pe_lungexam
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pe_lungexam


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Lung, Thorax & Spine Exams
Charlie Goldberg, M.D.
Professor of Medicine, UCSD SOM
Charles.goldberg@va.gov
Exposure Is Key \u2013 You Cant 
Examine What You Can\u2019t 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 \u2013 Courtesy Ortho Spine
Spine Exam
\u2022 W/patient standing, observe: shape of spine.
\u2013 Stand behind patient, have them bend@ waist \u2013 if 
Scoliosis (curvature) one shoulder appears 
\u201chigher\u201d
\u2022 Range of motion \u2013 Direct patient to:
\u2013 Bend backwards
\u2013 Bend side to side, rotate @ waist
\u2022 Palpate lightly w/fist over entire spine \u2013 if 
underlying inflammation (e.g. fracture, infection, 
tumor)Æpain \u2013 rare to elicit on screening exam 
Pathologic Changes In Shape Of 
Spine
Thoracic Kyphosis (bent forward)
Scoliosis (curved to one side)
Lung Exam
\u2022 Includes Vital Signs and Cardiac
Exam
\u2022 4 Elements: Observation, 
Palpation, Percussion, 
Auscultation (also for Cardiac & 
Abdominal)
Observation
\u2022 ? Ambulates w/out breathing
difficulty? 
\u2022 Appearance Æ? sitting up, leaning 
forward, inability to speak, pursed
lipsÆsignificant compromise
\u2022 ? Use of accessory muscles of neck 
(sternocleidomastoids, scalenes)Æ
significant compromise.
Scalene and Sternocleidomastoid Anatomy
(http://www.amtamassage.org)
Observation (cont)
\u2022 Audible noises?
\u2022 Shape of spine and chestÆ can affect 
lung volumes and function
\u2022 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
\u2022 Several Sources of Tension: 
\u2013 Area examined must be reasonably exposed \u2013 yet 
patient kept as covered as possible
\u2013 Palpate sensitive areas to perform accurate exam -
requires touching people w/whom you\u2019ve little 
acquaintance \u2013 awkward, particularly if opposite 
gender
\u2013 Exam not natural/normal part of interpersonal 
interactions - as newcomers to medicine, you\u2019re 
particularly aware & hence very sensitive Æ a good 
thing!
Keys To Performing a Respectful & 
Effective Exam
\u2022 Explain what you\u2019re doing (& why) before doing itÆ
acknowledge \u201celephant in the room\u201d!
\u2022 Expose minimum amount of skin necessary - \u201cartful\u201d use 
of gown & drapes (males & females)
\u2022 Examining heart & lungs of female patients:
\u2013 Ask pt to remove bra prior (can\u2019t hear well thru fabric)
\u2013 Expose L side of chest to extent needed
\u2013 Enlist patient\u2019s assistanceÆ positioning breasts to enable 
cardiac exam
\u2022 Don\u2019t rush, act in a callous fashion, or cause pain
\u2022 PLEASE\u2026 don\u2019t examine body parts thru gown:
\u2013 Poor technique
\u2013 You\u2019ll miss things
\u2013 You\u2019ll lose points on scored exams (OSCE, CPX, USMLE)!
NO! NO!
NO!
Good Exam Options
Palpation
\u2022 Patient in gownÆchest accessible & 
exposed
\u2022 Explore painful &/or abnormally 
appearing areas 
\u2022 Chest expansion \u2013 position hands as 
below, have patient inhale deeplyÆ
hands lift out laterally
Palpation \u2013 Assessing Fremitus 
\u2022 Fremitus =s normal vibratory
sensation detected by 
palpating hand when patient 
speaks
\u2022 Place ulnar aspect (pinky 
side) of hand firmly against 
chest wall
\u2022 Ask patient to say \u201cninety-
nine\u201d
\u2022 You\u2019ll feel transmitted 
vibratory sensationÆ
fremitus!
\u2022 Assess posteriorly & 
anteriorly (i.e. lower & upper 
lobes)
Lung Pathology - Simplified
\u2022 Lung =s sponge, 
pleural cavity =s 
plastic container
\u2022 Infiltrate (e.g. 
pneumonia) =s fluid
within lung tissue 
itself
\u2022 Effusion =s fluid in 
pleural space but 
outside of lung
Fremitus - Pathophysiology
\u2022 Fremitus:
\u2013 increased w/consolidation (e.g. pneumonia)
\u2013 Decreased in absence of air filled lung tissue (e.g. 
effusion).
