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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