This document provides guidance on examining a patient presenting with cough. Key areas of examination include vital signs, inspection of respiratory rate and effort, palpation of the chest, percussion notes, auscultation of breath sounds and other lung sounds, and examination of other organ systems affected by pulmonary disease such as the cardiovascular system. Specific examination findings are outlined for different pulmonary conditions.

1. EXAMINATION OF A
PATIENT WITH
COUGH

2. GENERAL EXAMINATION
 Attitude:
Sit in a propped up position if
dyspnoea present
 Mental state:Mental confusion,stupor and
flapping tremors…Respiratory failure

3.  Recentloss of weight: Pulmonary
tuberculosis & Bronchogenic carcinoma
 Fever: Tuberculosis & Pneumonia

4.  Pallor
1. Severe haemoptysis
2. Tuberculosis:Malnutrition & anaemia

5.  Cyanosis
Central: Respiratory failure & CHF

6. Clubbing
 Tumours
1. Bronchogenic carcinoma
2. Mesothelioma
 Interstitial lung disease
 Chronic pulmonary tuberculosis

7.  Sepsis
1. Bronchiectasis
2. Lung abcess
3. Empyema

8. Pulmonary osteoarthropathy
 Painful clubbing+thickening of
periosteum of distal parts of
radius,ulna,tibia,fibula+ painful
enlargement of ankles & wrists
 Bronchogenic carcinoma

9. Lymphadenopathy
 Pulmonary tuberculosis
 Carcinoma
 Sarcoidosis
 Scalene nodes

10. Edema
 RHF secondary to pulmonay diseases is
termed COR PULMONALE.
1. Emphysema
2. Pulmonary fibrosis

11. Head to foot examination
 Subcutaneous nodules raised, firm tender:
Metastatic lung cancer
 Erythema nodosum over the shin:Acute
sarcoidosis

12. VITALS!!!!
 BP
1. High BP:COPD , Pulmonary embolism
2. Low BP:Pulmonary edema, ACEI,
Community acquired pneumonia
(CRB-65)
 JVP
 Raised in cor pulmonale

13. Examination of oropharynx
 Evidence of postnasal drip
 Oropharyngeal mucosa erythema or
cobble stone appearance

14.  Movement of accessory muscles of
respiration
 Examination
of neck:Posture,Movement of
accessory muscles,Jugular veins

15. RESPIRATORY SYSTEM
INSPECTION
 Shape of the chest
Barrel shaped chest
Emphysema
Drooping of the shoulders

16. Respiration
 Rate
 >15/min+increase ventilatory drive
1. Acute asthma
2. Exacerbation of COPD
 >15/min+decrease ventilatory drive
1. Pneumonia

17.  >30/min:Community acquired pneumonia
 Decrease rate: Respiratory failure
 Use of accessory muscles of respiration

18. Movements of the chest
 Intercostalrecession:Indrawing of
intercostal spaces with respiration…
Severe airway obstruction..laryngeal ds or
tumours of trachea

19. PALPATION
 Position of trachea
1. Deviation to same side:Fibrosis
2. Deviation to opp side:Pneumothorax,
Pleural effusion

20.  Apex beat
 Palpation of the chest for any tenderness
 Expansion of the chest
Decrease expansion in
consolidation,emphysema

21.  Vocal fremitus
 Decrease in bronchial obstrn,emphysema
 Increase in pneumonic consolidation &
neoplasms
 Rhonchial fremitus
 Palpable rhonchi

22. PERCUSSION
 Hyperresonant in emphysema
 Tympanic in a superficial cavity of lung
 Dullness in consolidation

23.  Cracked pot sound:percussion note over
cavities which communicate with bronchus
 Cardiac
dullness obliterated in
emphysema

24. AUSCULTATION
 Breath sounds

25.  Decreased intensity
1. Collapse & Fibrosis
2. Bronchial obstruction
 Bronchial breathing
 Pneumonic consolidation

26. Added sounds
 Wheezes are musical sounds assoc.
with airway narrowing.
1. Polyphonic wheezes heard in expiration:
asthma & COPD
2. Monophonic wheezes in localised
narrowing of bronchus & tumour or
foreign body

27.  Stridor is a harsh croaking inspiratory
noise aagravated by cough
 Should be investigated always.
1. Foreign body
2. Tumour occluding larynx,trachea or a
bronchus

28.  Crackles are short,explosive sounds
often described as bubbling or clicking
1. U/L early inspiratory:bronchial infn or
pneumonia
2. B/L basal:pulmonary edema

29.  Bronchiectasis: coarse crackles
 Diffuseinterstitial fibrosis:fine crackles but
late inspiratory
 COPD:crackles at the beginning of
respiration

30. Vocal resonance
 Increasedin pneumonic consolidation
 Whispering pectoriloquy present
 Decreased in emphysema

31. Position VF Percussio VR
of trachea n
Pneumoni No shift increse dull increase
c
consolidat
ion
Emphyse No shift decrease hyperreso decrease
ma nant

32. Also examine…
 CVS
 Cor pulmonale
 Pulmonary edema