Chest Exam / Lung
Topography
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Physical examination employs the use of
inspection, palpation, percussion, and
auscultation to determine patients’ clinical
status and their response to therapy
Each examination is modified according to
the purpose of the examination
Physical examination skills develop over
time with practice
Examination of the Head and
Neck
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Identify the patient’s facial expression,
looking for evidence of pain or acute
distress
Look for evidence of cyanosis around
the lips and oral mucosa
Patients may use pursed-lip breathing
when COPD is present
Eyes
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The eyes are inspected for pupillary
response to light when neurologic
defects are suspected
Dilated and fixed pupils suggest brain
death in some patients
The eyelids may droop (ptosis),
indicating damage to the third cranial
nerve
Neck
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The trachea should be midline
If it is deviated to one side, a unilateral lung
problem is probably present
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The status of the jugular veins in the neck is
important
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Atelectasis
pneumothorax
Patients with cor pulmonale have JVD
Use of accessory muscles in the neck
suggests obstructive lung disease
Lung Topography
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Anterior chest is
defined by the
midsternal and
midclavicular
lines
Lung Topography
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Lateral chest is
defined by midaxillary,
anterior axillary and
posterior axillary lines
Lung Topography
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Posterior chest is
defined by the
midspinal and
midscapular lines
Thoracic Cage Landmarks
Thoracic Cage Landmarks
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On the posterior
chest, C7 is seen as
the most prominent
spinous process at
the base of the neck
Thoracic Cage Landmarks
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The angle of Louis,
or sternal angle, is
located on the
anterior chest.
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Formed by the
ridge between the
manubrium and the
gladiolus
Lung Fissures
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The oblique fissure
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starts at rib six on the anterior
chest at the midclavicular line
It runs up and laterally crosses
the midaxillary line at fifth rib
and across the posterior chest,
ending at T3
horizontal fissure
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passes from the fourth rib at
the midsternal line laterally to
the fifth rib in the midaxillary
line
Tracheal Bifurcation
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At T4 on
posterior chest
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At sternal angle
on anterior
chest
Tracheal Bifurcation
Diaphragm
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The diaphragm is a
dome-shaped
muscle
The top of the dome
rests at about the
fifth rib anteriorly and
at T9 on the posterior
chest normally
Lung Borders
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On the anterior
chest the upper
border of the lung
extends 2 to 4 cm
above the medial
third of the
clavicles. The
inferior border of
the lung is at rib
six normally
Lung Borders
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On the lateral
chest the lower
margin of the lung
is at rib eight
Lung Borders
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On the posterior
chest the superior
border of the lung
extends to T1. The
inferior border
varies with
breathing but is
usually at about
T10
Examination of the Thorax
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Look
Feel
Listen
Look For
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A barrel chest or
evaluate the A-P
diameter
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An in crease A-P
diameter is
consistent with
COPD
Look For
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Kyphoscoliosis
is present when
the spine is bent
laterally and
from front to
back
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Can causea
restrictive lung
problem
Look For
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Pectus carinatum is
seen as an
abnormal sternal
protrusion
Look For
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Pectus excavatum
is seen as
depression of the
sternum
Look For
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Breathing pattern is important to identify when lung disease is present
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Rapid and shallow breathing is consistent with restrictive disease
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A prolonged expiratory time is consistent with obstructive lung disease
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Retractions are seen as inward depression of the skin around the rib cage
with inspiration
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Abdominal paradox is seen as inward movement of the abdomen with
inspiration
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This suggests a high work of breathing (WOB)
This suggests diaphragm paralysis or fatigue
Hoover’s sign is seen as inward movement of the lateral chest with inspiration.
It is a sign of severe COPD.
Feel For (Palpation)
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Vocal fremitus is assessed to identify
pathologic changes in the lung.
Increased vocal fremitus is consistent
with pneumonia and atelectasis.
Decreased vocal fremitus is consistent
with lung hyperinflation, pleural
disorders, and obesity.
Palpation
Palpation
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Use
palpation to
assess for
uniform
chest
excursion
Percussion
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Percussion is done to
determine the condition
of the underlying lung.
Increased resonance is
heard with
pneumothorax and lung
hyperinflation.
Decreased resonance is
heard with pneumonia
and atelectasis.