The chest contains the primary organs of circulation and breathing, and thus a thorough assessment of the chest can provide clues to a host of clinical conditions. While the definitive examination of the chest consists primarily of radiographic studies, the physical exam techniques of thoracic assessment are easily mastered by all levels of EMS providers.
Hank is a 64-year-old male who has suffered a persistent cough for the past 72 hours. He slept poorly last night and began to complain of chest pain and dyspnea early this morning, prompting his wife to call 9-1-1.
The responding EMS crew finds Hank sitting on the edge of the bed, coughing frequently and grimacing in pain with every cough. Audible rhonchi can be heard from across the room, and Hank tells the EMTs, “You gotta help me. I can barely catch my breath, and every time I cough it feels like someone is sticking a knife between my ribs.”
While one medic obtains vital signs and an EKG, her partner questions Hank about his medical history. He has a history of CHF, asthma and hypertension, and had an MI followed by placement of two coronary stents six years ago. Noting the ashtray sitting on the bedside table, the medic asks him about his smoking habit, and he defensively claims, “I’ve cut way back. When I had my heart attack, I was smoking 2½ packs a day, and now I’m smoking only one.”
His medications are furosemide, potassium chloride, lisinopril, Plavix, aspirin and sublingual nitroglycerin. He says he’s been taking his medications as prescribed, and took three nitroglycerin tablets and an extra baby aspirin without relief prior to calling 9-1-1.
His skin feels moist and hot to the touch, and vital signs are BP 106/94; heart rate 116 and regular; respirations 28 and slightly labored, with scattered wheezes bilaterally and coarse rales over the left lung fields. The EKG rhythm is sinus tachycardia with occasional PACs, and SpO2 is 89% on room air.
Anatomy and Physiology
The chest cavity is lined by a two-layered membrane called the pleura. The parietal pleura lines the chest cavity itself, and like all parietal cavity membranes is richly supplied with somatic sensory nerve fibers. The visceral pleura covers the lungs themselves and is much less richly supplied with sensory nerves. In normal physiology, the space between the two layers is a potential space only, and they are held in close proximity to each other via surface tension provided by pleural fluid, allowing the lungs to expand along with the rib cage during inhalation. This pleural fluid also provides lubrication between the two layers.
The area in the chest containing the heart, vena cavae and aorta, distal end of the trachea and mainstem bronchi is known as the mediastinum and lies in the center of the chest, directly behind the sternum. Within the mediastinum is also found the hilum of the lungs, the point at which the bronchi, pulmonary arteries and veins, lymphatic vessels and nerves enter each lung. The heart itself is covered with a tough, inelastic membrane called the pericardium and is suspended in the chest cavity by the ligamentum arteriosum, which is formed from the remnants of the ductus arteriosus that was present during fetal circulation.
While her partner administers oxygen and obtains a 12-lead EKG, the paramedic continues her line of questioning, asking Hank about the quality of his chest pain. He says the pain has gradually increased over the past 24 hours, describes it as “stabbing,” and says it worsens dramatically with a cough or deep inhalation. The pain does not radiate and is confined to an area over his left lateral chest. He says it’s different in character from the chest pain he experienced during his MI. He reports a 101.3ºF fever and fatigue, but denies weakness, dizziness, nausea and vomiting.
When vital signs indicate the patient is hemodynamically stable and there is no imminent threat to the ABCs, the next appropriate step is to obtain a history, focusing on the patient’s chief complaint and associated signs and symptoms. The traditional format of OPQRST/ASPN works well for assessment of respiratory and cardiac problems:
Onset: What was the patient doing when the symptoms began? Are the dyspnea and chest pain constant or intermittent? What, if any, recent illnesses or injuries preceded the chief complaint? Did the symptoms appear gradually or suddenly? Sudden onset of dyspnea during the night, known as paroxysmal nocturnal dyspnea, is a common finding in acute CHF exacerbation and pulmonary edema.
Provocation/Palliation: What actions make the symptoms worse or better? Are the symptoms worsened by exertion or relieved by rest? Chest pain that worsens with cough or deep inspiration points to inflammation of the parietal pleura, which often occurs with respiratory illnesses. Chest pain that can be reproduced with palpation or patient movement indicates a musculoskeletal cause, but it should be noted that as many as 15% of MI patients, particularly women, report pleuritic or somatic chest pain.
Quality: Have the patient describe the symptoms in his or her own words. Since the heart is poorly supplied with sensory nerve fibers, cardiac pain is often described as a vague heaviness, pressure or tightness, whereas pleuritic pain, due to the rich innervation of parietal membranes with sensory fibers, is usually described as sharp or stabbing, and is easily defined in one part of the chest.
Radiation: Since visceral organs often share sensory nerve roots, cardiac pain may radiate to other areas of the body, particularly the left arm, shoulders, jaw and neck. Pleuritic pain is often highly localized and radiates very little. Radiation of musculoskeletal pain is usually limited to contiguous muscle groups.
Severity: Ask the patient to rate their pain on a 1–10 scale, or use a visual analog pain scale such as the Wong-Baker faces. While dyspnea is difficult to quantify using a subjective numerical scale or visual analogs, it is possible to rate the severity of distress based upon objective findings such as pulse oximetry, waveform capnography, respiratory rate and breathing mechanics.
