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Lung, Thorax & Spine Exams
Charlie Goldberg, M.D.
Professor of Medicine, UCSD SOM
Charles.goldberg@va.gov
Exposure Is Key – You Cant 
Examine What You Can’t See!
Anatomy Of The Spine
Cervical: 7 Vertebrae
Thoracic: 12 Vertebrae
Lumbar: 5 Vertebrae
Sacrum: 5 Fused Vertebrae
Note gentle curve ea segment
Anatomic Images courtesy Orthospine.com
Spine Anatomry – Courtesy Ortho Spine
Spine Exam
• W/patient standing, observe: shape of spine.
– Stand behind patient, have them bend@ waist – if 
Scoliosis (curvature) one shoulder appears 
“higher”
• Range of motion – Direct patient to:
– Bend backwards
– Bend side to side, rotate @ waist
• Palpate lightly w/fist over entire spine – if 
underlying inflammation (e.g. fracture, infection, 
tumor)Æpain – rare to elicit on screening exam 
Pathologic Changes In Shape Of 
Spine
Thoracic Kyphosis (bent forward)
Scoliosis (curved to one side)
Lung Exam
• Includes Vital Signs and Cardiac
Exam
• 4 Elements: Observation, 
Palpation, Percussion, 
Auscultation (also for Cardiac & 
Abdominal)
Observation
• ? Ambulates w/out breathing
difficulty? 
• Appearance Æ? sitting up, leaning 
forward, inability to speak, pursed
lipsÆsignificant compromise
• ? Use of accessory muscles of neck 
(sternocleidomastoids, scalenes)Æ
significant compromise.
Scalene and Sternocleidomastoid Anatomy
(http://www.amtamassage.org)
Observation (cont)
• Audible noises?
• Shape of spine and chestÆ can affect 
lung volumes and function
• Color & shape nails (clubbing, 
cyanosisÆ rare)
Pathologic Changes In Shape Of 
Chest
Barrel Chested (hyperinflation secondary to emphysema)
Clubbing and Cyanosis
clubbing cyanosis
Lung Anatomy
(please wait for video to load)
Thoughts On Gown Management & 
Appropriately/Respectfully Touching 
Your Patients
• Several Sources of Tension: 
– Area examined must be reasonably exposed – yet 
patient kept as covered as possible
– Palpate sensitive areas to perform accurate exam -
requires touching people w/whom you’ve little 
acquaintance – awkward, particularly if opposite 
gender
– Exam not natural/normal part of interpersonal 
interactions - as newcomers to medicine, you’re 
particularly aware & hence very sensitive Æ a good 
thing!
Keys To Performing a Respectful & 
Effective Exam
• Explain what you’re doing (& why) before doing itÆ
acknowledge “elephant in the room”!
• Expose minimum amount of skin necessary - “artful” use 
of gown & drapes (males & females)
• Examining heart & lungs of female patients:
– Ask pt to remove bra prior (can’t hear well thru fabric)
– Expose L side of chest to extent needed
– Enlist patient’s assistanceÆ positioning breasts to enable 
cardiac exam
• Don’t rush, act in a callous fashion, or cause pain
• PLEASE… don’t examine body parts thru gown:
– Poor technique
– You’ll miss things
– You’ll lose points on scored exams (OSCE, CPX, USMLE)!
NO! NO!
NO!
Good Exam Options
Palpation
• Patient in gownÆchest accessible & 
exposed
• Explore painful &/or abnormally 
appearing areas 
• Chest expansion – position hands as 
below, have patient inhale deeplyÆ
hands lift out laterally
Palpation – Assessing Fremitus 
• Fremitus =s normal vibratory
sensation detected by 
palpating hand when patient 
speaks
• Place ulnar aspect (pinky 
side) of hand firmly against 
chest wall
• Ask patient to say “ninety-
nine”
• You’ll feel transmitted 
vibratory sensationÆ
fremitus!
• Assess posteriorly & 
anteriorly (i.e. lower & upper 
lobes)
Lung Pathology - Simplified
• Lung =s sponge, 
pleural cavity =s 
plastic container
• Infiltrate (e.g. 
pneumonia) =s fluid
within lung tissue 
itself
• Effusion =s fluid in 
pleural space but 
outside of lung
Fremitus - Pathophysiology
• Fremitus:
– increased w/consolidation (e.g. pneumonia)
– Decreased in absence of air filled lung tissue (e.g. 
effusion).
Normal
Increased
Normal
Decreased
Percussion
• Normal lung filled w/air
• Tapping over it 
generates drum-like
soundÆresonance
• When no longer over 
lung, percussionÆdull
(decreased resonance)
• Work in “alley” between 
vertebral column & 
scapula.
Percussion - Technique
• Have patient cross 
arms in front, grasping 
opposite shoulder 
(pulls scapula out of 
way)
• Place middle finger of 
one hand flat against 
back, other fingers off
• Strike distal 
interphalangeal joint
with middle finger of 
other hand - strike 2-3 
times @ ea spot
Percussion (cont)
• Use loose, floppy wrist action 
– percussing finger =s hammer
• Start @ top of one sideÆthen 
move across to same level, 
other sideÆalternate R & L as 
move downÆrepeat ‘til reach 
bottom (3-4 spots/side)
• @ Bottom of lungs, detect 
diaphragmatic excursionÆ
difference between 
diaphragmatic level @ full 
inspiration v expiration (~5-
6cm)
• Percuss upper lobes 
(anterior)
• Cut nails to limit bloodletting!
