smaller with an estimated
23 divisions before ending at an alveolus.
 Lung has 23 Generations Cough happens at 17 generation.
 Duration: Persistent, Short (or) Paroxysmal
 Timing: Nocturnal or All day.
 Mechanism:
1. Contraction of diaphragm and External intercostal muscles (negative pressure in
Lung).
2. Air rush into Lung.
3. Closure of glottis’s (increase Intrathoracic pressure).
4. Abdominal muscles Contraction (↑ Intra-abdominal pressure).
5. Sudden Opening of glottis followed by Air Rushing outside lung.
 Dry non Productive Cough: don’t produce sputum.
 Productive Cough: cough with sputum (expectoration).
  Cough reflex:

2) Expectoration
 Amount
 Color: c.g., whitish, yellowish, reddish, greenish, rusty.
 Odor: odorless (or) foul odor
 Aspect: watery, mucoid, mucopurulent, purulent.
 Relation to posture

3) Hemoptysis
 Hemoptysis is defined as coughing of blood originating from below the vocal cords.
 Life threatening (or) Massive hemoptysis is defined as coughing of blood > 150
ml/time (or) > 1000 ml/24 hours.
 Type & Color: (frank, mixed or blood tinged)
 Amount
 Frequency
 Last attack
 Management/Blood transfusion

Causes of Hemoptysis
 Pulmonary:
• Tuberculosis.
• Tumor.
 • Pneumonia.
• Abscess
• Infarction.
• Trauma.
• Cystic fibrosis.
• Alveolar hemorrhage.
• Arteriovenous malformation

 Cardiovascular:
• Left Ventricular Failure.
• Mitral stenosis.
• Aortic aneurism.

 Tracheobronchial:
• Bronchitis (acute & chronic).
• Bronchiectasis.
• Foreign body.
• Tumor (eg, bronchial carcinoma, tracheal & laryngeal tumors).

 Other causes:
• Blood diseases.
• Anticoagulant therapy.

Differences between True Hemoptysis & False Hemoptysis:

True hemoptysis False hemoptysis

Below vocal cords Above vocal cords
May be mixed with sputum Not mixed with sputum
History of cardiopulmonary disease Obvious by ENT examination
CXR may be abnormal Normal CXR
Differences between Hemoptysis & Hematemesis:

Hemoptysis Hematemesis
Coughing of blood Vomiting of blood
History of cardiopulmonary disease History of GIT disease
Bright red in color Dark brown in color
Mixed with sputum Mixed with gastric contents
Alkaline Acidic

4) Dyspnea:
Definition: Shortness of breath
Associated symptoms: eg, chest pain, hemoptysis & wheezes
Grading of Dyspnea
 GRADE 1 -Dyspnea only with unusual exertion.
 GRADE 2- Dyspnea on doing ordinary activity
 GRADE 3- Dyspnea on doing less than ordinary activity.
 GRADE 4- Dyspnea at rest.
Types: Acute, Chronic, positional.
Positional dyspnea:
 Paroxysmal nocturnal: shortness of breath and coughing that generally occur at
night.
 Orthopnea: shortness of breath, which occurs when lying flat.
 Trepopnea: sensed while lying on one side but not on the other.
 Platypnea: shortness of breath worsens when sitting or standing up.
Chest Causes of Acute Onset Dyspnea
 Pneumothorax
 Bronchial Asthma
 Pulmonary Embolism
 Foreign body
5) Chest Pain
 Onset
 Course
 Duration
 Character: stitching, stabbing, sawing (or) burning.
 Site
 Radiation (or) Referral
 What increase it & what decrease it.
 Severity: Interfering with daily activity (or) sleep rhythm.
 Associated symptom & History of trauma (or) surgery
 Causes of Acute Chest Pain
• Coronary artery disease.
• Pulmonary embolism/infarction.
• Pneumothorax.
• Pleurisy/ Pericarditis.
• Dissecting aortic aneurysm.
• Esophageal spasm.
6) Cyanosis
Definition: it is a bluish discoloration of the skin, mucous membranes, tongue, lips, or nail
beds and is due to an increased concentration of reduced hemoglobin (Hb) in the
circulation.

