Pulmonary: Examination
  1. Environment, general appearance
  2. Nails, hands, arms
  3. Eyes, nose, sinuses
  4. Mouth, voice, cough, sputum
  5. Neck, JVP, trachea 
  6. Chest posterior: insp, palp, expansion, fremitus, perc, ausc, resonance
  7. Anterior chest
  8. Heart, abdomen, legs
Environment
  • Table: inhalers, cigarettes.
  • Ventilator, O2 mask, nasal tube.
  • Sputum cup.
  • Pneumatic boots (PE risk).
General appearance
  • 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).
Nails
  • 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.
Hands
  • 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.
Arms
  • Blood pressure, if relevant.
Eyes
  • 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.
  • [tear that doesn't drop] (CO2 retention).
  • Eye fundus: papilloedema. See Fundus Examination.
  • Conjunctiva: pale (anemia).
Nose, sinuses
  • Deviated septum (nasal obstruction).
  • Nasal polyps (asthma).
  • Swollen turbinates (allergies).
  • Palpate sinuses for tenderness (sinusitis).
Mouth, voice
  • 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.
Cough, sputum
  • 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).
Neck
  • 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.
JVP
  • Landmark is sternal notch to heads of SCM to earlobe.
  • Anything >3cm is significant.
  • See JVP Reference.
Trachea
  • 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.
Chest: inspection
  • Ask. pt. to undress to waist.
  • Chest shape:
    • Barrel chest (emphysema).
    • Pigeon chest aka pectus carinatum  (rickets).
    • Funnel chest aka pecus 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.
Chest: palpation
  • Ask pt if any part tender: examine that last.
  • Ribs (fracture). 
Chest: palpation: expansion
  • 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.
Chest palpation: vocal fremitus
  • Vocal fremitus (consolidation):
  • 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 (consolidation).
Chest: percussion
  • 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).
Chest: auscultation
  • Have pt. cross arms. Ask pt. to "breath in and out, though your mouth, on your own time".
  • Breath sounds.
  • Adventitious sounds.
Chest: auscultation: resonance
  • 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).
Anterior chest
  • 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. 
Heart
Abdomen
  • Abdominal breathing: more than normal.
  • Palpate liver if RHF. See Liver Palpation.
Legs
  • Peripheral cyanosis.
  • Ankle swelling (DVT, so PE risk).
  • Toenails and foot showing same symptoms as Fingernails and Hands.