Narrator: Start off the exam by inspecting the patient from the waist up. The patient should be relaxed. The best time to do this is while you are taking the history. General observations should be made about the respiratory rate, breathing pattern, respiratory effort, ratio of inspiration to expiration, symmetry and shape of the chest, noisy breathing, and skin color.
(Written: CC: cough and fever. HPI: Mr. Eric, age 25, was referred to me by Dr. Smith. He presents to my office with complaints of cough. Cough is wet and productive with thick yellow sputum. Pt self medicating with Robitussin DM PRN at home with mild relief of symptoms. PMH: denies past medical or surgical history. No allergies. No current medications other than previously noted. Family history noncontributory. SH: Drinks socially on weekends. Denies tobacco or illicit drug use. ROS: Noncontributory except as noted in HPI.)
Narrator: General observations should include any signs of distress, including air hunger.
(Written: Inspection.)
Narrator: At this point, try and visualize the underlying anatomy and locate thoracic landmarks for future reference. As you can see, we've outlined the border of the lungs for visualization. Note the supraclavicular notch, the clavicles, the sternum, and the xiphoid process. Also note the angle of the ribs and the costal angle.
When assessing respirations, note the rate and rhythm. The thoracic and abdominal cavities should expand with inspiration; however, abdominal expansion is more dominant in men whereas thoracic expansion is more dominant in women. Note if the expiratory rate is prolonged. Listen for audible breath sounds, such as wheezes, as you observe for any retractions, nasal flaring, or use of accessory muscles that may indicate distress. Other signs of distress include purse-lipped breathing and cyanosis of the lips and nails. When inspecting the nails for cyanosis, also inspect for clubbing.
Confirm symmetric chest expansion by placing your warmed hands on the posterior lateral chest with thumbs at the level of T-9 to T-10. Slide your hand medially to pinch a small fold of skin between your thumbs. Ask the person to take a deep breath. Your hands serve as mechanical amplifiers as the person inhales deeply. Your thumbs should move apart symmetrically. Use either the base of your fingers or the ulnar edge of one hand and touch the person's chest while he or she repeats words, “99” or “blue moon.” Start over the lung apices and palpate from one side to the other. Fremitus varies among person, but symmetry is most important, the vibration should feel the same in the corresponding area on each side. Note the posterior landmarks used to assess fremitus.
Inspect the trachea for any deviations from its usual midline position, then feel for any deviation. Place your finger along one side of the trachea and note the space between it and then the sternomastoid. Compare it with the other side. The spaces should be symmetrical.
Palpate symmetric chest expansion. Place your hands on the anterior lateral with thumbs along the costal margins and pointing towards the xiphoid process. Ask the person to take a deep breath. Watch your thumbs move apart symmetrically and note smooth chest expansion with your fingers. Any limitations in thoracic expansion is easier to detect on the anterior chest because greater range of motion exists with breath here. Begin palpating over the lung apices in the supraclavicular areas. Compare vibrations from one side to the other as the person repeats, “99.” Avoid palpating over female breast tissue because breast tissue normally dampens the sound.
(Written: Percussion.)
Narrator: Percussion involves striking one object against another to produce vibration and subsequent sound waves. In the physical exam your finger functions as a hammer and the vibration is produced by the impact of the finger against the underlying tissue. Sound waves are heard as percussion tones, called resonance. The percussion tone over air is loud, over fluid, less loud, and over solid areas, soft. Differentiating percussion tone is difficult, especially for the beginner. It is often easier to focus on distinguishing for changes in sound as you move from one area to another. A partially full milk carton is a good tool for practicing percussion skills. Work your way downward and listen for the change in sound as you encounter the milk.
Resonance, the expected sound, can usually be heard over all areas of the lung. Hyper-resonance, dullness, flatness, and tympani are considered abnormal.
Ask the patient to fold his arms in front of his chest and bend his head forward. This moves the scapula laterally, exposing more of the lung. Place your non-dominant hand on the chest with the fingers slightly spread. The distal phalanx of the middle finger should be placed firmly on the body's surface with the other finger slightly elevated off the surface. Snap the wrist of your hand downward, and with the tip of the middle finger sharply tap the interphalangeal joint of the finger that is on the body's surface. The tap should be sharp and rapid. Once the finger has struck quickly, lift the finger off to prevent any dampening of sounds. Move systematically from superior to inferior and medial to lateral. The model is marked with a common sequence, but not the only one used in practice. Note the location and quality of percussion sounds and compare one side to the other, noting any asymmetry.
Next we will percuss the lateral chest walls. Ask the patient to raise both arms over his head and proceed with percussions systematically, comparing differences in tone. Continue percussion on the anterior chest with the patient in the same position. You should hear resonance over all lung fields.
