Heart and Lungs
The 4 major
components of the lung exam (inspection, palpation,percussion and
auscultation) are also used to examine the heart and abdomen. Learning
the appropriate techniques at this juncture will therefore enhance your
ability to perform these other examinations as well. Vital signs, an
important source of information, are discussed else
Inspection/Observation: A great deal of
information can be gathered from simply watching a patient breathe. Pay
particular attention to:
- General comfort and breathing pattern of the patient. Do
they appear distressed, diaphoretic, labored? Are the breaths regular
- Use of accessory
muscles of breathing (e.g. scalenes, sternocleidomastoids). Their use
signifies some element of respiratory difficulty.
the patient, in particular around the lips and nail beds. Obviously,
blue is bad!
Cyanosis of nail
- The position of
the patient. Those with extreme pulmonary dysfunction will often sit
up-right. In cases of real distress, they will lean forward, resting
their hands on their knees in what is known as the tri-pod position.
Patient with emphysema bending over in Tri-Pod
- Breathing through
pursed lips, often seen in cases of emphysema.
- Ability to speak.
At times, respiratory rates can be so high and/or work of breathing so
great that patients are unable to speak in complete sentences. If this
occurs, note how many words they can speak (i.e. the fewer words per
breath, the worse the problem!).
- Any audible noises associated with breathing as
occasionally, wheezing or the gurgling caused by secretions in large
airways are audible to the "naked" ear.
- The direction of abdominal wall movement during
inspiration. Normally, the descent of the diaphragm pushes
intra-abdominal contents down and the wall outward. In cases of severe
diaphragmatic flattening (e.g. emphysema) or paralysis, the abdominal
wall may move inward during inspiration, referred to as paradoxical
breathing. If you suspect this to be the case, place your hand on the
patient's abdomen as they breathe, which should accentuate its
- Any obvious chest
or spine deformities. These may arise as a result of chronic lung
disease (e.g. emphysema), occur congenitally, or be otherwise acquired.
In any case, they can impair a patient's ability to breathe normally. A
few common variants include:
- Pectus excavatum: Congenital posterior displacement of
lower aspect of sternum. This gives the chest a somewhat "hollowed-out"
appearance. The x-ray shows a subtle concave appearance of the lower
- Barrel chest: Associated with emphysema and lung
hyperinflation. Accompanying xray also demonstrates
increased anterior-posterior diameter as well as diaphragmatic
- Kyphosis: Causes the patient to be bent forward.
Accompanying X-Ray of same patient clearly demonstrates extreme
curvature of the spine.
- Scoliosis: Condition where
the spine is curved to either the left or right. In the pictures below,
scoliosis of the spine causes right shoulder area to appear somewhat
higher than the left. Curvature is more pronounced on
Palpation: Palpation plays a relatively
minor role in the examination of the normal chest as the structure of
interest (the lung) is covered by the ribs and therefore not palpable.
Specific situations where it may be helpful include:
- Accentuating normal chest excursion: Place your hands on
the patient's back with thumbs pointed towards the spine. Remember to
first rub your hands together so that they are not too cold prior to
touching the patient. Your hands should lift symmetrically outward when
the patient takes a deep breath. Processes that lead to asymmetric lung
expansion, as might occur when anything fills the pleural space (e.g.
air or fluid), may then be detected as the hand on the affected side
will move outward to a lesser degree. There has to be a lot of plerual
disease before this asymmetry can be identified on exam.
Detecting Chest Excursion
Fremitus: Normal lung transmits a palpable vibratory sensation to the
chest wall. This is referred to as fremitus and can be detected by
placing the ulnar aspects of both hands firmly against either side of
the chest while the patient says the words "Ninety-Nine." This maneuver
is repeated until the entire posterior thorax is covered. The bony
aspects of the hands are used as they are particularly sensitive for
detecting these vibrations.
Pathologic conditions will alter fremitus. In particular:
- Lung consolidation:
Consolidation occurs when the normally air filled lung parenchyma
becomes engorged with fluid or tissue, most commonly in the setting of
pneumonia. If a large enough segment of parenchyma is involved, it can
alter the transmission of air and sound. In the presence of
consolidation, fremitus becomes more pronounced.
- Pleural fluid:
Fluid, known as a pleural effusion, can collect in the potential space
that exists between the lung and the chest wall, displacing the lung
upwards. Fremitus over an effusion will be decreased.
In general, fremitus is a pretty subtle finding and should
not be thought of as the primary means of identifying either
consolidation or pleural fluid. It can, however, lend supporting
evidence if other findings (see below) suggest the presence of either
of these processes.
painful areas: If the patient complains of pain at a particular site it
is obviously important to carefully palpate around that area. In
addition, special situations (e.g. trauma) mandate careful palpation to
look for evidence of rib fracture, subcutaneous air (feels like your
pushing on Rice Krispies or bubble paper), etc.
technique makes use of the fact that striking a surface which covers an
air-filled structure (e.g. normal lung) will produce a resonant note
while repeating the same maneuver over a fluid or tissue filled cavity
generates a relatively dull sound. If the normal, air-filled tissue has
been displaced by fluid (e.g. pleural effusion) or infiltrated with
white cells and bacteria (e.g. pneumonia), percussion will generate a
deadened tone. Alternatively, processes that lead to chronic (e.g.
