Pulm Exam

Question 1

General pulmonary exam components

Answer 1

1. inspect
2. palpate
3. percuss
4. auscultate

Question 2

Pulmonary exam inspection

Answer 2

  Size, shape and symmetry:
       Back
       Front
       Ribs
  Observe breathing pattern for regularity
  Observe for use of accessory muscles
  Observe for retractions
  Skin for cyanosis
  Nails for clubbing

Question 3

Pulmonary exam palpation

Answer 3

 Sternal notch
 Sternal angle
 Costal-sternal articulation of 2nd rib
 Thoracic muscles and skeleton for:
 Tenderness
 Expansion
 Tactile fremitus (compare side to side)

Question 4

Pulmonary exam percussion

Answer 4

Percuss (Compare side to side on all):
 Anterior chest: minimum 2 regions
 Posterior chest: minimum 3 regions

Question 5

Pulmonary exam auscultation

Answer 5

Auscultate (Compare side to side on all):
  Anterior chest: minimum 2 regions
  Posterior chest: minimum 3 regions
  Axillae: minimum 1 region
  Egophony
  Bronchophony

Question 6

Tactile fremitus technique

Answer 6

• Fremitus = palpable vibration transmitted to the chest wall when patient speaks
• Use either the ball of the hand or the ulnar surface of hand.
• Palpate both sides of the chest at the same time
• Palpate the four areas on the back
• Verbalization Pearl: Each time I place my hands on your back say “99”
• Decreased or absent fremitus may signal that vibrations from the larynx to the chest wall are being impeded by COPD, pleural effusion, pneumothorax, fibrosis, tumor, or could be very thick chest wall)
• Increased fremitus is more likely a pneumonia
• Fremitus is a rough exam tool but can help identify areas to focus examination during percussion and auscultation

Question 7

Percussion technique

Answer 7

• Striking the finger of one hand against the middle finger placed firmly on the chest
• Percussion may produce sounds that are flat, dull, resonant, hyperresonant or tympanic
• Resonance is what one hears on a normal lung
• Dullness replaces resonance in the presence of fluid like pneumonia, a pleural effusion would transmit as more flat
• Hyperresonance and Tympany are heard in COPD, pneumothorax (page 300 Bates’)

Question 8

Egophony and bronchophony technique

Answer 8

• Egophony (say “E”)
a. If the E sounds like “ay” and is nasally this may indicate lobar consolidation from pneumonia

• Bronchophony (say “99”)
a. Abnormal if exaggerated vocal resonance present aka the words sound clearer through stethoscope, suggests the lung is airless (multiple causes)