Physical exam: Thorax & Lungs exam

Question 1

Thorax and Lungs exam: Learning objectives

Answer 1

1. Apply correct techniques to examination of the posterior and anterior chest including inspection, palpation, percussion, and auscultation
2. Accurately identify percussion notes and breath sounds.

Question 2

Common concerns for T and L exam

Answer 2

1. Chest pain (also cardiac)
2. Shortness of breath (dyspnea) (also cardiac)
3. Wheezing
4. Cough
5. Blood-streaked sputum (hemoptysis)
6. Sputum production

Question 3

Palpation: Findings (anterior and posterior)

Answer 3

• Tenderness
• Chest expansion: Thumbs in the middle line; expansion should be 2 cm
• Tactile fremitus: Say 99
  - Lung pathology: Increased tactile fremitus
  - Pleural pathology: Decreased tactile fremitus

Question 4

Percussion: Findings

Answer 4

I am going to tap on your chest:

a) Apex (2) / b) back (6) / c) sides (2): “Percussion is symmetrical and resonant”
1. Hyperresonance: COPD
2. Dullness: Effusion

Question 5

Auscultation: Findings

Answer 5

a) Whenever you feel the stethoscope touching your back, can you please take a deep breath in and out from your mouth?
b) Start in supraclavicular fossa using the bell
c) “Normal vesicular breathing sounds bilateral, no wheezing or Ronchi were heard”

Types of sounds:

• Vesicular
• Bronchial
• Bronchovesicular: 1st and 2nd interspaces anteriorly

Adventitious (or added) sounds:

1. Crackles: Pneumonia, pulmonary fibrosis, early HF
2. Fine crackles: CHF
3. Coarse crackles: Longer and louder.
4. Wheezes: Asthma
5. Ronchi: Secretions in long bronchi

Now I am going to demonstrate special tests that I would do if I hear abnormal sounds or suspect consolidations:

a. Say 99: Bronchophony, Louder sounds reflecting transmission through airless tissue.
b. Can you say the letter “E”: Egophony, “E” to “A” changes. Seen in lobar consolidation (pneumonia)
c. Whisper 1/2/3: Pectorilogy, Louder suggest consolidation

Question 6

Inspection: Findings

Answer 6

• Face: Nasal flaring or laboured breathing
• Eyes: Jaundice or palor
• Mouth: No central cyanosis, dehydration, exudates
• Hands: Clubbing, peripheral cyanosis. Capillary refill. Nicotine stains. Needle marks. Flapping tremor (CO2 retention).
• Neck: Mr ___, can you lower your gown, please? The trachea is central (Important! on the checklist), no use of accessory muscles is noted.
• Chest: Symmetrical, no intercostal retraction. Look from the side! (No increase in the A/P diameter of the chest. No kyphosis, scoliosis, pectus excavatum, pectus carinatum, barrel chest.

Question 7

Phrase when finishing physical exam:

Answer 7

Look at the examiner and say: “I would normally do the same thing from the front and do a complete cardiac exam”.

Question 8

Common pitfalls!

Answer 8

• Examining through clothing
• Placement of the stethoscope: Do not examine over scapulae.
• Not comparing sides: Be sure to examine and compare right to the left side at each dermatome level.
• Not listening to a full breath
• Distractions: Do not talk when you auscultate.