Thorough Pulmonary Physical Examination Write-Up
A comprehensive pulmonary physical examination should include inspection, palpation, percussion, and auscultation of the chest, along with assessment of vital signs and evaluation of respiratory effort and pattern.
Initial Assessment
Vital Signs
- Pulse rate and regularity
- Blood pressure
- Respiratory rate
- Oxygen saturation (SpO2)
- Temperature
General Appearance
- Positioning (tripod position, orthopnea)
- Level of distress
- Use of accessory muscles
- Pursed-lip breathing
- Cyanosis (central or peripheral)
- Clubbing of fingers
- Body habitus
Inspection
Chest Configuration
- Shape (barrel chest, pectus excavatum, pectus carinatum)
- Symmetry
- Scars, deformities
- Visible pulsations
- Intercostal retractions
Respiratory Dynamics
- Breathing pattern (regular, irregular, Cheyne-Stokes)
- Respiratory rate and depth
- Chest wall movement symmetry
- Diaphragmatic excursion
- Thoracoabdominal synchrony/paradoxical breathing
- I:E ratio (normal 1:2, prolonged expiration in obstructive disease)
Neck Examination
- Jugular venous pressure (elevated in cor pulmonale)
- Tracheal position (midline or deviated)
- Accessory muscle use (sternocleidomastoid, scalene)
- Supraclavicular retractions
Palpation
Chest Wall
- Tenderness
- Subcutaneous emphysema (crepitus)
- Chest expansion (symmetry and degree)
- Tactile fremitus (increased with consolidation, decreased with pleural effusion or pneumothorax)
- Thrills or vibrations
Trachea
- Position (midline or deviated)
- Mobility
Lymph Nodes
- Cervical, supraclavicular, axillary (enlargement may suggest malignancy or infection)
Percussion
Technique
- Systematic percussion of all lung fields (anterior, lateral, posterior)
- Compare side-to-side at equivalent levels
Findings to Document
- Resonance (normal lung)
- Hyperresonance (emphysema, pneumothorax)
- Dullness (consolidation, pleural effusion)
- Flatness (large pleural effusion)
- Diaphragmatic excursion (measure by percussion)
Auscultation
Breath Sounds
- Vesicular (normal peripheral lung)
- Bronchial/tubular (over trachea or with consolidation)
- Bronchovesicular (normal over major bronchi)
- Diminished (emphysema, pleural effusion, pneumothorax)
- Absent (severe pathology)
Adventitious Sounds
- Crackles/rales (fine or coarse, early or late inspiratory)
- Wheezes (monophonic or polyphonic, inspiratory or expiratory)
- Rhonchi (sonorous, musical)
- Pleural friction rub
- Stridor
- Egophony (E-to-A changes)
- Whispered pectoriloquy
- Bronchophony
Voice Sounds
- Bronchophony
- Egophony (E-to-A changes)
- Whispered pectoriloquy
Cardiovascular Assessment Relevant to Pulmonary Function
- Heart sounds (S3 may indicate heart failure)
- Murmurs (valvular disease may affect pulmonary function)
- Pulsus paradoxus (>10 mmHg drop in systolic BP during inspiration may indicate severe obstructive disease)
Additional Observations
- Cough characteristics (productive/non-productive, hemoptysis)
- Sputum (color, consistency, amount)
- Signs of cor pulmonale (peripheral edema, hepatomegaly, elevated JVP)
- Evidence of systemic disease (digital clubbing, cyanosis)
Functional Assessment
- Exercise tolerance (6-minute walk test if appropriate)
- Dyspnea with exertion or at rest
- Ability to complete full sentences
The physical examination findings should be interpreted in the context of the patient's history, symptoms, and relevant diagnostic tests such as pulmonary function tests, chest imaging, and laboratory studies 1, 2, 3. This comprehensive approach ensures thorough evaluation of respiratory status and helps guide appropriate management decisions for pulmonary patients.