emphysema) or acute (e.g. pneumothorax) air trapping in the lung or
pleural space, respectively, will produce hyper-resonant (i.e. more
drum-like) notes on percussion. Initially, you will find that this
skill is a bit awkward to perform. Allow your hand to swing freely at
the wrist, hammering your finger onto the target at the bottom of the
down stroke. A stiff wrist forces you to push your finger into the
target which will not elicit the correct sound. In addition, it takes a
while to develop an ear for what is resonant and what is not. A few
things to remember:
percussion! Try finding your own stomach bubble, which should be around
the left costal margin. Note that due to the location of the heart,
tapping over your left chest will produce a different sound then when
performed over your right. Percuss your walls (if they're sheet rock)
and try to locate the studs. Tap on tupperware filled with various
amounts of water. This not only helps you develop a sense of the
different tones that may be produced but also allows you to practice
you're percussing with your right hand, stand a bit to the left side of
the patient's back.
- Ask the patient to cross their hands in front of their
chest, grasping the opposite shoulder with each hand. This will help to
pull the scapulae laterally, away from the percussion field.
- Work down the
"alley" that exists between the scapula and vertebral column, which
should help you avoid percussing over bone.
- Try to focus on
striking the distal inter-phalangeal joint (i.e. the last joint) of
your left middle finger with the tip of the right middle finger. The
impact should be crisp so you may want to cut your nails to keep
blood-letting to a minimum!
- The last 2 phalanges of your left middle finger should rest
firmly on the patient's back. Try to keep the remainder of your fingers
from touching the patient, or rest only the tips on them if this is
otherwise too awkward, in order to minimize any dampening of the
- When percussing any one spot, 2 or 3 sharp taps should
suffice, though feel free to do more if you'd like. Then move your hand
down several inter-spaces and repeat the maneuver. In general,
percussion in 5 or so different locations should cover one hemi-thorax.
After you have percussed the left chest, move yours hands across and
repeat the same procedure on the right side. If you detect any
abnormality on one side, it's a good idea to slide your hands across to
the other for comparison. In this way, one thorax serves as a control
for the other. In general, percussion is limited to the posterior lung
fields. However, if auscultation (see below) reveals an abnormality in
the anterior or lateral fields, percussion over these areas can help
identify its cause.
- The goal is to
recognize that at some point as you move down towards the base of the
lungs, the quality of the sound changes. This normally occurs when you
leave the thorax. It is not particularly important to identify the
exact location of the diaphragm, though if you are able to note a
difference in level between maximum inspiration and expiration, all the
better. Ultimately, you will develop a sense of where the normal lung
should end by simply looking at the chest. The exact vertebral level at
which this occurs is not really relevant.
percussion" may help to accentuate the difference between dull and
resonant areas. During this technique, the examiner moves their left
(i.e. the non-percussing) hand at a constant rate down the patient's
back, tapping on it continuously as it progresses towards the bottom of
the thorax. This tends to make the point of inflection (i.e. change
from resonant to dull) more pronounced.
Auscultation: Prior to listening over any one area
of the chest, remind yourself which lobe of the lung is heard best in
that region: lower lobes occupy the bottom 3/4 of the posterior fields;
right middle lobe heard in right axilla; lingula in left axilla; upper
lobes in the anterior chest and at the top 1/4 of the posterior fields.
This can be quite helpful in trying to pin down the location of
pathologic processes that may be restricted by anatomic boundaries
(e.g. pneumonia). Many disease processes (e.g. pulmonary edema,
bronchoconstriction) are diffuse, producing abnormal findings in
- Put on your
stethoscope so that the ear pieces are directed away from you. Adjust
the head of the scope so that the diaphragm is engaged. If you're not
sure, scratch lightly on the diaphragm, which should produce a noise.
If not, twist the head and try again. Gently rub the head of the
stethoscope on your shirt so that it is not too cold prior to placing
it on the patient's skin.
- The upper aspect of the posterior fields (i.e. towards the
top of the patient's back) are examined first. Listen over one spot and
then move the stethoscope to the same position on the opposite side and
repeat. This again makes use of one lung as a source of comparison for
the other. The entire posterior chest can be covered by listening in
roughly 4 places on each side. Of course, if you hear something
abnormal, you'll need to listen in more places.
- The lingula
and right middle lobes can be examined while you are still standing
behind the patient.
- Then, move around to the front and listen to the anterior
fields in the same fashion. This is generally done while the patient is
still sitting upright. Asking female patients to lie down will allow
their breasts to fall away laterally, which may make this part of the
A few additional things worth noting.
get in the habit of performing auscultation through clothing.
- Ask the patient
to take slow, deep breaths through their mouths while you are
performing your exam. This forces the patient to move greater volumes
of air with each breath, increasing the duration, intensity, and thus
detectability of any abnormal breath sounds that might be present.
- Sometimes it's
helpful to have the patient cough a few times prior to beginning
auscultation. This clears airway secretions and opens small atelectatic
(i.e. collapsed) areas at the lung bases.
- If the patient
cannot sit up (e.g. in cases of neurologic disease, post-operative
states, etc.), auscultation can be performed while the patient is lying
on their side. Get help if the patient is unable to move on their own.
In cases where even this cannot be accomplished, a minimal examination
can be performed by listening laterally/posteriorly as the patient
- Requesting that the patient exhale forcibly will
occasionally help to accentuate abnormal breath sounds (in particular,
wheezing) that might not be heard when they are breathing at normal