Key components in the evaluation of patients with pulmonary symptoms are the history, physical examination, and, in most cases, a chest x-ray. These components establish the need for subsequent testing, which may include pulmonary function testing and ABG analysis (see Tests of Pulmonary Function (PFT): Overview of Tests of Pulmonary Function), CT or other imaging test (see Diagnostic Pulmonary Procedures: Chest imaging), and bronchoscopy (see Diagnostic Pulmonary Procedures: Bronchoscopy).
The history can often establish whether symptoms of dyspnea, chest pain, wheezing, stridor, hemoptysis, and cough are likely to be pulmonary in origin. When more than one symptom occurs concurrently, the history should focus on which symptom is primary and whether constitutional symptoms, such as fever, weight loss, and night sweats, are also present. Other important information includes occupational and environmental exposures; family history, travel history, and contact history; previous illnesses and use of prescription, OTC, or illicit drugs; and previous test results (eg, tuberculin skin test, chest x-rays).
Physical examination starts with assessment of general appearance. Discomfort and anxiety, body habitus, and the effect of talking or movement on symptoms (eg, inability to speak full sentences without pausing to breathe) all can be assessed while greeting the patient and taking a history and may provide useful information relevant to pulmonary status. Next, inspection, auscultation, and chest percussion and palpation are done.
Inspection should focus on
Signs of hypoxemia include cyanosis (bluish discoloration of the lips, face, or nail beds), which signifies low arterial O2 saturation (< 85%); the absence of cyanosis does not exclude the presence of hypoxemia.
Signs of respiratory difficulty include tachypnea and use of accessory respiratory muscles (sternocleidomastoids, intercostals, scalene) to breathe. Patients with COPD sometimes brace their arms against their legs or the examination table while seated (ie, tripod position) in a subconscious effort to provide more leverage to accessory muscles and thereby enhance respiration. Intercostal retractions (inward movement of the rib interspaces) are common among infants and older patients with severe airflow limitation; paradoxical breathing (inward motion of the abdomen during inspiration) signifies respiratory muscle fatigue or weakness.
Signs of possible chronic pulmonary disease include clubbing, barrel chest (the increased anterior-posterior diameter of the chest present in some patients with emphysema), and pursed lip breathing. Clubbing is enlargement of the fingertips (or toes) due to proliferation of connective tissue between the fingernail and the bone. Diagnosis is based on an increase in the profile angle of the nail as it exits the finger (to > 176°) or on an increase in the phalangeal depth ratio (to > 1—see Fig. 1: Approach to the Pulmonary Patient: Measuring finger clubbing.). “Sponginess” of the nail bed beneath the cuticle also suggests clubbing. Clubbing is most commonly observed in patients with lung cancer but is an important sign of chronic pulmonary disease, such as cystic fibrosis and idiopathic pulmonary fibrosis; it also occurs (but less commonly) in cyanotic heart disease, chronic infection (eg, infective endocarditis), stroke, inflammatory bowel disease, and cirrhosis. Clubbing occasionally occurs with osteoarthropathy and periostitis (primary or hereditary hypertrophic osteoarthropathy); in this instance, clubbing may be accompanied by skin changes, such as hypertrophied skin on the dorsa of the hands (pachydermoperiostosis), seborrhea, and coarse facial features. Digital clubbing can also occur as a benign hereditary abnormality that can be distinguished from pathologic clubbing by the absence of pulmonary symptoms or disease and by the presence of clubbing from an early age (by patient report).
Chest wall deformities, such as pectus excavatum and kyphoscoliosis, may restrict respirations and exacerbate symptoms of preexisting pulmonary disease.
Abnormal breathing patterns cause fluctuations in respiratory rate so respiratory rate should be assessed and counted for 1 min.
Jugular venous distention, sometimes observed during inspection, indicates an increase in right atrial and right ventricular pressure. The elevated pressure is usually caused by left ventricular dysfunction, but it may also be due to a pulmonary disorder causing pulmonary hypertension (see Approach to the Cardiac Patient: Neck veins). The presence of jugular venous distension should prompt a search for other signs of cardiac disorder (eg, 3rd heart sound [S3 gallop], dependent edema).
Auscultation is arguably the most important component of the physical examination. All fields of the chest should be listened to, including the flanks, to detect abnormalities associated with each lobe of the lung. Features to listen for include
Cardiac auscultation (see Pulmonary Hypertension), conducted simultaneously with pulmonary auscultation, may reveal signs of pulmonary hypertension, such as a loud pulmonic 2nd heart sound (P2), and of right heart failure, such as a right ventricular 4th heart sound (S4) and tricuspid regurgitation.
The character and volume of breath sounds are useful in identifying pulmonary disorders. Vesicular breath sounds are the normal sounds heard over most lung fields. Bronchial breath sounds are slightly louder, harsher, and higher pitched; they normally can be heard over the trachea and over areas of lung consolidation, such as occur with pneumonia.
Adventitious sounds are abnormal sounds, such as crackles, rhonchi, wheezes, and stridor.
Vocal sounds involve auscultation while patients vocalize.
Friction rubs are grating or creaking sounds that fluctuate with the respiratory cycle and sound like skin rubbing against wet leather. They are a sign of pleural inflammation and are heard in patients with pleurisy or empyema and after thoracotomy.
I:E ratio is normally 1:2 but is prolonged to ≥ 1:3 when airflow is limited, such as in asthma and COPD, even in the absence of wheezing.
Percussion and palpation:
Percussion is the primary physical maneuver used to detect the presence and level of pleural effusion. Finding areas of dullness during percussion signifies underlying fluid or, less commonly, consolidation.
Palpation includes tactile fremitus (vibration of the chest wall felt when a patient is asked to speak); it is decreased in pleural effusion and pneumothorax and increased in pulmonary consolidation (eg, lobar pneumonias). Point tenderness on palpation may signal underlying rib fracture or pleural inflammation.
In cor pulmonale (see Heart Failure: Cor Pulmonale), a right ventricular impulse at the left lower sternal border may become evident and may be increased in amplitude and duration (right ventricular heave).
Last full review/revision July 2009 by Noah Lechtzin, MD, MHS
Content last modified February 2012