Normal
Increased
Normal
Decreased
Percussion
\u2022 Normal lung filled w/air
\u2022 Tapping over it 
generates drum-like
soundÆresonance
\u2022 When no longer over 
lung, percussionÆdull
(decreased resonance)
\u2022 Work in \u201calley\u201d between 
vertebral column & 
scapula.
Percussion - Technique
\u2022 Have patient cross 
arms in front, grasping 
opposite shoulder 
(pulls scapula out of 
way)
\u2022 Place middle finger of 
one hand flat against 
back, other fingers off
\u2022 Strike distal 
interphalangeal joint
with middle finger of 
other hand - strike 2-3 
times @ ea spot
Percussion (cont)
\u2022 Use loose, floppy wrist action 
\u2013 percussing finger =s hammer
\u2022 Start @ top of one sideÆthen 
move across to same level, 
other sideÆalternate R & L as 
move downÆrepeat \u2018til reach 
bottom (3-4 spots/side)
\u2022 @ Bottom of lungs, detect 
diaphragmatic excursionÆ
difference between 
diaphragmatic level @ full 
inspiration v expiration (~5-
6cm)
\u2022 Percuss upper lobes 
(anterior)
\u2022 Cut nails to limit bloodletting!
Ohio State University School of Medicine 
Interactive Learning Center \u2013 Simulated Percussion
1 2
34
5 6
78
\u2022 Difficult to master technique & to detect 
subtle tone changes - expect to be 
frustrated!
\u2022 Practice \u2013 on friends, yourself (find your 
stomach, tap on your cheeks, etc)
\u2022 Detect fluid level in container
\u2022 Find studs in wall
Expect To Be Frustrated!
Percussion: Normal, 
Dull/Decreased or 
Hyper/Increased Resonance
\u2022 Causes of Dullness:
\u2013 Fluid outside of lung 
(effusion)
\u2013 Fluid or soft tissue filling 
parenchyma (e.g. 
pneumonia, tumor)
\u2022 Causes of hyper-
resonance:
\u2013 COPDÆ air trapping
\u2013 Pneumothorax (air filling 
pleural space)
Hyper-Resonant 
all fieldsÆCOPD
Hyper-Resonant R 
lungÆPneumothora
Dull
Normal
Ausculatation
\u2022 Normal breathing creates soundÆ appreciated 
via stethescope Æ \u201cvessicular breath sounds\u201d
\u2022 Expiration normally softer then inspiration
\u2022 Time of expiration ~2x > inspiration
\u2022 Pay attention to: quality of sound, inspiration v 
expiration, location & intensity
Lobes Of Lung
Where you listen dictates what you\u2019ll 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
\u2022 Put on stethescope - ear
pieces directed away from 
you, diaphragm engaged
\u2022 Have patient cross arms, 
grasping opposite shoulders
Areas To Auscult
\u2022 Posteriorly (lower lobes) ~ 6-8 
places - Alternate btwn R v L 
as move down (comparison) -
ask patient to take deep 
breaths thru mouth 
\u2022 Right middle lobe \u2013 listen in ~ 
2 spots \u2013 lateral/anterior
\u2022 Anteriorly - Upper lobes \u2013
listen ~ 3 spots ea side
\u2022 Over trachea
1 2
34
5 6
78
Pathologic Lung Sounds
\u2022 Crackles/Rales \u2013 \u201cScratchy\u201d sounds 
associated w/fluid in alveoli (e.g. pulmonary 
edema, pneumonia)
\u2022 Ronchi \u2013 \u201cGurgling\u201d type noise, caused by 
fluid in large & medium sized airways (e.g. 
bronchitis, pneumonia)
\u2022 Wheezing-Whistling type noise, loudest on 
expiration, caused by air forced thru 
narrowed airways (e.g. asthma)
\u2022 Stridor - Inspiratory whistling type sound 
due to tracheal narrowingÆ heard best over 
trachea
Pathologic Lung Sounds (cont)
\u2022 Bronchial Breath Sounds \u2013 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.
\u2022 Absence of Sound- In chronic severe 
emphysema, often small tidal volumes & thus 
little air movement. 
\u2013 Also w/very severe asthma attack, effusions, 
pneumothorax
Lung Sounds