Internal Diseases · MU Sofia

Practical · 10. Physical methods of examination of a patients with pulmonary disease — inspection, palpation

Covers inspection of the chest and palpation for pulmonary examination. Inspection runs through exposing the patient, observing breathing pattern and accessory muscle use, chest shape with abnormal types such as barrel, pigeon and funnel chest, chest movement, signs of respiratory distress and other clues like cyanosis and clubbing. Palpation addresses tracheal position, chest expansion posteriorly and anteriorly, symmetry of upper and lower zones, vocal fremitus with its interpretation, and checking the ribs for fracture. Several pictures illustrate hand placements and chest features.

Inside: 3 sections · 8 labelled pictures · 14 flashcards · 2 min

Topic 67 of 88 in the MU Sofia syllabus for Internal Diseases (Dental Medicine, Year 4). The free AceMed note covers it in 3 sections, about 329 words (2 min of reading), with 14 flashcards.

In this note

  1. Physical methods of examination of a patients with pulmonary disease — inspection, palpation
  2. I. INSPECTION
  3. II. PALPATION

I. INSPECTION

  1. 1. Expose patient adequately – ensure upper body is uncovered.
  1. 2. Observe from front and back.
  2. 3. Respiratory Pattern:
  • Rate, rhythm, depth of breathing
  • Use of accessory muscles (neck, intercostals, abdominal)
  1. 4. Chest Shape:
  • Normal: symmetrical, anteroposterior < transverse
  • Abnormal:
  • Barrel chest – emphysema/COPD
  • Pigeon chest – pectus carinatum
  • Funnel chest – pectus excavatum
  • Kyphosis, scoliosis
  1. 5. Chest Movement:
  • Symmetry – observe lagging or reduced movement on one side
  • Paradoxical movement – flail chest
  1. 6. Signs of respiratory distress:
  • Nasal flaring, intercostal/subcostal retractions
  • Tripod posture (leaning forward for ease of breathing)
  • Orthopnea (unable to lie flat)
  1. 7. Other clues:
  • Cyanosis (lips, fingers)
  • Clubbing of fingers
  • Audible wheeze or stridor

II. PALPATION

A. Tracheal Position

  • Place index finger in the suprasternal notch.
  • Trachea should be midline.
  • Deviation may suggest:
  • Pulled toward pathology: fibrosis, collapse
  • Pushed away: tension pneumothorax, massive pleural effusion

B. Chest Expansion

  1. 1. Posterior:
  • Place both hands over the lower posterior chest (10th rib level)
  • Thumbs should meet at the midline
  • Ask patient to take deep breath – thumbs should move symmetrically outward
  1. 2. Anterior:
  • Place hands under the clavicles or around the lower anterior ribs
  • Observe for symmetry of expansion

C. Symmetrical Breathing Movement Assessment

Upper Zones:

  • Hands placed on trapezius, thumbs pointing toward C7 (find C7 by palpating vertebrae)
  • Fingers placed in infraclavicular area
  • Ask patient to breathe – assess for symmetrical expansion

Lower Zones:

  • Hands placed around 10th intercostal space, thumbs parallel to the spine
  • Ask patient to inhale – assess symmetrical rising of both hands

D. Vocal Fremitus (Tactile Fremitus)

  • Use ulnar edge of hands or palmar surface
  • Ask patient to say “ninety-nine” (English) or “33” (Bulgarian)
  • Place hands symmetrically in multiple spots:
  • Posterior: paravertebral and parascapular areas (at least 6 spots)
  • Anterior and lateral if needed
  • Interpretation:
  • Increased fremitus → consolidation (e.g., pneumonia)
  • Decreased fremitus → pleural effusion, pneumothorax

E. Fractured Ribs Check

  • Gently palpate each rib for tenderness or crepitus
  • Ask if there’s pain or involuntary flinching
  • Confirm with chest X-ray if fracture suspected

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