PULMONARYEXAMINATION

20122013
PhysicalExaminationoftheChest
Thetroublewithmostdoctorsisntsomuchthattheydont
knowenough,asitisthattheydontseeenough.
DomanicCorrigan

Nogreateropportunityorobligationcanfallthelotofahuman
being,thantobeaphysician.Incaseofthesufferingheneeds
technicalskill,scientificknowledgeandhumanunderstanding.
Hewhousesthesewithcourage,humilityandwisdomwillprovide
auniqueserviceforhisfellowmanandwillbuildanenduringedifice
ofcharacterwithinhimself.Thephysicianshouldaskofhisdestiny
nomorethanthisandheshouldbecontentwithnoless.
TinsleyHarrison

Lethim,onmeetingafellowmortal,learnataglancetodistinguish
thehistoryofthemanandthetradeorprofessiontowhichhebelongs.
Byamansfingernails,byhiscoatsleeve,byhisboot,byhistrouser
knees,bythecallositiesofhisforefingerandthumb,byhisexpression
byhisshirtcuffs,byeachofthesethingsamanscallingisplainly
revealed.
SherlockHolmes.
AstudyinScarlet

Theexaminationdoesnotawaittheremovaloftheshirt.
R.Waring

Athoroughhistoryandphysicalexaminationformthecornerstoneofahigh
levelofcompetenceinmedicalpractice.
Developathorough,systematicroutinethatisthesameforeachpatientyousee.

I.THEPHYSICALEXAMINATIONISFOCUSEDBYTHEHISTORY.
Thefollowingsixsymptomsareofsuchspecificimportanceinpulmonarydiseasediagnosisthat
theywarrantspecialdiscussion:
1.
2.
3.
4.
5.
6.

Cough
Sputumproduction
Hemoptysis
Chestpain
Dyspnea
Wheezing

1. Coughsshouldbecharacterized:timeofday,isitproductiveornonproductiveofsputum.
Coughshouldberelatedtoanyexacerbatingfactorse.g.runningincoldweather.
2. Sputumproductionshouldbedescribed:e.g.1cupadayoffoulsmellingsputum.
3. Hemoptysis(coughingupblood)mustbedistinguishedfromhematemesis(vomitingblood).
4. Chestpainshouldbewellcharacterized:pleuropulmonary,cardiovascularorneuromuscular.
5. Dyspnearequiresquantifying.Apatientwhousuallyruns5milesadaywhothennotices
dyspneaafterrunningonemileadaymayhavenewdisease.Apatientwhousuallycanrun
uptwoflightsofstairswhothennoticesdyspneaafterwalkinguponeflightofstairsmay
havenewdisease.
6. Wheezing.Knowtheimportanceofinspiratorystridorandunilateralwheezing.Inspiratory
stridorshouldberecognizedimmediatelysincetheobstructionissituatedinthelarynxor
tracheaandthereliefoftheobstructionmaybeamatterofgreaturgency.Forunilateral
wheezing,inmostinstances,thelesionwillbebronchogeniccarcinoma,althoughother
tumors,foreignbodiesorinflammatorystenosinglesionsmayoccasionallybethecauseof
unilateralwheezing.
II.FOURCOMPONENTSOFTHEEXAMINATION
A.
B.
C.
D.

Inspection
Palpation
Percussion
Auscultation

1. INSPECTION
1.

FIRSTANDMOSTIMPORTANTISTHERESPIRATORYRATE.TOBEACCURATE
RESPIRATORYRATESHOULDBECOUNTEDFOR30SECONDS.Istherespiratory
rateincreasedordecreased?(NORMALRATEVARIESBETWEEN8AND14).Whatis
thelengthofinspirationandexpiration?
INSPIRATIONLASTSTWICETOTHREETIMESLONGERTHANEXPIRATION.Is
thepatientinrespiratorydistress?

2.

CHESTWALLSTRUCTURE
Contour
Symmetry
Hyperinflation
Sternaldeformity:PectusCarinatum
PectusExcavatum
Spinialdeformity:Kyphosis
Gibbus
Lordosis
Scoliosis

3.

INSPECTIONMEANSMORETHANOBSERVINGTHECHEST:

USEOFACCESSORYRESPIRATORYMUSCLESsuchassternocleidomastoidretraction
Signifiesincreasedworkofbreathingandrespiratorydistress.
CLUBBINGisassociatedwithlungcancer,iscommonlyassociatedwithdiffusefibrosisofthe
lungandisalmostalwaysseeninpatientswithcysticfibrosis.Itis NOT amanifestationof
asthma,chronicbronchitisoremphysema.
SKINcyanosis,rashes
2. PALPATION
1.Examineforadenopathy
2. Examinetheneck
TrachealpositionShouldbeinthemidline.Maydeviateslightlytotherightinolder
patients.
ThyroidglandAtthebaseoftheneck
3. Chestwalltenderness
4. Precordium
PMI
Ventricularheave

PalpableP2

5.

