One out, TV anatomy studies by inspections of the chest and second in the palpitation and palpitation precautions, ECG and endoscopy, bronchoscopy, gastroscopy, and radiography, electromyography, and diagram and EEG.
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I now have sufficient textbook content to construct a comprehensive answer. Let me compile the full response covering all the topics requested: chest inspection, palpation (with precautions), ECG, endoscopy/bronchoscopy/gastroscopy, radiography, electromyography (EMG), and EEG.
Clinical Examination & Diagnostic Procedures
1. Inspection of the Chest (Physical Examination)
Physical examination begins the moment the clinician first sees the patient. For chest inspection, sufficient clothing must be removed and the patient suitably draped so the entire thorax is visible. The patient ordinarily sits upright.
What to observe:
- Shape and symmetry - reveals kyphoscoliosis, pectus excavatum (sunken sternum), pectus carinatum (pigeon chest), ankylosing spondylitis, gynecomastia, or surgical scars
- Breathing pattern - rate, depth, rhythm, and type (e.g., Cheyne-Stokes, Kussmaul, Biot's)
- Accessory muscle use - suggests increased work of breathing
- Smell - tobacco stains on teeth/fingers/clothing; odor of ethanol or ketones (diabetic ketoacidosis); foul odor of anaerobic lung abscess; sweet smell of Pseudomonas infection
Murray & Nadel's Textbook of Respiratory Medicine, p. 397
2. Palpation of the Chest
Technique and findings:
- Detect bony abnormalities - cervical rib, subcutaneous calcinosis (in systemic sclerosis)
- Point tenderness and thoracic spinal tenderness - essential when evaluating chest pain
- Fluctuant areas - suggest empyema necessitans
- Crepitant areas - suggest subcutaneous emphysema
- Tracheal deviation from the suprasternal notch - indicates mediastinal shift (toward collapse, away from tension pneumothorax or large effusion)
- Chest wall lag - place both hands symmetrically over each hemithorax and feel/observe whether movement is symmetric
Vocal Fremitus:
- Elicited by having the patient say "one, two, three" while the examiner's palms move top to bottom across both hemithoraces
- Increased fremitus - consolidation (pneumonia) enhances sound transmission
- Decreased fremitus - pleural effusion impairs sound transmission
Cardiac palpation:
- Always search for apical impulse, heaves/lifts, thrills, and palpable valve closure
- In severe COPD, abnormal cardiac movements are often better felt in the subxiphoid region than over the precordium
Murray & Nadel's Textbook of Respiratory Medicine, p. 397
Palpation Precautions:
- Avoid deep palpation over areas of suspected rib fractures or flail chest
- Be gentle over areas of known or suspected pathology (abscess, empyema)
- In suspected spinal injury, avoid any movement that could compromise the cord
- Subcutaneous emphysema (crepitus) should not be forcefully compressed
- Assess for tenderness before applying full pressure
3. Percussion of the Chest
Skillful percussion depends on a uniform, free, easy stroke of the plexor finger onto the pleximeter finger. It is predominantly felt, not just heard.
| Percussion Note | Condition |
|---|---|
| Resonant | Normal air-containing lung |
| Hyperresonant / Tympanitic | Pneumothorax (tympanitic when under tension) |
| Dull | Pleural effusion, pneumonia/consolidation |
| Flat | Percussing over liver (solid tissue) |
With large pleural effusions, three tonal zones are detected: resonance above the fluid, dullness in the middle, and flatness at the bottom.
4. Auscultation of the Chest
The diaphragm of the stethoscope detects higher-pitched sounds; the bell detects lower-pitched sounds (must be applied lightly - e.g., for the low rumble of mitral stenosis).
Breath sound classification (American Thoracic Society):
| Sound Type | Characteristics | Significance |
|---|---|---|
| Normal breath sounds | 200-600 Hz, decreasing power, soft, inspiratory | Normal lung |
| Crackles (fine) | Short, explosive, discontinuous | Interstitial fibrosis, pulmonary edema |
| Crackles (coarse) | Louder, lower pitch | Pneumonia, bronchiectasis |
| Wheezes | High-pitched (>400 Hz), continuous (>250 ms) | Airway obstruction, asthma |
| Rhonchi | Low-pitched (<200 Hz), continuous; may clear with cough | Secretions in larger airways |
Voice-generated sounds:
- Egophony ("E to A" test) - "E" sounds like "A" over consolidated lung (pneumonia)
- Bronchophony / Pectoriloquy - spoken or whispered words transmitted with increased intensity and clarity through consolidation
Murray & Nadel's Textbook of Respiratory Medicine, p. 398
5. ECG (Electrocardiogram)
The ECG records electrical potentials generated by the heart at the body surface.
Generation of the ECG waveform:
- P wave - SA node fires → impulse propagates through atria via specialized conduction tissue → atrial depolarization and contraction
- PR interval - represents the conduction delay at the AV node (normally 120-200 ms)
- QRS complex - impulse travels through the His bundle → left and right bundle branches → Purkinje fibers → ventricular cardiomyocytes depolarize
- T wave - ventricular repolarization
The AV node is a region of relatively slow conduction, creating the delay between atrial and ventricular contraction. From the distal His bundle, the impulse passes through the bundle branches and finally the Purkinje system, which activates the ventricular myocardium.
