Beginning the Physical Examination

• Thorax and lung examination

  • Key questions to ask
  • Key medical equipment
  • Maneuvers used
  • Order of examination
  • Components of examination
  • Recording findings
  • Physiologic processes of lung sounds
• It is helpful to examine the posterior thorax and lungs while the patient is sitting, and the anterior thorax and lungs with the patient supine
• Order of examination


  1. Inspect

  2. Palpate

  3. Percuss

  4. Auscultate
• Try to visualize the underlying lobes, and compare one side with the other
• For men, arrange the patient's gown so that you can see the chest fully
• For women, cover the anterior chest when you examine the back

  
• For the anterior examination, drape the gown over each half of the chest as you examine the other half
• With the patient sitting, the patient's arms should be folded across the chest with hands resting on the opposite shoulders
• The supine position makes it easier to examine women because the breasts can be gently displaced
• Wheezes, if present, are more likely to be heard in the supine position
• For patients who cannot sit up without aid, try to get help to examine the posterior chest in the sitting position
• If this is impossible, roll the patient to one side and then to the other
• Ventilation is relatively greater in the dependent lung
• Bradyspnea


  Less than 14 times a minute
• Tachypnea


  More than 20 times a minute
• Always inspect the patient for any signs of respiratory difficulty
• Cyanosis


  Signals hypoxia
• Clubbing of the nails

  Associated with lung abscesses, malignancy, congenital heart disease
• Audible stridor


  A high-pitched wheeze, an ominous sign of airway obstruction in the larynx or trachea
• During inspiration, observe for contraction of the accessory muscles or supraclavicular retraction
• Inspiratory contraction of the sternomastoids and scalenes at rest

  Signals severe difficulty in breathing
• Lateral displacement of the trachea

  Indicates pneumothorax, pleural effusion, or atelectasis
• The anteroposterior (AP) diameter may increase with aging
• The AP diameter may also increase in chronic obstructive pulmonary disease (COPD)
• From a midline position behind the patient, note the shape of the chest and how the chest moves

  
• Retraction


  Abnormal retraction of the interspaces during inspiration
• Impaired respiratory movement


  Suggests disease of the underlying lung or pleura
• Palpate the chest focusing on areas of tenderness and abnormalities in the overlying skin, respiratory expansion, and fremitus
• Intercostal tenderness


  Over inflamed pleura
• Identify tender areas and carefully palpate any area where pain has been reported
• Bruises over a fractured rib

  Indicate injury
• Sinus tracts


  Usually indicate infection of the underlying pleura and lung
• Test chest expansion


  1. Place thumbs at 10th ribs

  2. Ask patient to inhale deeply

  3. Watch distance between thumbs

  4. Feel for range and symmetry of rib cage
• Fremitus


  The palpable vibrations transmitted through the broncho-pulmonary tree to the chest wall
• Fremitus is decreased or absent when the voice is soft or when the transmission of vibrations is impeded
• Asymmetric fremitus may indicate unilateral pleural effusion, pneumothorax, or neoplasm
• Percussion is one of the most important techniques of physical examination
• Percussion


  Helps establish whether the underlying tissues are air-filled, fluid-filled, or solid

  
• Percussion penetrates only 5 cm to 7 cm into the chest
• Percussion technique


  1. Hyperextend middle finger

  2. Press distal interphalangeal joint

  3. Strike with right middle finger

  4. Aim at distal interphalangeal joint

  5. Withdraw striking finger quickly