Physical Signs in the Chest Part II Professor

In this section some of the causes of the common physical signs are listed. Mediastinal shift Mediastinal shift to one or other side is detected by deviation of the trachea or of the heart. Naturally the trachea is more often deviated be abnormalities in the upper part of the chest, or occupying the whole of one side of the chest, and the heart by abnormalities in the lower part of the chest. If the heart is deviated to the left the apex beat will be deviated to that side. If there is no obvious cause of enlargement of the heart one can provisionally assume, depending on the later detection of consistent physical signs, that deviation is due to mediastinal shift. It is less easy to be sure of deviation to the right, especially if the abnormal physical signs are present in the right lower zone and dullness at the right base makes it impossible to detect the right border of the heart. Inward deviation of the apex beat, unless it is gross, might be due to the patient having a relatively small heart. In this case initial impressions may have to confirmed by x-ray. Copyright Royal Medical Society. All rights reserved. The copyright is retained by the author and the Royal Medical Society, except where explicitly otherwise stated. Scans have been produced by the Digital Imaging Unit at Edinburgh University Library. Res Medica is supported by the University of Edinburgh’s Journal Hosting Service: http://journals.ed.ac.uk ISSN: 2051-7580 (Online) ISSN: 0482-3206 (Print) Res Medica is published by the Royal Medical Society, 5/5 Bristo Square, Edinburgh, EH8 9AL Res Medica, Spring 1964, 4(2): 23-26 doi: 10.2218/resmedica.v4i2.423 ectasis, although they may sometimes occur in bronchitis. T H E P H Y S IC A L SIG N S OF COMMON C H E ST

ectasis, although they m ay som etim es occur in bronchitis.

T H E P H Y S IC A L S IG N S O F CO M M O N C H E S T C O N D IT IO N S
I n this section will be listed not all the conceivable physical signs, as stated in text books, but the physical signs which are most frequently present and which arc m ost helpful in m aking the diagnosis. Consolidation.
( 1 ) D im inished m ovement of the affected side.
(2) M arked dullness to percussion, although this will only be present in lobar consolidation and absent with patchy consolidation.
(3) Increased vocal fremitus, som etim es use ful in distinguishing from a thin layer of fluid.
(6) In the early stages of consolidation there are usually no crepitations but fine crepitations may be present later.
(7) A p leural rub is often present or the catching of the breath on inspiration may indicate the presence of dry pleurisy.
(1) D im in ish ed m ovem ent.
(2) D eviation of the m ediastinum to the same side.
(4) C om m on ly dim inish ed breath sounds, but som etim es, if the collapse is due to obstruc tion of the smaller bronchi and the larger bronchi remain open, bronchial breathing.
(5) Crepitations may or may not be present.( 6) A cgophony and w hispering pectoriloquy if there is bronchial breathing.

Pleural effusion.
Pleural effusions, of course, may be of all sizes and m ay be difficult to detect if the effusion is very small.
(1) D im in ish ed m ovem ent.
(2) D eviation of the mediastinum to the o pposite side.T h is is only detectable when the effusion is relatively large.
(5) Breath sounds dim inish ed or, if the layer of fluid is a thin one, and quite com m only over the upper part of the effusion, bronchial breathing.
O n the whole the shape of the upper level of dullness in pleural effusion is not very help ful.Classically this rises into the axilla and is lower anteriorly but in practice this is not very helpful.Stony dullness, absence o f vocal frem itus and d im inish ed or absent breath sounds are the main diagnostic physical signs.
(2) D eviation of the m ediastinum to the opposite side, only if the pneum othorax is large.
(3) Percussion note m ore resonant on that side than on the opposite side.
(4) D im inu tion in breath sounds, which is much the m ost com m on physical sign although, as m entioned above, cavernous or amphoric breathing may som etim es occur.
(5) Pleural c lic k s: T h ese clicks are occasion ally heard in a left-sided pneum othorax in the cardiac area and in tim e with the beating of the heart.T h ey are usually due to the approx imation and separation of the two layers of pleura lying over the heart when these are separated only by a very thin layer of air during systole and the two layers com e together dur ing diastole.As the heart contracts the two sticky layers of pleura separate with a click.
D im inution in breath sounds is the only consistent sign of pneum othorax.A spontan eous pneum othorax is usually suspected on the strength of the history.If dim inution of breath sounds is found on one side, with a normal or hyper-resonant percussion note, pneum othorax should be suspected.D eviation of the m edia stinum will only be found if the pneum othorax is large.Rather quaint physical signs, such as " the coin sound" , have been described in pneum othorax but are archaic relies of the prex-ray period.

H ydropneum othorax.
In hydropneumothorax fluid is present as well as air.T h e classical signs of pneum othorax may be found in the upper part of the chest and those of effusion in the lower part of the chest, usually with a well-defined upper border of dullness for the effusion; the position of this