Diaphragmatic excursion will be evaluated next. Ask the patient to sit up, inhale deeply, and hold his breath. Percuss quickly down the scapular line to the lower border where resonance changes to dullness. Mark this point with a skin pencil or a piece of tape. Allow the patient to take a few normal breaths and when ready, exhale fully and hold it. Percuss up from the first point and mark where the tone changes from dullness to resonance. Be sure to tell the patient it is now okay to breathe normally again. Repeat these actions on the other side. Last, measure the distance between the marks on each side. Excursion usually ranges from 3–6 centimeters and it is normal for the right to be higher than the left because it sits over the bulk of the liver.
The findings in this patient revealed a 3 centimeter difference in diaphragmatic excursion.
(Written: Auscultation.)
Narrator: Auscultation of the lung involves listening to the lungs with a stethoscope. As with percussion, all breath sounds are characterized by intensity, pitch, quality, and duration. To start, ask the patient to sit as straight as possible with his or her shoulders back. Place the bell of your stethoscope on one side of the patient's chest. Ask the patient to breathe slowly and deeply through the mouth with exaggerated normal breathing patterns. Listen to all the anterior lung fields in a side-to-side pattern, lowering your stethoscope by several centimeters each time. As you see in the video, I have a common auscultation pattern numbered on the patient's chest; however, there are many variations that are commonly used. It is important for you to be comfortable, consistent, and assess all areas.
Vesicular breath sounds are low-pitched, low intensity sounds that are heard over the majority of the lung fields and healthy lung tissue. Broncovesicular sounds are moderate in pitch and intensity and are heard over the major bronchi. Bronchial sounds are high in pitch and intensity and are heard over the trachea. If either broncovesicular or bronchial sounds are heard anywhere else these are considered abnormal findings.
To listen to the posterior fields, ask the patient to sit with his head bent forward and their arms folded in front. This position enlarges the listening fields. As with the anterior chest, you want to start at the top of the back and proceed from side to side and downward. Again, the numbers here donate a common listening pattern. Just remember to be comfortable, consistent, and thorough. Ask the patient to breathe slowly and deeply through the mouth while you listen to each location. While listening to the lungs, be sure to be alert for any adventitious breath sounds.
Some common abnormal breath sounds include crackles, bronchi, and wheezes. Crackles are often heard over, during inspiration and are discreet and continuous. Crackles can be fine, high-pitched with a short duration or course, low-pitched with a relatively longer duration. They are caused by a disruption in airflow through the small airways. Crackles are easier to hear when present in the upper airways and more difficult to hear in the lower airways. Bronci are deeper in tone with a rumbling quality. They are more likely to be prolonged and continuous and are more pronounced during expiration. Bronchi are caused by the passage of air through thick secretions, muscular spasms, new growth, or external pressure. Bronchi may also be palpable and can be cleared via coughing. Wheezes are continuous high-pitched sounds heard during inspiration and expiration. They are caused by airflow through a narrow or obstructed airway, such as with asthma, bronchospasms, chronic bronchitis, or obstruction via a foreign body.
When you are through listening to the posterior field, have the patient raise their arms above their head while remaining in an erect position. Again, ask the patient to breathe slowly and deeply through the mouth. Note the posterior landmarks for auscultation.
Vocal resonance is when the spoken voice is transmitted through the lungs. Vocal resonance can be assessed using the pattern and sequence you use when listening to breath sounds. In each spot you place your stethoscope, ask the patient to repeat a chosen word. Normally, vocal resonance sounds are muffed, indistinct, and best heard medially. Pay close attention to any areas that reveal abnormal findings in any other part of your exam, as you are more likely to find alterations in vocal resonance in these areas. Sounds that are greater in clarity and/or loudness are called, “bronchophony.” Whispered pectoriloquy occurs when bronchophony is so extreme even a whisper can be heard clearly and intelligibly through the stethoscope. When the intensity of the voice increases and there is a nasal quality, such as when “Es” become stuffy, broad “As,” this is called, “egophony,” which may present in any condition that consolidates lung tissue.
When you're finished with your assessment, gather your findings.
(Written: Findings. Inspection—1: Productive cough, 2: Splinting right side chest, 3: Tachypnic, shallow respirations. Palpation—1: Change in fremitus right lower lobe anteriorly and posteriorly. Percussion—1: Dullness in tones over right lower lobe. Auscultation—1: Faint broncovesicular sounds and crackles in right lower lobe, 2: egophony and bronchophony in right lower lobe.)
Make sure to discuss your findings with the patient and together develop an individualized plan of care. Mr. Eric has a suspected right lower lobe pneumonia. We decided to send him for labs and a chest x-ray.
(Written: Did we miss anything?…Correct!!!!! Don't forget to palpate the anterior, posterior, and lateral chest!)
Narrator: Now examine the posterior portion of the chest. Let the patient know that what you are getting ready to do. Make sure to ask him to note any areas of pain, tenderness, or numbness as you do your exam. Proceed to the anterior chest, asking the patient again to note any areas of pain, tenderness, or numbness as you do your exam. Make sure to move systematically down the chest so you do not miss any areas.