Types:
 Central cyanosis is a generalized bluish discoloration of the body and the visible
mucous membranes, which occurs due to inadequate oxygenation secondary to
conditions that lead to an increase in deoxygenated hemoglobin or presence of
abnormal hemoglobin.
Central cyanosis may be due to the following causes:

 Central nervous system (impairing normal ventilation).

 Respiratory system e.g. COPD
 Cardiovascular system e.g. Tetralogy of Fallot
 Hemoglobinopathies
 Others e.g. High altitude

 Peripheral cyanosis is the bluish discoloration of the distal extremities (hands,

fingertips, toes).Mucous membranes are generally not involved. Peripheral cyanosis
is the blue color in fingers or extremities, due to an inadequate or obstructed
circulation (e.g. peripheral vascular disease, Raynaud phenomenon)

 Differential cyanosis is the bluish coloration of the lower but not the upper extremity
and the head. This is seen in patients with a patent ductus arteriosus. The upper
extremity remains pink because deoxygenated blood flows through the patent duct
and directly into the descending aorta while sparing the brachiocephalic trunk, left
common carotid, and left subclavian arteries.

Central cyanosis Peripheral cyanosis

Mechanism Diminish arterial o2 sat Diminish flow of blood to
the local part
Sites Skin, mucous membrane Only skin involved
Temperature Warm (co2) Cold
Clubbing Present Absent
On warming Cyanosis same Cyanosis reduces
Oxygen therapy Pulmonary cause can Cyanosis reduces
improve
Exercise Cyanosis worsens Cyanosis same or improve
Arterial blood gas Po2, low Po2, normal
7) Clubbing:
Def: Obliteration of the angle between the nail and the nailbed. Clubbing is a physical sign
characterized by bulbous enlargement of the ends of one or more fingers or toes due to
proliferation of connective tissue between the fingernail and the bone.

Clubbing of the fingernail: The red line shows the outline of a clubbed nail.

Normally, the angle between the nail plate and the skin overlying the proximal part of the
distal phalanx is about 160 degrees or less. With clubbing this angle increase to more than
160 degrees.
Causes:
 It is associated with lung cancer, lung infections, interstitial lung disease, cystic
fibrosis, or cardiovascular disease. Clubbing may also run in families, and occur
unassociated with other medical problems.
 Occupational: shoe workers.
Grades:

Schamroth’s window test: The sign is elicited by placing the dorsal surfaces of terminal
phalanges on opposing fingers together. The normally formed diamond shaped window is
obliterated in the presence of clubbing. This sign is also known as diamond sign.
 B. General Examination:
1) Vital signs (mentioned before)
2) Menital Status
Alert
Fully Conscious
Co-operative
Mood and memory
Well oriented to time and place

3) Built of body

-Over built →Edematous

eg: Corapulmonale, Chronic bronchitis
-Underweight eg: Emphysema T.B.

4) Decubitus
Preferred Position of the patient
eg/ Orthopnea→ high Supine
Asthmatic→ Leaning forward

5)Over- View From Heads to toes

- Face: (Cyanosis, pallor, Jaundice)

-Eyes: Edema may be due to chronic cough or Cardiac disease
-Lips: Cyanosis
-Neck: Spasm in neck muscles, Congested neck veins (heart problems)
-Upper & Lower limbs:
Temperature:Place the dorsal aspect of your hand onto the patient’s to assess temperature:
In healthy individuals, the hands should be symmetrically warm, suggesting adequate
perfusion. Cool hands may suggest poor peripheral perfusion. Excessively warm and sweaty
hands can be associated with CO2 retention.
Nails: (color / Clubbing)
Edema: an abnormal accumulation of fluid in the intercellular tissue that results from an
abnormal expansion in interstitial fluid volume.
It may be generalized or localized edema, and may be Symmetrical or asymmetrical.
There are two types of edema
Pitting edema is described as an indentation that remains in the edematous area after
pressure is applied. It is mainly assessed on the medial malleolus, the bony portion of the
tibia, and the dorsum of the foot.
Non-pitting edema is seen in lymphedema.
 Chest examination sheet

A)History

 Personal History:

 Name :
 Age :
 Sex :
 Occupation :
 Marital status :
 Habits :
 Diagnosis :
 chief complaint:

 History of present illness:

 Site :
 Onset :
 Course :
 Location :
 Duration :
 Date of recent attack:
 Date of admission :
 Date of 1st physical therapy session if existed:
  Characteristics:
 Current situation:
 Effect on activity of daily living (ADL):
 Current medications :
 Appetite / bowel , bladder / nutrition:
 Smoking:
 Exercise tolerance:
 Home environment:
 Economic condition - poor / fair / good:

 Past history:
 Previous diagnosis of similar episodes:
 Previous treatment ( drugs )and efficacy:
 Thoracic , nasal , pharyngeotracheal , trauma or surgery:
hospitalisation for pulmonary disorders:
 Use of ventilation - assisting devices:
 Other chronic disorders - cardiac , cancer , blood clotting
disorders:
 Endoscopy , tracheostomy , lobectomy:
 previous physical therapy treatment:

 Family History :
 parents consanguinity:
 Disease runs in families:
 Subjective assessment (signs & symptoms)
 Dyspnoea:

Type:

 Cough
Onset :

Duration:

Nature :

Type :

Odour :
Sputum

Amount :

Colour:

Odour:

Time of the day:

 CHEST PAIN –

site of pain :

character :

radiation :

precipitating and alleviating factors:

 Hemoptysis:

yes □ No □
 Other Symptoms:
 Fever (pyrexia) – TB:
 Headache - morning headache - nocturnal CO2
retention:
 Peripheral edema - right heart failure:
 Shivering:
 Weight loss:
 Palpitations:
 Vomiting and nausea(Gastro intestinal reflex):
 B) General apperance

 Level of awareness ( consciousness):

Alert responsive Cooperative lethargic disoriented Inattentive

 Body type

Normal Obes Cachectic

e

 Colour:

Central cyanosis(lip) Peripheral cyanosis (nail

beds)

 Accessory muscles:

Normal Hypertrophoid

 Use of pursed lip breathing: yes □ No □

 Clubbing Of Digits: yes □ No □

 C) Analysis of Chest Shape and dimensions

Barrel Pectus excavatum Pectus carinatum Other chest No

chest (funnel breast) (pigeon breast) deformity deformity

D) Posture or Preferred Positioning

……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………

E) Breathing pattern

Normal tachypnia Bradypnea. Hyperventilation others

breathig

E) Chest Mobility and Symmetry of chest movement.

...........................................................................................................
...........................................................................................................
...........................................................................................................
 F) Palpation

 Tactile vocal fremitus:

 Normal  Abnormal  site

 Site of chest pain:

 Mediastinal shift:

G) Mediate Percussion
 Normal  Abnormal Which sound?

Auscultation of Breath Sounds

 Normal  Abnormal Which sound?
 Functional assessment
1) Lung volume and capacities:
……………………………………………………………
……………………………………………………………
……………………………………………………………
2) Arterial blood gases:
PH…………PaO2………….HCO3……………...PaCO2………………..

Acidosis/ alkalosis……………………………………………………………….

Respiratory/metabolic………………………………………………..……….....

Compensated / non compensated……………………………………………..…

Normal compensation / second disoreder………………….……………………

3) Pulse oxymeter:

……………………………………………………………
……………………………………………………………
Other investigations:
X- Ray:………………………………………………...
…………………………………………………....
C.T Scan:……………………………………………...
.......………………………………………………
MRI:…………………………………………………...
…………………………………………………...
Bronchoscope:………………………………………...
…………………………………………………...
 ICU patient

Diagnosis / Current History:

Past Medical History:

C/O (Complain of):

Neurological:

Cardiac:

Pulmonary:

GIT:

Orthopaedic:

Imaging:

Temp:

R R:

HR:

BP (map):

ABGs:
PH…………PaO2………….HCO3……………...PaCO2………………..

Acidosis/ alkalosis……………………………………………………...

Respiratory/metabolic……………………………………………….....

Compensated / non compensated………………………………………

Normal compensation / second disoreder………………………………

Pain score:

GCS Score:
Ventilation
Self-ventilating Breathing pattern:

NoN-invasive ventilation:

Invasive ventilation:

mood : CMV A/C SIMV+PS CPAP+PS BIPAP

Settings

Peak pressure:

PEEP:

FI02:

VT:

RR:

Insp pause:

Other:

Route of ventilation

Nasal cannula:

Face mask:

Endotracheal tube:

Tracheostomy:
Physical therapy treatment:

Problem list:
-

Goals of Treatment

 Short term goals:

 Long term goals: