Pulmonary: Examination
- Environment, general appearance
- Nails, hands, arms
- Eyes, nose, sinuses
- Mouth, voice, cough, sputum
- Neck, JVP, trachea
- Chest posterior: insp, palp, expansion, fremitus, perc,
ausc, resonance
- Anterior chest
- Heart, abdomen, legs
- Table: inhalers, cigarettes.
- Ventilator, O2 mask, nasal tube.
- Sputum cup.
- Pneumatic boots (PE risk).
- Ask pt. to sit over edge of bed, if well enough.
- Colors:
• Cyanotic.
• Pink (emphysema, CO2 toxicity).
• White (anemia).
• Jaundiced (lung CA metastatic to liver).
• See Skin Colors Reference.
- Dyspnea, wheeze, difficulties.
- Breathing rate [normal: 14 breaths/min].
- Using accessory muscles of respiration.
- Edema.
- Cough type. More detail later in Cough, Sputum exam
below.
- Thyroxicosis (goiter impinging on trachea).
- Nicotine stains.
- CLUBBING (Lung dz: hypoxia, lung cancer, bronchiectasis, CF).
• Emphysema, chronic bronchitis don't cause clubbing.
- Leuconychia (hypoalbuminism 2° to cirrhosis).
- Muehrke's lines (hypoalbuminism 2° to cirrhosis).
- See Nails Reference.
- Peripheral cyanosis.
- CO2 flapping tremor (CO2 retention):
• Pt.does a policeman "stop" position with both hands.
• Unlike liver flap, both hands go down at once.
- HPO (lung CA).
- Erythema (CO2).
- Tremor (asthma inhaler).
- Veins (CO2).
- Muscle wasting of hands: inspect, then ask pt. to adduct/abduct against Dr's resistance
(brachial plexus palsy 2° to lung CA).
- Pallor of palmar creases (anemia 2° to blood loss).
- Pulse: rate (asthma has tachycardia), rhythm, character, pulsus paradoxus (severe
asthma). See Pulse Reference.
- Blood pressure, if relevant.
- Horner's syndrome (lung CA in apex):
• Ptosis.
• Miosis: partially constricted, but reacts normally to light.
• Anhydrosis: Dr's back of finger over each eyebrow to compare sweating.
- Chemosis [tear that doesn't drop] (CO2 retention).
- Eye fundus: papilloedema. See Fundus
Examination.
- Conjunctiva: pale (anemia).
- Deviated septum (nasal obstruction).
- Nasal polyps (asthma).
- Swollen turbinates (allergies).
- Palpate sinuses for tenderness (sinusitis).
- Lips blue: (peripheral cyanosis).
- Pursed lips breathing (emphysema, but not chronic bronchitis).
- Teeth: nicotine stains.
- Teeth: broken, rotten (predisposition to pneumonia or lung abscess).
- Tonsils: tonsils inflamed (upper RTI).
- Pharynx: reddened (upper RTI)
- Tongue: leucoplakia (smoking, spirits, sepsis, syphilis, sore teeth).
- Under tongue (central cyanosis).
- Voice: hoarseness (recurrent laryngeal nerve).
- Voice: stridor (upper airway obstruction).
- FET: listen for wheeze.
- Productive cough (typical pneumonia, bronchiectasis, chronic bronchitis).
- Dry cough (ACEi, asthma, atypical pneumonia, bronchial CA).
- Bovine cough [lacks initial hard sound] (paralyzed vocal cords).
- Sputum: colour, amount, consistency, blood, purulence.
• Red jelly sputum (Klebsiella).
• Rusty sputum (Strep pneumonia).
- Expose pt's chest and neck, covering women's breasts with loose material.
- Hypertrophied accessory muscles of inspiration.
- Obese neck with receding chin (obstructive sleep apnea).
- Signs of tracheostomy, other surgeries.
- Goiter (trachea impingement).
- Lymph nodes. See Nodes Reference.
- Landmark is sternal notch to heads of SCM to earlobe.
- Anything >3cm is significant.
- See JVP Reference.
- Dr's middle finger on sternal notch.
- Keeping middle finger on notch, put index on one side, then ring on other side.
- Assess deviation (enlarged thyroid, intrathoracic dz).
- If deviated, focus ensuing chest exam to upper lobe problem.
- Ask. pt. to undress to waist.
- Chest shape:
• Barrel chest (emphysema).
• Pigeon chest aka pectus carinatum (rickets).
• Funnel chest aka pectus excavatum (congenital defect).
- Harrison's sulcus [depression above costal margin] (rickets, childhood asthma).
- Asymmetry during respiration.
- Spine curvature: kyphosis, scholiosis, lordosis, kyphoscliosis (polio, Marfan's).
- Chest drains.
- Scars.
- Radiotherapy marks.
- Veins (SVC obstruction).
- Local swellings. If on breast, See Breast Examination.
- Ask pt if any part tender: examine that last.
- Ribs (fracture).
- Pt leans forward, crossing arms to get scapula out of the way for palpation, percussion,
auscultation of back.
- Pt lets their breath all the way out
- Dr places palms on pt's back, thumbs together.
- Pt breathes all the way in.
- Dr records how far thumbs have spread, and whether 1 thumb moved less than the other.
- Usual expansion is 4cm.
- Alternatively: use a measuring tape.
- Ulnar edge of Dr's pronated, flattened hand slips into upper intercostal space.
- Pt says "99".
- Dr's hand moves to opposite side, and repeat down intercostal spaces.
- Listening for a change in sensation:
- Increased fremitus (pneumothorax helping conduction).
- Decreased fremitus (consolidation preventing conduction).
- Percuss by comparing left to right each time as move from top to bottom of lung.
- Supraclavicular region.
- Back.
- Tidal percussion (diaphragm paralysis).
- DDx:
• Dull: solid (liver, consolidated lung).
• Stony dull [very dull]: fluid (pleural effusion).
• Hyper-resonant: hollow (pneumothrorax, bowel).
- Have pt. cross arms. Ask pt. to "breath in and out, though your mouth, on your own
time".
- Breath sounds.
- Adventitious sounds.
- Pt says "99" each time Dr listens to each part of chest
- Clearly heard aegophony speech [bleating goat] means consolidation.
- Muffled is normal.
- If aegophony, assess "whispering pectoriloquy":
• Pt whispers "1,2,3,4".
• See if can hear whisper clearly with stethoscope (extreme consolidation).
- Palpate apex beat for presence, deviation. See Apex
Beat Reference.
- Pemberton's sign (SVC obstruction):
• Pt raises arms over head.
• Pt develops facial plethora, non-pulsatile JVP elevation and inspiratory
stridor.
- Abdominal breathing: more than normal.
- Palpate liver if RHF. See Liver Palpation.
- Peripheral cyanosis.
- Ankle swelling (DVT, so PE risk).
- Toenails and foot showing same symptoms as Fingernails and Hands.