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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

1 2
34

5 6
78

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 Sounds
Ohio 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