Time: Ask the patient when symptoms began. Rapid onset of respiratory distress may indicate a life-threatening condition such as anaphylaxis or an acute coronary syndrome.
Associated Symptoms and Pertinent Negatives: Ask the patient about any other symptoms associated with the chief complaint, and document the answers. If the patient denies the presence of any symptoms associated with known clinical syndromes, document the absence of these symptoms as pertinent negatives.
Recognizing the signs of pleuritic chest pain, the paramedic begins a thorough physical assessment of Hank’s chest. The 12-lead EKG reveals evidence of left ventricular hypertrophy, and Q waves in inferior leads are indicative of an old MI. There is no acute ST-segment elevation. His chest exhibits the increased anterior-posterior diameter common in emphysema patients but bears no scars or signs of recent injury. The patient’s pain is not reproducible by movement or palpation.
A thorough physical examination of the chest is best accomplished through the methodical application of inspection, auscultation, palpation and percussion techniques:
Inspection: Look for signs of chronic respiratory pathology, such as the characteristic barrel chest and hypertrophied neck muscles of emphysema. Are there any telltale scars that may yield clues to the patient’s history, such as the midline sternotomy scar from a coronary artery bypass graft or other heart surgery? Is there a lump just beneath the skin that could be a pacemaker or automatic implantable cardioverter-defibrillator (AICD)? Are there medication patches present? Is the patient exhibiting increased work in breathing, such as use of accessory muscles, intercostal retractions or a prolonged expiratory phase? Listen for any airway sounds that are audible without a stethoscope, such as stridor or rhonchi. Stridor indicates significant upper airway edema, while rhonchi indicate fluid or mucus in the large airways.
Auscultation: With the diaphragm of your stethoscope, listen to the patient’s anterior chest above and below the clavicles and at the fourth intercostal space in the midclavicular line, and at the fourth and sixth intercostal spaces in the midaxillary line. On the patient’s posterior chest, listen in the same general areas, omitting the areas covered by the scapulae. Listen from side to side, noting any asymmetry of lung sounds. Note if there is a prolonged expiratory phase (greater than 1:2). Listen for heart tones at the fifth intercostal space at the left sternal border, noting any abnormal findings such as an S3 sound (Ken-TUH-kee; see sidebar) that is often present in CHF. Note any abnormal lung sounds, such as:
- Wheezes—Inspiratory wheezes indicate bronchospasm, while inspiratory and expiratory wheezes indicate bronchospasm with a significant degree of airway edema. Wheezes are typically heard over the lower lung fields, but resonance through the large airways may make them audible even in the upper fields.
- Rales—These fine crackles indicate fluid from infection, increased mucus production or pulmonary edema. Coarse rales over the large airways usually indicate mucus, but severe pulmonary edema may present with diminished breath sounds in lower lung fields and coarse rales in the large airways.
- Crepitus—Fractured ribs can often be heard to make a clicking noise during auscultation over the injured area.
Palpation: Feel the patient’s chest for equal chest excursion, subcutaneous emphysema or rib crepitus. SQ emphysema is best appreciated in the axillary and supraclavicular regions. If the patient is able to follow commands, assess for tactile fremitus by having the patient say “ninety-nine” while you palpate their chest. You should feel the vibration equally on both sides, and any loss of vibration may indicate lung consolidation or pneumothorax in the affected side.
Percussion: Using the same landmarks as for auscultation, hyperextend the middle finger of one hand and place the distal joint over the area you wish to percuss, firmly in contact with the patient’s chest. Sharply rap the joint with the end of the middle finger of your other hand. Characterize the sounds you hear as normal, dull or hyperresonant. Note any asymmetry of findings. Dull sounds indicate fluid, such as pleural effusion or pneumonia, while hyperresonant sounds indicate trapped air, such as in chronic emphysema or, in acute cases, pneumothorax.
The paramedic notes faint expiratory wheezes bilaterally, as well as coarse rales and a dull percussion note over the left middle chest. Tactile fremitus over that area is also diminished. Noting the patient’s fever and malaise, she suspects pneumonia and the potential for sepsis. En route to the hospital, she administers nebulized levalbuterol and ipratropium bromide, establishes IV access and boluses the patient with 500 ml of normal saline, and notifies the ED of a sepsis alert. Within an hour of ED arrival, the patient is diagnosed with left lower lobe pneumonia and sepsis and started on broad-spectrum antibiotics. He goes on to make a full recovery.
Assessing the chest can pose a challenge, but the techniques can be easily mastered by all levels of EMTs. Some of these techniques, such as percussion, assessing tactile fremitus or auscultating heart tones, are barely covered in the classroom and thus rarely done in the field. Nonetheless, appropriate application of these assessment techniques can yield valuable clues to the patient’s condition and keep the provider from veering down the wrong treatment path.
Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He is the author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.
William E. (Gene) Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate’s degree paramedic program for a community college and served as both a volunteer and paid paramedic. He lives in Tucson, AZ.