Chestwallexpansion.Placehandsatthebaseoftheribcagewiththumbsequidistantfrom
spinousprocesses.Askpatienttotakeslow,deepbreathsandobserveforanyasymmetric
motionofyourhands.

6.

Fremitus(palpablebreathsounds):Withthepalmaraspectofthefingersortheulnaraspect
ofthehand,appreciate tactilefremitus byaskingthepatienttosay(bluemoon,99,
onetwothree).

Fremitusn.pl.(L.fremere,tomurmur).Apalpablevibration.
Fremitus is enhanced by consolidation and decreased by pleural fluid or trapped air
(pneumothorax=airinthepleuralspace).
Palpation is the best method for evaluation of the degree and symmetry of expansion with
respiration,aswellasforappreciationofthetransmittedvibrationsofthespokenvoice.
C. PERCUSSION
Amethodofevaluatingtheconsistencyoftissuesbelowtheskinbythequalityofreflected
sound and palpable vibrations generated by tapping on the body surface. A poor mans
ultrasound.
MethodPlacethevolarsurfaceofonemiddlefingerfirmlyagainsttheareatobeexamined
(PLEXIMETER)andtapwiththemiddlefingeroftheotherhand(PLEXOR).Listenandfeel
thevibrations.
Soundsyoumighthear:
Resonancetheclearlonglowpitchedsoundelicitedoverthenormallung.
Hyperresonanceamorevibrant,lowerpitched,louderandlongersoundheardnormally
overthelungsduringmaximuminspiration.
Dullnessshort,highpitched,softandthuddingsoundwhichlacksthevibratoryquality
ofaresonantsound.Dullnessoccurswhentheaircontentoftheunderlyingtissueis
decreasedanditssolidityisincreased.
Flatnessveryshort,andhighpitched(absolutedullness).Flatnessoccurswhenthereis
noairpresentintheunderlyingtissue.Forexample,flatnessisfoundoverthemuscleof
thearmorthigh.
Note:Variationsinresonancemaybeperceivedtoagreaterdegreebythepleximeterfingerthan
by the ear. SO AS YOU ARE LEARNING PERCUSSION LISTEN AND FEEL THE
VIBRATIONS.

D. AUSCULTATION
Instructthepatienttobreathewithhismouthopen,alittledeeperandfaster.Demonstrateitto
thepatientyourself.
1. Evaluationofbreathsounds
INTENSITY
REGIONSListenoveralllobes/segments
QUALITY
TrachealLoud,harsh,turbulentsoundheardoverthesternalnotch.
BronchovesicularLessharsh,easily,heardsoundsofairflowheardincentralairways
understernum.
VesicularNormalquietwhishingnoiseofairflowthroughsmallairways.
THESOUNDSHEARDOVERNORMALLUNGPARENCHYMAARE
CALLEDVESICULARBREATHSOUNDS.
Bronchial (AlsocalledTubular)Similartotrachealbreathsoundsbutareabnormal
becausetheyareheardovertheperipherallungwhereonlyvesicularsoundshouldbe
heard. BRONCHIAL OR TUBULAR SOUNDS ARE CLASSICALLY OBSERVED
OVERTHECONSOLIDATEDLOBEOFLOBARPNEUMONIA.
AmphoricHollow,metallicsoundheardoveralargecavity.
ADVENTITIOUSSOUNDS(L.Adto+veniretocome)1.accidentaloracquired;notnaturalor
hereditary: Adventitioussoundsarevibrationsalwaysresultingfromsomepathologicprocess
andarenotheardoverhealthlungtissue.
Therearefourmajortypesofadventitioussounds.
1. CracklesorRalesCrisp,cracklingsoundsheardprimarilyatlungbases.They
indicatefibrosisoflungorfluidinalveoliandterminalairways.Theyoccurduring
midtolateinspiration.
2. RhonchiRattling,coarsesoundscausedbyturbulencearoundmucusinlarger
airways.
3. WheezesDiffuseorlocalizedwhistlingsoundscausedbyairflowthroughnarrowed
distalairwaysorobstructedlargerairways.

4. RubHarsh,scratchingsoundheardineitherinspirationorexpirationcausedby
inflamedpleuralsurfaces(visceralsurfaceagainstparietal)slidingovereachother.
MANEUVERSFORAUSCULTATIONOFTHECHEST.Astherearemaneuversinthe
cardiovascularexaminationwhichaidthedetectionanddefinitionofvariousmurmursthereare
maneuversusedintheauscultationofthechestwhichaidinthedetectionanddefinitionoflung
disease.
ForcedExpiratoryTime(FET).Durationoftimeittakesapatienttoblowoutairasquickilyas
theyareable,fromafullbreath(totallungcapacity)untilairflowstops.NORMALLYIT
TAKES3SECONDSORLESS.TheprolongationofFET(LONGERTHAN4SECONDS)
correlatesverywellwiththeseverityofobstructionasinchronicbronchitisorasthma.FETISA
VERYSENSITIVEMEASUREOFAIRWAYOBSTRUCTION.
WhisperedPectoriloquyhighpitched,intensifiedspeechheardoverareaofconsolidationwhen
thepatientisaskedtowhisperlowpitchedwords.
Bronchophonyachangeinthepitchofspokenwordoveranareaofconsolidation.
EgophonyThesoundofaspokenEchangestoAoveranareaofconsolidation.The
spokenEisheardasAwhenlisteningovertheconsolidationbecausethefrequenciesofthe
vibrationsarealteredbytheconsolidation.EtoAchangesmayalsooccurinasmallband
likeareajustaboveapleuraleffusionbecauseofcompressionoflungtissuethatoccursjust
abovetheeffusion.ThisiscalledSkodiacresonanceinhonorofthephysicianSkodawhofirst
describedthistowarnphysiciansnottoconfusetheseEtoAchangeswiththatfoundin
consolidation.

PHYSICALEXAMINATIONFINDINGSOF
COMMONPULMONARYCONDITIONS
PLEURAL PNEUMONIA
EFFUSION

TRACHEAL
POSITION

SHIFTEDOR
MIDLINE

ENDO
PNEUMO
BRONCHIAL
THORAX
TUMOR

MIDLINE SHIFTEDOR
SHIFTED

MIDLINE
ORMIDLINE

CHESTWALLREDUCEDREDUCEDOR REDUCEDOR
MOVEMENTORNORMALNORMALNORMAL

REDUCED

FREMITUSDECREASEDINCREASEDNORMALORNONE

DECREASED
PRECUSSIONDULL

DULLNORMALOR
DULL

BREATHDECREASED
SOUNDS

INCREASEDNORMALORDECREASED/
DECREASED ABSENT

CRACKLESNONE

USUALLYNONE

WHEEZE

NONE

HYPER
RESONANT

NONE

NONEPOSSIBLENONE

EGOPHONYBANDABOVE PRESENT
EFFUSION
(skodiac)

NONE

NONE

PRACTICEQUESTIONS
FORSELFASSESSMENT
TRUEORFALSE
1. Patientsmayconfusecoughingupbloodwithvomitingblood.
2. Thecomplaintofdyspneaafterwalkingupaflightofstairsisneverworrisome.
3. Respiratoryratecanbeaccuratelyassessedbycountingfor15secondsandmultiplyingby
four.
4. Inanormalbreath,theexpiratoryphasetakesmoretime.
5. Anormalrespiratoryrateisfrom1620perminute.
6. Anarterialbloodgasistheonlywaytodetermineifapatientisinrespiratorydistress.
7. Clubbingisnotamanifestationofasthma,chronicbronchitisoremphysema.
8. Inspiratorystridorisacommonmanifestationofasthma.
9. Unilateralwheezingisacommonmanifestationofasthma.
10. Fremitusisenhancedbyconsolidation.
11. Fremitusisdecreasedbypleuralfluid.
12. Fremitusisdecreasedbypneumothorax.
13. Percussionisbestassessedbysimplylistening.
14. Hyperresonanceisusedtodescribethepercussionnotefoundinthenormallung.
15. Dullnessoccurswhentheaircontentoftheunderlyinglungtissueisincreased.
16. Thesoundsheardovernormallungparenchymaarecalledbronchialbreathsounds.
17. Cracklesandrhonchirefertothesametypeofadventitioussound.
18. Arubmaybeheardinairwayobstruction.
19. Whenausculating,thepatientshouldbeinstructedtobreaththroughhisnose.

20. Bronchialbreathsoundsareheardonthesideofthechestwiththepneumothorax.
21. Forcedexpiredtime(FET)correlatesverywellwithrestrictivelungdisease.
22. AnormalFETisbetween4and5seconds.
23. Whisperedpectoriloquyisbestelicitedbylisteningoverthetrachea.
24. EgophonyiselicitedbyhavingthepatientsayA.
25. Egophonyisheardinthemiddleofapleuraleffusion.
CHOOSETHEONEBESTANSWER
26. Whichofthefollowingbestcharacterizesthefindingsofpneumoniaonphysical
examination?
A. Decreasedfremitus,dullnesstopercussionanddecreasedbreathsounds.
B. Normalfremitus,dullnesstopercussionanddecreasedbreathsounds.
C. Decreasedfremitus,hyperresonanttopercussionanddecreasedbreathsounds.
D. Increasedfremitus,dullnesstopercussion,increasedbreathsoundsandcrackles.
27. Whichofthefollowingbestcharacterizesthefindingsofpleuraleffusiononphysical
examination?
A.Decreasedfremitus,dullnesstopercussionanddecreasedbreathsounds.
B. Normalfremitus,dullnesstopercussionanddecreasedbreathsounds.
C. Decreasedfremitus,hyperresonanttopercussionanddecreasedbreathsounds.
D.Increasedfremitus,dullnesstopercussion,increasedbreathsoundsandcrackles.
28. Whichofthefollowingbestcharacterizesthefindingsofapneumothorax(airinthepleural
space)?
A. Increasedfremitus,dullnesstopercussionanddecreasedbreathsounds.
B. Normalfremitus,dullnesstopercussionanddecreasedbreathsounds.
C. Absenceoffremitus,hyperresonanttopercussionanddecreasedorabsentbreath
sounds.
D. Increasedfremitus,dullnesstopercussion,increasedbeathsoundsandcrackles.
ANSWERSTOSELFASSESSMENT
1. TRUE.Itisoftendifficultforthepatienttodistinguishhemoptysisfromhematemesisand
sometimesthephysicianmustaskseveralquestionstodistinguishthetwo.
2. FALSE.Achangeinexercisetolerancebeforedyspneaifnoticedmaybeverysignificantin
apreviouslyhealthyadult.Thisiswhydyspneamustbequantitated.

3. FALSE.Respiratoryrateshouldbemeasuredfor30secondstoinsureaccuracy.
4. FALSE.Takeabreathyourself.Inspirationislongerthanexpiration.
5. FALSE.Anormalrespiratoryrateisfrom8to14.
6. FALSE.Youcandetermineifapatientisinrespiratorydistressbyinspection.Arapid
respiratoryrateandtheuseofaccessorymusclesareexamplesofsignsofrespiratory
distress.
7. TRUE.Clubbingisnotamanifestationofasthma,chronicbronchitisoremphysema.
Clubbingisassociatedwithlungcancer,iscommonlyassociatedwithdiffusefibrosisofthe
lungandisalmostairwaysseeninpatientswithcysticfibrosis.
8. FALSE.Inspiratorystridorisamanifestationoftrachealorlaryngealobstruction.
Inspiratoryandexpiratorywheezingisacommonmanifestationofasthma.
9. FALSE.Inasthmathereisbilaterallywheezing.
10. TRUE.Fremitusisenhancedbyconsolidation.
11. TRUE.Fremitusismarkedlydecreasedbypleuralfluid.
12. TRUE.Fremitusisdecreasedbypneumothorax.
13. FALSE.Percussionisbestassessedbylisteningandfeelingtheresonancedetectedwiththe
fingerusedasthepleximeter.
14. FALSE.Hyperresonanceisusedtodescribethepercussionnotefoundinoverexpanded
lungsandinpneumothorax.
15. FALSE.Dullnessoccurswhentheaircontentoftheunderlyinglungtissueisdecreased.
16. FALSE.Thesoundsheardovernormallungparenchymaarecalledvesicular.Bronchialor
tubularbreathsoundsareheardinareasofconsolidation.
17. FALSE.Cracklesarecrispsoundsheardprimarilyatlungbasesindicatingfibrosisofthe
lungorfluidinalveoliandterminalairways.Rhonchiarerattling,coarsesoundscausedby
turbulencearoundmucusinlargerairways.
18. FALSE.Arubisheardwhenthepleuralsurfacesrubagainsteachother.
19. FALSE.Whenauscultating,thepatientshouldbeinstructedtobreaththroughhismouth.
Furthermore,thepatientshouldbeshownwhattododuringtheexaminationbythe
physicians.

20. FALSE.Breathsoundsaremarkedlydecreasedorabsentonthesideofapneumothorax.
21. FALSE.FETcorrelatesverywellwithdegreeofobstruction.FETisnormalordecreasedin
restrictivelungdisease.
22. FALSE.AnormalFETis3secondsorless.
23. FALSE.Whisperedpectoriloquyisappreciatedinareasofconsolidation.
24. FALSE.EgophonyiselicitedbyhavingthepatientsayE.Wherethereisconsolidation,
EchangestoA.
25. FALSE.Egophonyissometimesheardjustaboveapleuraleffusion.Thisisalsocalled
Skodiacresonance.
26. AnswerisD.Increasedfremitus,dullnesstopercussion,increasedbreathsoundsand
cracklesareheardinconsolidation(Pneumonia).
27. AnswerisA.Decreasedfremitus,dullnesstopercussionanddecreasedbreathsoundsare
foundwithpluraleffusion.
28. AnswerisC.Absenceoffremitus,hyperresonanttopercussionanddecreasedorabsent
breathsounds.