Physical exam findings for pulmonary conditions

Question 1

What are the key physical exam findings for pleural effusion?

Answer 1

• Decreased breath sounds
• Dullness to percussion
• Decreased tactile fremitus
• Tracheal deviation away if large

Question 2

Why does pleural effusion cause dullness to percussion?

Answer 2

Fluid accumulation in the pleural space absorbs sound, leading to dullness.

Question 3

Why is tactile fremitus decreased in pleural effusion?

Answer 3

Fluid in the pleural space impairs the transmission of vibrations from the bronchial tree to the chest wall.

Question 4

How does pleural effusion affect tracheal position?

Answer 4

The trachea remains midline unless the effusion is large, in which case it shifts away from the affected side.

Question 5

What are the key physical exam findings for lung consolidation?

Answer 5

• Increased breath sounds (crackles/rales)
• Dullness to percussion
• Increased tactile fremitus
• trachea remains midline

Question 6

Why does consolidation cause increased breath sounds?

Answer 6

Fluid-filled alveoli conduct sound more efficiently, leading to louder breath sounds.

Question 7

What are the characteristic lung sounds in consolidation?

Answer 7

Increased breath sounds, bronchial breath sounds, egophony, whispered pectoriloquy, and crackles (rales). Bronchial breath sounds are loud, high-pitched, and similar to tracheal sounds. They are heard in consolidation due to increased sound transmission through fluid-filled alveoli. Egophony is when a patient says ‘E’ but it sounds like ‘A’ upon auscultation. It occurs due to enhanced transmission of high-frequency sounds through fluid-filled lung tissue. Whispered pectoriloquy is when whispered words are heard more clearly than normal due to increased sound transmission through consolidated lung tissue.

Question 8

Why does consolidation cause increased tactile fremitus?

Answer 8

Solidified lung tissue (due to infection/inflammation) transmits vibrations more effectively than air-filled lungs.

Question 9

A 62-year-old man presents to the emergency department for evaluation of shortness of breath and cough which began a day ago. The patient also has been experiencing fever and chills. Past medical history is notable for hypertension and type Il diabetes mellitus. The patient smokes a pack of cigarettes daily. Temperature is 39.0 °C (102.2 °F), blood pressure is 143/87 mmHg, pulse is 108/min, respiratory rate is 23/min, and SpO2 is 90% on room air. The patient is ill-appearing on physical examination. During the visit, the patient frequently coughs and produces viscous, yellowish sputum. A chest radiograph is obtained and is shown below. Which of the following additional findings will most likely be present on this patient’s physical examination?
A) Increased tactile fremitus
B) Hyperresonance to percussion
C) Lack of bronchophony
D) Lack of egophony
E) Overlying skin erythema

Answer 9

Patients with pneumonia often present with fever, tachypnea, tachycardia and low oxygen saturation. If there is lobar pneumonia, physical examination can be notable for the presence of egophony, bronchophony and tactile fremitus, and decreased resonance to percussion. This patient has dyspnea, fever, and a productive cough. Imaging reveals focal pacifications in the right lung (likely upper lobe). These findings are most concerning for lobar pneumonia. Pneumonia is a lung infection that results in inflammation of one or both lungs. Usually it is caused by bacteria (e.g. Streptococcus pneumoniae) and viruses (e.g. influenza), but it can also be caused by fungi (e.g., Pneumocystis). Physical examination will show fever, tachypnea, and tachycardia. Lung auscultation over the affected area may reveal rales (clicking and rattling sounds). Wheezing generally only occurs in patients with obstructive lung disease. With lobar consolidation, the fluid that has accumulated within the infected lobe can result in the following findings on lung examination: 1) Bronchophony - an increase in intensity and clarity of a patient’s voice when auscultating the lung. This is because sound is transmitted better through fluid than air. 2) Egophony - when the patient is asked to say “ee” it sounds like “ah” rather than “ee.” 3) Increased tactile fremitus - increased conduction of vibrations to the chest wall when the patient is speaking, which can be felt by placing a hand on the patient’s chest while he is repeating a phrase. Similar to bronchophony, this occurs because sound is transmitted better through fluid than air. 4) Decreased resonance to percussion

Question 10

What are the key physical exam findings for pneumothorax?

Answer 10

• Decreased breath sounds
• Hyperresonance to percussion
• Decreased tactile fremitus
• Tracheal deviation away in tension pneumothorax

Question 11

Why does pneumothorax cause hyperresonance to percussion?

Answer 11

Excess air in the pleural space increases resonance during percussion.

Question 12

What is the difference between simple and tension pneumothorax on physical exam?

Answer 12

Tension pneumothorax pushes the trachea away from the affected side, while simple pneumothorax does not cause significant deviation.

Question 13

What are the key physical exam findings for atelectasis?

Answer 13

• Decreased breath sounds
• Dullness to percussion
• Decreased tactile fremitus
• Tracheal deviation toward the affected side if large

Question 14

Why does atelectasis cause tracheal deviation toward the affected side?

Answer 14

Collapsed lung tissue creates negative pressure, pulling the trachea toward the affected lung.

Question 15

What are the key physical exam findings for COPD/emphysema?

Answer 15

• Decreased breath sounds
• Hyperresonance to percussion
• Decreased tactile fremitus
• Trachea remains midline

Question 16

Why do COPD and emphysema cause hyperresonance to percussion?

Answer 16

Air trapping and hyperinflation increase lung compliance, leading to hyperresonance.

Question 17

Why are breath sounds decreased in emphysema?

Answer 17

Destruction of alveolar walls reduces airflow and sound transmission through the lungs.

Question 18

Which conditions cause dullness to percussion?

Answer 18

Pleural effusion, consolidation, and atelectasis.

Question 19

Which conditions cause hyperresonance to percussion?

Answer 19

Pneumothorax and COPD/emphysema.

Question 20

Which conditions cause increased tactile fremitus?

Answer 20

Consolidation (e.g., pneumonia).

Question 21

Which conditions cause decreased tactile fremitus?

Answer 21

Pleural effusion, pneumothorax, atelectasis, and COPD/emphysema.

Question 22

Which conditions shift the trachea away from the affected side?

Answer 22

Large pleural effusion and tension pneumothorax.

Question 23

Which conditions shift the trachea toward the affected side?

Answer 23

Large atelectasis.

Question 24

What is digital clubbing?

Answer 24

A deformity of the nails characterized by increased convexity, broadening, and hypertrophic changes of the distal fingers.

Question 25

What are other terms used for digital clubbing?

Answer 25

Hippocratic fingers, drumstick fingers, watch-glass nails.

Question 26

What is the proposed pathophysiology of digital clubbing?

Answer 26

Increased vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF) leading to increased connective tissue proliferation and periosteal changes. Another proposed pathology for digital clubbing includes the fact that platelets tend to be broken up within the lung and when you have decreased lung parenchyma or diseased parenchyma and vessels, platelets are not broken up as effectively in the lung and so they end up in the distal extremities such as the fingers and start to break up there increasing the amount of cytokines in the fingertips.

Question 27

Which pulmonary conditions are associated with digital clubbing?

Answer 27

Lung cancer (especially non-small cell carcinoma), interstitial lung disease (e.g., pulmonary fibrosis), pulmonary tuberculosis, pulmonary lymphoma, and bronchiectasis.

Question 28

Why does lung cancer cause digital clubbing?

Answer 28

Tumor cells release growth factors (VEGF, PDGF) that promote distal phalangeal hypertrophy and periosteal changes.

Question 29

Why is digital clubbing seen in interstitial pulmonary fibrosis?

Answer 29

Chronic hypoxia and increased VEGF/PDGF stimulate connective tissue proliferation in the distal fingers.

Question 30

Is digital clubbing seen in COPD?

Answer 30

No, digital clubbing is NOT typically associated with COPD unless lung cancer is also present.

Question 31

Which cardiovascular conditions are associated with digital clubbing?

Answer 31

Cyanotic congenital heart disease (e.g., Tetralogy of Fallot, Eisenmenger syndrome), infective endocarditis, and chronic heart failure.

Question 32

Why does cyanotic congenital heart disease cause digital clubbing?

Answer 32

Long-standing hypoxia triggers VEGF release, promoting digital clubbing and hypertrophic osteoarthropathy.

Question 33

How does infective endocarditis lead to digital clubbing?

Answer 33

Chronic infection and inflammation lead to increased platelet-derived growth factor (PDGF) and connective tissue proliferation.

Question 34

What is hypertrophic osteoarthropathy (HOA)?

Answer 34

A syndrome characterized by digital clubbing, periostitis, and painful joint swelling, often associated with lung cancer.

Question 35

What is the relationship between digital clubbing and hypertrophic osteoarthropathy?

Answer 35

Clubbing is often the first sign of HOA, which progresses to distal extremity bone and joint pain.

Question 36

What are the clinical features of digital clubbing?

Answer 36

Loss of the angle between the nail and nail bed (>180°), increased nail convexity, sponginess of the nail bed, and widening of the fingertips.

Question 37

How is digital clubbing assessed on physical exam?

Answer 37

The **Schamroth sign** (loss of the diamond-shaped gap between the opposing nails when placed together).

Question 38

Is digital clubbing reversible?

Answer 38

It can be reversible if the underlying cause is treated early, but in chronic cases, it may persist.

Question 39

Which major conditions cause digital clubbing?

Answer 39

Lung cancer, interstitial lung disease, pulmonary fibrosis, cyanotic congenital heart disease, infective endocarditis, and hypertrophic osteoarthropathy.

Question 40

Does COPD alone cause digital clubbing?

Answer 40

No, clubbing in a patient with COPD suggests an alternative diagnosis, such as lung cancer or bronchiectasis.

Question 41

What is the most common malignancy associated with digital clubbing?

Answer 41

Non-small cell lung carcinoma (NSCLC), especially adenocarcinoma.