Ohio State University School of Medicine 
Interactive Learning Center – Simulated Percussion
1 2
34
5 6
78
• Difficult to master technique & to detect 
subtle tone changes - expect to be 
frustrated!
• Practice – on friends, yourself (find your 
stomach, tap on your cheeks, etc)
• Detect fluid level in container
• Find studs in wall
Expect To Be Frustrated!
Percussion: Normal, 
Dull/Decreased or 
Hyper/Increased Resonance
• Causes of Dullness:
– Fluid outside of lung 
(effusion)
– Fluid or soft tissue filling 
parenchyma (e.g. 
pneumonia, tumor)
• Causes of hyper-
resonance:
– COPDÆ air trapping
– Pneumothorax (air filling 
pleural space)
Hyper-Resonant 
all fieldsÆCOPD
Hyper-Resonant R 
lungÆPneumothora
Dull
Normal
Ausculatation
• Normal breathing creates soundÆ appreciated 
via stethescope Æ “vessicular breath sounds”
• Expiration normally softer then inspiration
• Time of expiration ~2x > inspiration
• Pay attention to: quality of sound, inspiration v 
expiration, location & intensity
Lobes Of Lung
Where you listen dictates what you’ll hear!
LUL RUL
LLL RLL
RUL LUL
RMLRLL LLL
Posterior View Anterior View
Lobes Of The Lung (cont)
RLL RML
RUL
LLL
LUL
Lateral Views
Trachea
Trachea
Auscultation (listening 
w/Stethescope) - Technique
• Put on stethescope - ear
pieces directed away from 
you, diaphragm engaged
• Have patient cross arms, 
grasping opposite shoulders
Areas To Auscult
• Posteriorly (lower lobes) ~ 6-8 
places - Alternate btwn R v L 
as move down (comparison) -
ask patient to take deep 
breaths thru mouth 
• Right middle lobe – listen in ~ 
2 spots – lateral/anterior
• Anteriorly - Upper lobes –
listen ~ 3 spots ea side
• Over trachea
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Pathologic Lung Sounds
• Crackles/Rales – “Scratchy” sounds 
associated w/fluid in alveoli (e.g. pulmonary 
edema, pneumonia)
• Ronchi – “Gurgling” type noise, caused by 
fluid in large & medium sized airways (e.g. 
bronchitis, pneumonia)
• Wheezing-Whistling type noise, loudest on 
expiration, caused by air forced thru 
narrowed airways (e.g. asthma)
• Stridor - Inspiratory whistling type sound 
due to tracheal narrowingÆ heard best over 
trachea
Pathologic Lung Sounds (cont)
• Bronchial Breath Sounds – Heard normally 
when listening over the trachea. If 
consolidation (e.g. severe pneumonia) upper 
airway sounds transmitted to periphery & 
apparent upon auscultation over affected area.
• Absence of Sound- In chronic severe 
emphysema, often small tidal volumes & thus 
little air movement. 
– Also w/very severe asthma attack, effusions, 
pneumothorax
Lung SoundsOhio State University School of Medicine 
Interactive Learning Center – Lung Sounds
R.A.L.E Lung Sound Repository
UCLA Heart & Lung Sound Simmulator
Other Auscultation “Tools”
• Egophany – in setting of suspected 
consolidation, ask patient to say “eee” while 
auscultating. Normally, sounds like “eee”..
Listening over consolidated area generates a 
nasally “aaay” sound.
Putting It All Together: Few findings 
pathognomonic Æ put ‘em together to paint 
best picture.
• Effusion 
– AuscultationÆ
decreased/absent 
breath sounds
– PercussionÆ dull
– FremitusÆ decreased
– EgophanyÆabsent
• Consolidation
– AuscultationÆ broncial
breath sounds
– PercussionÆdull
– FremitusÆincreased
– EgophanyÆ present
Vs
Summary of Skills 
□Wash hands
Spine
□ Inspect (shape, curves); Examine (range of motion, palpation)
Lungs and Thorax
Observation & Inspection 
□ Patient breathing
□ Chest shape
□ Fingers/nails
Palpation
□ Chest excursion 
□ Fremitus 
Percussion
□ Alternating R & L lung fields posteriorly topÆbottom; & anteriorly
□ Determines diaphragmatic excursion
Auscultation
□ R & L lung fields posteriorly, top Æbottom, comparing side to side
□ R middle lobe
□ Anterior fields bilaterally
Time Target: < 10 minutes
	Lung, Thorax & Spine Exams
	Exposure Is Key – You Cant Examine What You Can’t See!
	Anatomy Of The Spine
	Spine Exam
	Pathologic Changes In Shape Of Spine
	Lung Exam
	Observation�
	Observation (cont)
	Pathologic Changes In Shape Of Chest
	Clubbing and Cyanosis
	Slide Number 11
	Thoughts On Gown Management & Appropriately/Respectfully Touching Your Patients
	Keys To Performing a Respectful & Effective Exam
	Slide Number 14
	Good Exam Options
	Palpation
	Palpation – Assessing Fremitus 
	Lung Pathology - Simplified
	Fremitus - Pathophysiology
	Percussion
	Percussion - Technique
	Percussion (cont)
	Expect To Be Frustrated!
	Percussion: Normal, Dull/Decreased or Hyper/Increased Resonance
	Ausculatation
	Lobes Of Lung
	Lobes Of The Lung (cont)
	Trachea
	Auscultation (listening w/Stethescope) - Technique
	Pathologic Lung Sounds
	Pathologic Lung Sounds (cont)
	Lung Sounds
	Other Auscultation “Tools”
	Putting It All Together: Few findings pathognomonic  put ‘em together to paint best picture.
	Summary of Skills