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Pulmonary Examination for Internal Medicine

A systemic examination is different from a general examination in the sense that a general examination deals with the outwardly appearance and characteristics of the patient. For example, a general examination begins as soon as you enter the patient's room. Part of the general examination includes talking to the patient and/or observing the sitting posture of the patient. All systemic examinations must be done in a specific sequence, i.e., inspection (seeing), palpation (feeling), percussion (tapping), and auscultation (listening). The ideal position for a patient undergoing a respiratory systemic examination is sitting up, i.e., the tripod position. Make sure you disrobe the patient and note any skeletal or cutaneous abnormalities.

Basic respiratory anatomy:

The right bronchus is in alignment with the trachea. This makes it easier for an inhaled substance to land up in the right lower lobe. For example, if a seizure patient presents with right lower lobe pneumonia, it may very well be aspiration pneumonia. There are two fissures on the right side - oblique and horizontal. The oblique fissure starts at T2 and hits the diaphragm about 3cm from the midline. The horizontal fissure begins at the second rib and ends at the fourth rib in the axilla. So, whatever your hear above the second or third rib is the right upper lobe. However, if you hear anything below that it is the right middle lobe. On the left side there is only one fissure - the oblique fissure. Anything that you hear in the front anterior chest wall of the left side is all upper lobe. The best place to look for upper, middle, and lower lobe is in the upper, middle, and lower axilla of the patient respectively.

Pulmonary inspection:
Before you begin the respiratory examination, make sure the patient is sitting up, leaning forward with their hands on a table or on the knees. This way, the scapula is pushed away from the back so we can have a lot of area to percuss. Make sure you disrobe the patient up to the waist line. Stand behind the patient and look for any drooping or distortion of the shoulders, cyanosis, the usage of accessory breathing muscles (note: this is the inspection part.) Now comes the palpation part where you confirm what you see on inspection. For example, now you'll touch or feel any rashes you previously saw on the patient. Whenever a patient complains of pain, make sure you always palpate that area for pain; if it is a reproducible pain it is definitely not cardiac or pulmonary but is musculoskeletal.

Position of trachea:
It is important to look for the position of the trachea because that will lead you to the final diagnosis. In order to palpate correctly, place your middle finger on the patient's trachea and place your index finger between the trachea and the sternocleidomastoid to make sure the trachea is in the center (Hint: make sure you have short nails). By the way, the normal position of the trachea is in the center or slightly to the right side. Now, if the right shoulder is angled below the left shoulder, you'll see the trachea shifted to the right side too. Do not press on the trachea too hard. The two conditions that pull the trachea on the same side are atelectasis and fibrosis. The two conditions that push the trachea to the opposite side are pneumothorax (hyperresonance to percussion) and pleural effusion (dull to percussion).

Size of chest wall:

The normal expansion of the chest wall is about 7-8 cm (just make sure it is over at least over 5 cm). If chest expansion is less than 1 cm we're thinking emphysema or barrel-shaped chest. If you don't have a measuring tape you can stand behind the patient, place both your hands on the lower back, raise two skin folds, and ask the patient to take a deep breath. You'll see the skin folds moving when the patient inhales and exhales; you can find pictures of this test in Bates. Not that both the skin folds must be moving equidistantly from the central line, if not, chest expansion may be limited on one of the sides.

Percussion of chest wall:

In order to percuss, make sure you finger is in the intercoastal space. You'll be comparing the sounds of all the six quadrants of the back. The six positions are - suprascapular, midscapular, and infrascapular; supra-axillary, mid-axillary, and inferior axillary; supra mammary, mammary, and infra mammary. Whenever you're percussing, carefully listen to the sound and feeling. Make sure you can differentiate normal from abnormal; note hyperresonance and dullness. A long-standing pneumonia may lead to a pulmonary collapse or fibrosis.

Auscultation of chest wall:

When you auscultate, you make note of the intensity of breath sounds. The sounds can be hyperresonant or dull. Lung sounds can be dull with or without any etiology, for example, breath sounds may be distant in patients with a barrel-shaped chest or in morbidly obese patients. There are two types of normal breath sounds - vesicular and bronchial. Sound heard over the tracheo-bronchial tree is the bronchial breath sound (ie., sound heard when air moves in a solid big tube) and sound heard over the actual lung tissues is the vesicular breath sound. However, there is an etiology involved when these two breath sounds are heard in areas other than the mentioned areas. For example, bronchial breath sounds heard over the right infra-scapular area always indicate consolidation. Furthermore, bronchial breath sounds in the right or left supra-scapular are perfectly normal.

Vocal fremitus vs whispering pectoriloquy:

We can also use tactile or vocal fremitus in order to locate consolidation. Whenever someone says that tactile or vocal fremitus is increased or decreased, it just means there is pneumonia sitting in that lung. Basically, you ask the patient to say something while you feel vibrations over the chest wall. If vibrations are present, tactile or vocal fremitus is present. Another concept exactly similar to tactile or vocal fremitus is called whispering pectoriloquy. In whispering pectoriloquy, you ask the patient to whisper instead of speak.

Adventitious breath sounds:

There are two types of adventitious breath sounds: crepitations (rales or crackles and is indicative of fluid or fibrotic alveola) and ronchi (which indicates bronchospasm due to COPD or asthma because narrowed tubes). Note that ronchi is a sign and wheeze is a symptom. By the way, what is the bedside test used to differentiate between an asthmatic and COPD patient? These patients can be differentiated using a peakflow meter. If the peak flow improves by at least 12%, it is most likely an asthmatic patient. Asthma is a reversible condition and COPD isn't. NOTE: in COPD patients, the oxygen level must be maintained at 90% not 100% otherwise his only breathing drive will also be inhibited.