Pulmonary Physical Exam Checklist
Pulmonary Exam: Explain to patient (“I’m going to check your lungs/breathing now”) Patient seated on the exam table and the examiner in front of the patient 1 General Observe rate (at least 30 seconds), rhythm, depth, and effort Clubbing can indicate COPD, Assessment of breathing; cyanosis; shape of chest (normal if lateral > congenital heart disease both of anteroposterior diameter); clubbing of fingers, nicotine which can cause chronic hypoxia staining Severe COPD/asthma: patient might sit with arms supported on knees (tripod posture) and lips pursed during exhalation
2 Ask respiratory- Ask about at least 2 review of systems: (start with general While asking Pulm ROS also observe related ROS if not question) “Tell me about any shortness of breath; wheezing; general appearance: signs of already done cough (dry/productive); hemoptysis; tobacco use distress, SOB, cough, retractions, (prior/current) diaphoresis, tripod position.
POSTERIOR CHEST: Patient seated on exam table and examiner in back and to right of patient 3 Adjust patient’s Ask/explain to patient that you will need to untie the gown at gown and position the upper and lower back
4 Inspection Observe the shape of the chest, movement with respiration, Barrel chest can be due to COPD or and skin lesions aging
Tracheal displacement can be a sign of large pneumothorax or neck mass
5 Palpation – Place thumbs at about level of 10th ribs with hands parallel to Asymmetric movement can be Chest Expansion lateral rib cage. Slide hands together to raise skin fold due to diaphragmatic paralysis, between thumbs. Ask patient to take a deep breath in and fibrotic disease of lung tissue, out. Watch as thumbs move apart and feel for movement pneumothorax (PTX), pleural during inspiration. effusion, pneumonia (PNA), mass, • normal – symmetrical rib cage expansion and contraction or obstruction.
6 Palpation – Ask patient to say “99” or “1-1-1” while palpating with ball or Vibration can be impeded by Tactile fremitus ulnar surface of hand at 4 bilateral areas (one hand at a time obstructed bronchus, COPD, or both hands simultaneously) effusion, infiltrating tumor or • normal – palpable vibrations, typically prominent pneumothorax interscapular > lower lung fields and right > left side vs abnormal – decreased or increased
Can ask patient to cross both arms in front of the chest with each hand gripping contralateral shoulder or upper arm 7 Percussion Percuss in ladder pattern at 4 bilateral locations (8 total), top Dull: due to atelectasis or pleural to bottom. effusion • normal – resonance Hyper-resonant at upper back while sitting: pneumothorax
*A consolidation cannot be noted on physical exam - this is only a radiographic finding. Instead use the word “dullness” to percussion.
8 Percussion – Diaphragm location and Diaphragm excursion: Abnormally high level Diaphragmatic Begin at the inferior angle of the scapula, ask patient to suggests pleural effusion, excursion “Exhale normally and hold it”, then percuss downward until atelectasis or resonance is replaced by dullness. Mark that spot. Let patient diaphragmatic paralysis. (Right and Left breathe again then ask patient to “take a deep breath in and sides) hold it” while percussing downward until dullness is replaced Asymmetric levels could be by resonance. Let patient breathe again due to tumor, anatomical • normal excursion is 5-6 cm obstruction.
9 Auscultation Ask patient to breathe in and out deeply through an open Wheezing: partial airway mouth. Listen with stethoscope diaphragm for entire obstruction from inhalation and exhalation cycle at 4+ bilateral (8 total) secretions, tissue locations in ladder pattern inflammation, foreign body • normal sounds – vesicular over most of lungs. Crackles = Rales: Upper lobes on anterior chest, lower lobes on posterior chest, pneumonia, fibrosis, early right middle lobe in right –midaxillary line. congestive heart failure (CHF)
Rhonchi: suggests secretions or obstruction in large airways
Consolidation cannot be noted on physical exam only on radiographic exam, instead say “absence” of breath sounds.
10 Auscultation – Listen with stethoscope diaphragm in ladder pattern at 4+ An abnormal finding for these tests Transmitted bilateral (8 total) locations: suggests that the area has become breath sounds • Bronchophony – Ask patient to say “99” airless, can be filled with fluid or (present/abnormal if loud and clear) other tissue: • Special Tests • Whispered pectoriloquy – Ask patient to “whisper 99” e.g. pneumonia or pleural (if indicated) (present/abnormal if loud and clear) effusion
• Egophony (E-to-A change) – Ask patient to say “ee” present/abnormal if hear nasal “a” sound)
ANTERIOR CHEST: Patient seated or supine on exam table and examiner in front and to right of patient 11 Adjust patient’s Ask/explain to patient that you will need to lower the front of gown and position the gown to check breathing in front
12 Inspection Observe shape of chest, presence of intercostal or Retractions suggest respiratory supraclavicular retractions (in peds we say “tracheal tugging”) fatigue, worsening respiratory and skin lesions distress and needs urgent evaluation
13 Auscultation Ask patient to breathe in and out deeply through an open mouth. Listen with stethoscope diaphragm for entire inhalation and exhalation cycle at bilateral upper lung lobes.
14 Additional maneuvers can be done on anterior chest if indicated Auscultation Bronchophony; Whispered pectoriloquy; Egophony Palpation – Chest Place thumbs along each costal margin with hands along lateral Expansion rib cage. Slide hands together to raise skin fold between thumbs. Ask patient to take deep breath in and out. Watch as
thumbs move apart and feel for movement during inspiration. (normal – symmetrical rib cage expansion and contraction)
Palpation – Tactile Ask patient to say “99” or “1-1-1” while palpating with ball or fremitus ulnar surface of hand at 3 bilateral areas; ask female patient to or displace breasts if necessary (normal – palpable vibrations; decreased or absent over precordium)
Percussion Percuss in ladder pattern at 5+ bilateral locations; displace female patient’s breast with left hand while percussing with right hand or ask patient to move breast to side (normal – resonance; dullness to left of sternum at 3rd-5th interspaces)