Miller's Anesthesia, 10e, p. 1364-1367
6. Endoscopy
Bronchoscopy - visual examination of the tracheobronchial tree via a flexible or rigid bronchoscope. Used to:
- Diagnose lung cancer, infections, hemoptysis
- Obtain BAL (bronchoalveolar lavage), brushings, or biopsies
- Remove foreign bodies or mucus plugs
Gastroscopy (Upper GI Endoscopy) - visual examination of the esophagus, stomach, and duodenum. Used to:
- Diagnose peptic ulcer disease, esophagitis, gastric cancer
- Identify sources of GI bleeding (e.g., varices, Mallory-Weiss tears)
- Obtain mucosal biopsies (e.g., H. pylori, Barrett's esophagus)
Rigid Sigmoidoscopy (lower endoscopy) - obligatory in patients with symptoms of large bowel or anal disease. The instrument (Lloyd Davies pattern, 14 or 19 mm diameter, up to 30 cm length) is lubricated and passed gently. Examines the rectal mucosa to at least 10 cm from the anal verge.
ERCP (Endoscopic Retrograde Cholangiopancreatography) - a specialized endoscopic procedure where the bile and pancreatic ducts are cannulated via a catheter introduced through a side-viewing duodenoscope, then visualized radiographically after contrast injection. Used to:
- Detect common bile duct stones and strictures
- Diagnose pancreatic duct obstruction (diagnostic of pancreatic cancer)
- Obtain bile and pancreatic juice for cytology
Pye's Surgical Handicraft, 22nd Ed, p. 287-298
7. Radiography
Plain radiography provides important anatomical and pathological information:
- Soft tissue X-ray - shows an enlarged liver or spleen; demonstrates radio-opaque gallstones
- Barium meal / swallow - discloses esophageal varices, alimentary tract cancer, widening of the duodenal loop (suggesting cancer of the head of the pancreas)
- Targeted films of the second part of the duodenum - may show an ampullary carcinoma
In the chest, CXR assesses:
- Lung fields (consolidation, collapse, effusions, pneumothorax)
- Cardiac size and mediastinal width
- Bony thorax abnormalities
Pye's Surgical Handicraft, 22nd Ed, p. 287
8. Electromyography (EMG)
EMG records the electrical activity of skeletal muscle using needle electrodes inserted into the muscle or surface electrodes on the skin.
What it measures:
- Insertional activity - brief burst on needle insertion (normally brief; increased in inflammatory myopathies, decreased in fibrosis)
- Spontaneous activity at rest - normally silent; fibrillation potentials and positive sharp waves indicate denervation
- Motor unit action potentials (MUAPs) - assessed for amplitude, duration, polyphasia
- Large, long-duration MUAPs = re-innervation (chronic neurogenic disease)
- Small, short-duration, polyphasic MUAPs = myopathy
Clinical uses:
- Distinguishing neuropathy (nerve damage) from myopathy (muscle disease)
- Diagnosing neuromuscular junction disorders (e.g., myasthenia gravis, Lambert-Eaton syndrome)
- Nerve conduction studies (NCS) are often done alongside EMG
9. EEG (Electroencephalography)
EEG records spontaneous electrical activity of the brain via electrodes placed on the scalp (typically 19-21 electrodes in the 10-20 international system).
Brain wave patterns:
| Wave | Frequency | State |
|---|---|---|
| Delta (δ) | <4 Hz | Deep sleep, encephalopathy, lesions |
| Theta (θ) | 4-8 Hz | Drowsiness, some encephalopathies |
| Alpha (α) | 8-13 Hz | Relaxed wakefulness, eyes closed |
| Beta (β) | >13 Hz | Active thinking, benzodiazepines |
Clinical uses:
- Epilepsy diagnosis - identifies seizure type (generalized vs. focal), inter-ictal spikes
- Encephalopathy - diffuse slowing in metabolic or toxic encephalopathy
- Brain death - electrocerebral silence (flat EEG)
- Sleep disorders - polysomnography includes EEG
- Monitoring during cardiac/neurosurgery (depth of anesthesia)
Summary Table
| Procedure | What it Examines | Primary Use |
|---|---|---|
| Inspection | Visual thorax assessment | Structural abnormalities, breathing patterns |
| Palpation | Tactile chest assessment | Fremitus, tenderness, tracheal deviation |
| Percussion | Resonance of thorax | Fluid vs. air vs. solid |
| Auscultation | Breath/heart sounds | Crackles, wheezes, murmurs |
| ECG | Cardiac electrical activity | Arrhythmias, ischemia, conduction defects |
| Bronchoscopy | Tracheobronchial tree | Lung cancer, infection, hemoptysis |
| Gastroscopy | Upper GI tract | Ulcers, bleeding, cancer |
| Radiography | Structural imaging | Bones, soft tissues, organ size |
| EMG | Skeletal muscle electrical activity | Neuropathy vs. myopathy |
| EEG | Brain electrical activity | Epilepsy, encephalopathy, brain death |
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