The clinical examination of the lungs is important for every patient anamnesis done in internal medicine. As a pulmonologist, your main focus will be on studying and examining the lungs. A dependable strategy to be followed during examinations enables routine work, helps to stay on top of things and prevents a physician from forgetting anything during daily clinical practice. For example, what is auscultated in case of pneumothorax or pleural effusion? What different shapes of thorax are there? How can tuberculosis be recognized from examining the patient's skin? Below you will find a checklist to be used during your practical work and oral exams!
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Stethoscope


General Observation of the Patient

  1. Does the patient look systematically unwell? Do they have a fever?
  2. What is their level of consciousness?
  3. Do they have difficulty in breathing at rest? Look for:
    • Abnormal breathing patterns
    • Use of accessory muscles
    • Purse lip breathing
    • Intercostal recession
  4. Any visible chest wall/ general abnormalities?

Some abnormal types of breathing patterns

Prolonged expiratory phase — indicates airways obstruction

Cheyne-Stokes breathing — alternating slow/ fast respiratory rate occurs in pulmonary edema, brain stem lesions

Kussmaul — rapid sighing respiration caused by metabolic acidosis

Irregular breathing pattern — indicative of imminent cardiorespiratory arrest

Audible stridor — an inspiratory wheeze suggesting significant major airways obstruction

Excess abdominal movements on inspiration — occurs in COPD

Paradoxical abdominal movements — indrawing of the abdomen on inspiration, indicates diaphragmatic weakness

Some visible general/ chest wall abnormalities

Cachexia — occurs in cancer, severe COPD, chronic infection

Obesity — increased risk of asthma, obstructive sleep apnoea, obesity hypoventilation

Shrunken lung — visibly smaller hemithorax, flattening of the upper anterior chest

Surgical scars — thoracotomy, pleural drains, mediastinoscopy, sternotomy

Hyperexpanded chest — severe airways obstruction: increased anterior/ posterior diameter, horizontal ribs

Kyphoscoliosis — anterior and lateral curvature of the spine, affects mechanics of ventilation

Chest wall masses — lipomas are common; tumors can occasionally erode

Inspection

The following can be studied just by looking at a patient:

  • Tachypnea (> 20/min), stridor, coughing, hoarseness, dyspnea
  • Breathing pattern: Kussmaul-breathing, Cheyne-Strokes breathing, Biot breathing
  • Accessory respiratory muscles, withdrawal
  • Symmetry of the thorax
  • Shape of the thorax: barrel chest, kyphoscoliosis, gibbus, pectus excavatum, pectus carinatum
respiratory abnormalities

Image: „Respiratory abnormalities — abnormal breathing patterns that can help diagnose or discover the underlying cause of pathological breathing.“ by Sav vas. License: CC BY-SA 3.0

Palpation

  • Is the trachea in the middle?
  • Spinal column/rips: pain upon percussion, fracture, Tietze syndrome, rachitis
  • Skin emphysema
  • Symmetric excursion
  • Pain upon compression

What was that again…?

Vocal fremitus: Place your hands laterally on the thorax of the patient and ask him/her to say the number “99” (loud and resounding). Palpable vibrations during infiltration of the lung (pneumonia, bronchiectasis, pulmonary congestion) are pathologically intensified. A weakened fremitus can be felt in cases where air or liquids are trapped in the pleural cavity (pneumothorax, pleural effusion).

