Lung Examination: Introduction – Lung Disease

00:01 There’s a good question as to why bother examining patients nowadays, now that we have such good investigations available. There are several answers to that question.

00:10 The first being most obviously is that actually the x-rays or the investigations you want to do may not be available. And that would happen if somebody presents with acute respiratory distress. You don’t have time to get the x-rays, the echocardiogram, the CT scan before you actually have to treat the patient. So clinical skills are essential in that circumstance.

00:32 In addition, you may not be considering doing the test that is required until you examine the patient and identify an unexpected finding that might suggest something that requires a specific investigation.

00:43 So, for example, you might hear a pleural rub and then start thinking the patient may have a pulmonary embolus and ask for a CT pulmonary angiogram which, previously, you weren’t considering.

00:52 And in addition there are signs that actually are not identified by investigations but are identified by examination which do have very important implications for the patient. And the most obvious one of that is clubbing. Finger clubbing indicates there’s a serious medical problem going on with the patient and there are no tests that we do which identify that. It’s purely on examination.

01:17 So what is the process of examination? Well, you’ve done your history and then you move on to examine the patient. And the idea of doing the examination is so that you can identify signs that might confirm the suspicions that you have of what diagnosis might explain the patient’s symptoms.

01:33 Not only that. You’re also looking for signs which might not fit with the diagnosis you’re thinking of and change your mind about what is going on. So, for example, we may have a smoker who presents with a several months’ history of breathlessness. And you think perhaps they might have COPD – smoking-related airways obstruction. When you examine the patient, you hear some crackles. Now crackles means that – it’s not a sign associated with COPD. And therefore you need to change your opinion of what may be happening and consider other diseases such as interstitial lung disease.

02:10 The actual examination itself fits with the standard format that we do for whatever medical conditions you’re looking at, whether it is an abdominal, a neurological, a cardiac or a respiratory problem.

02:21 We start with a general observation of the patient. And there are specific things that we look for when we examine a patient which are relevant for respiratory tract problems.

02:30 Then we move on to examine the hands where, in particular, we’re looking for clubbing and for two types of tremor: an essential tremor which occurs when people have had Beta2-agonists – a therapy for airways obstruction – and a carbon dioxide retention tremor – asterixis.

02:45 We also look for evidence of general medical problems which might be relevant for the lungs.

02:52 And a specific example is rheumatoid arthritis, which has a potential multiple different lung complications and is obvious in people’s hands when you examine them in many patients.

03:04 We need to measure the respiratory rate, we need to measure the pulse rate.

03:08 And then we move on to looking at the face and the neck. And in the face, particularly what we’re interested in is whether the patient may have central cyanosis: blue lips, blue tongue. In the neck there are two main things. There’s whether the patient has a raised JVP. And that is a sign of pulmonary hypertension and cor pulmonale and therefore relevant for respiratory medicine. Or whether they have palpable cervical lymph nodes. And that might occur in diseases such as tuberculosis or lung cancer where involvement of the cervical glands is relatively common.

03:38 After examining the neck, we move onto palpation of the chest. Initially, we want to know whether there is any mediastinal shift. To assess that, we feel for the position of the trachea and the apex beat.

03:52 We then see whether there’s any problem with chest expansion, either bilaterally or unilaterally.

03:57 And then we percuss the chest, a method of assessing whether there’s any material in the chest that shouldn’t be there. Normal percussion is clearly resonant because of air but, if there’s any liquid or solid material present, then it becomes dull.

04:13 We can also do tactile vocal fremitus that I will discuss in more detail later.

04:18 Only then, after what – all we’ve done before in the examination with palpation, examination of the neck, the hands, the respiratory rate – that we move on to listening, with auscultation using a stethoscope. And with that, we also do vocal resonance.

04:34 And at the end of the examination, it’s important not to forget to examine other parts of the body that might be relevant for respiratory disease. Specifically, look for peripheral oedema and also inspect whether there’s any sputum present. And, if there is sputum present, what the quality is: whether it’s mucoid, purulent, mucopurulent or has blood in it – haemoptysis.

04:57 Now the actual process of doing the examination is obviously a practical thing. I’m not going to discuss in detail exactly how we do an examination in this lecture because that is best described using one-to-one – well, using a tutorial with an examiner, a subject and then some students present by the bedside.

05:17 What we’ll discuss today are the abnormal findings we might expect, the potential causes.

05:22 And then at the end, I will give a synthesis of the sort of appearances – examination findings you may get in specific, important clinical respiratory conditions.