Percussion

  1. Poor technique (e.g. raised finger of chest wall)
  2. Pleural effusion — classically very dull and described as “stony dull”
  3. Lobar/ total lung collapse
  4. Previous pneumonectomy or lobectomy
  5. Extensive consolidation due to pneumonia
  6. Pleural thickening/ mesothelioma
  7. Obesity (relative, falsely dull)
  8. Raised hemidiaphragm (due to loss of lung volume or phrenic palsy)
  9. Normally over the liver and heart

Quality of percussion sound:

Hyper Sonor emphysema, pneumonthorax
Sonor normal, bronchitis, central pneumonia, pulmonary edema
Hypo Sonor pleural effusion, infiltrate, tumor, pleural

Auscultation

  • Respiratory sounds: tracheal, bronchial, bronchovesicular, vesicular (normal findings are known from many clinical reports: vesicular respiratory sounds)
  • Weakened/missing respiratory sounds: emphysema, status asthmaticus, pneumothorax, effusion, pleural fibrosis, tumor
  • Bronchial breath sounds: consolidation (in case of pneumonia, hemorrhages, edema)
  • Pleural rub (pleuritis)
  • Adventitious breath sounds:
    • Continuous wheezing and humming
    • Discontinuous: Fine bubbling rales are usually of high frequency and occur due to an opening of the small airways: Pulmonary fibrosis, beginning lung edema. Coarse bubble rales are usually of low frequency and occur due to trapped liquid in the small airways: bronchitis, lung edema
  • Bronchophony: Examination of the forwarding of higher tones. Ask your patient to say the number “66” in a high (slightly hissing) voice. The number can be heard better via infiltrated areas (pneumonia) due to a better forwarding. In case of pneumothorax or pleural effusion you might hear little or nothing at all!

Inspiratory/ expiratory breath sounds

  • Ratio of inspiration to expiration on breathing
  • Normally inspiration is slightly longer than expiration

breath-sounds

Breath sounds — added sounds and their common causes

Speed of onset Possible causes
Crepitations Consolidation due to pneumonia (asymmetric, coarse)

Pulmonary fibrosis, other interstitial lung diseases (fine)

Pulmonary edema (fine)

Bronchiectasis (coarse)

Wheeze Asthma exacerbation

COPD

Bronchiectasis

Partial obstruction of a major bronchus (monophonic)

Pulmonary edema (“cardiac asthma”)

Upper airways obstruction (inspiratory – stridor)

Pleural rub Pleural infection

Over consolidated lung in pneumonia

Pulmonary embolism

Other inflammatory effusions, e.g., Dressler´s syndrome

Recently drained pleural effusions

Systemic Examination

The lung is not the only organ that can give indications of pulmonary diseases.

Hands: The typical signs of chronic hypoxia are Hippocratic fingers and Hippocratic nails. Pay attention to venous filling and heart rate!

Hypoxia hands

Image: “Example of clubbing secondary to pulmonary hypertension in a patient with Eisenmenger’s syndrome” by Ann McGrath. License: Public Domain

Head: Color reveals a lot: Anemia, jaundice, cyanosis of the lips? How do the veins on the base of the tongue and the buccal mucosa look like?

Extremities: Sarcoidosis or hypertrophic osteoarthropathy are examples of diseases that can present symptoms of frequent pulmonary manifestation in other parts of the body. Are there signs of thrombosis on the lower leg? >> lung embolism. Edema would be a sign of right ventricular insufficiency with a backlog of blood and other problems with the lungs.

Skin:

  • Erythema multiforme: mycoplasma pneumoniae
  • Erythema nodosum: tuberculosis, sarcoidosis, histoplasmosis
  • Purpura: vasculitis
  • Lupus pernio: sarcoidose
  • Lupus vulgaris: tuberculosis

For the Pocket in your Doctor’s Coat: Everything Important at One Glance

Disease Inspection Palpation Percussion Auscultation
Status asthmaticus Hyperinflation, auxiliary respiratory muscles Fremitus Hyperresonant, depression of the diaphragm Expiration, wheezes
Pneumothorax Excursion Fremitus, shift of the trachea to the healthy side Hyperresonant Faint/no respiratory sound
Pleural effusion Excursion Fremitus, shift of the trachea to the healthy side Damped Faint respiratory sound
Atelectasis Excursion Fremitus, shift of the trachea to the diseased side Damped Faint respiratory sound
Consolidation Excursion Fremitus Damped Bronchial breath sounds, bronchophony
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