3.3 Thorax and Lung Examination
Key Takeaways
- The thorax and lung exam follows inspection, palpation, percussion, and auscultation, comparing findings side to side.
- Dull percussion with decreased fremitus and decreased breath sounds indicates pleural effusion; dull percussion with increased fremitus and bronchial breath sounds indicates consolidation.
- Hyperresonant percussion with decreased breath sounds and tracheal deviation signals a tension pneumothorax, a medical emergency.
- Chest pain reproducible by palpation favors a musculoskeletal cause; exertional pain relieved by rest favors angina.
- Orthopnea and paroxysmal nocturnal dyspnea point toward heart failure rather than a primary pulmonary or musculoskeletal cause.
3.3 Thorax and Lung Examination
Quick Answer: The thorax and lung exam follows the classic four-step sequence -- inspection, palpation, percussion, auscultation -- to distinguish pulmonary and cardiac chest pathology from chest wall (neuromusculoskeletal) pain. Part III tests whether you can recognize when chest pain, dyspnea, or an abnormal breath sound points away from a musculoskeletal cause and toward a condition requiring medical referral rather than manipulation or soft tissue treatment.
Chest complaints are common in chiropractic practice, and the ability to separate benign chest wall pain from cardiac, pulmonary, or vascular emergencies is one of the highest-yield safety skills tested on Part III. The thorax and lung examination uses the same four-step sequence taught for every body region -- inspection, palpation, percussion, auscultation -- applied specifically to breathing mechanics and lung findings.
Inspection
Inspection begins before you touch the patient:
- Respiratory rate and pattern -- normal, tachypneic, or using an abnormal pattern (e.g., Cheyne-Stokes, Kussmaul)
- Effort -- use of accessory muscles (scalenes, sternocleidomastoid), nasal flaring, intercostal retractions
- Chest wall shape -- barrel chest (associated with chronic obstructive pulmonary disease), pectus excavatum/carinatum, kyphoscoliosis affecting respiratory mechanics
- Symmetry of expansion -- asymmetric expansion suggests a unilateral process (pneumothorax, effusion, consolidation)
- Skin and color -- cyanosis, diaphoresis, visible trauma or surgical scars
Palpation
Palpation of the chest wall assesses both mechanical and pulmonary findings:
- Chest expansion -- hands placed symmetrically on the posterior chest to compare bilateral excursion during deep inspiration; asymmetric expansion suggests unilateral pathology
- Tactile fremitus -- vibration felt while the patient says "ninety-nine"; increased fremitus suggests consolidation, decreased fremitus suggests effusion, pneumothorax, or hyperinflation
- Point tenderness -- direct reproduction of pain over the costochondral or costosternal junctions strongly suggests a musculoskeletal source, such as costochondritis
- Crepitus -- a crackling sensation under the skin suggests subcutaneous emphysema, often from pneumothorax
Percussion
Percussion assesses the underlying density of lung tissue.
| Percussion Note | Normal or Abnormal Finding | Associated Condition |
|---|---|---|
| Resonant | Normal lung | Healthy air-filled lung |
| Hyperresonant | Abnormal | Pneumothorax, emphysema, severe hyperinflation |
| Dull | Abnormal | Consolidation (pneumonia), pleural effusion, atelectasis |
| Flat | Abnormal | Large pleural effusion, dense consolidation |
Diaphragmatic excursion is assessed by percussing the lower lung border at full exhalation and full inhalation; normal excursion is roughly 3-5 cm, and reduced excursion suggests restrictive disease or diaphragmatic dysfunction.
Auscultation
Breath sounds are assessed systematically over all lung fields, comparing side to side.
| Sound | Description | Significance |
|---|---|---|
| Vesicular | Soft, low-pitched, heard over most of the lung | Normal |
| Bronchial | Louder, hollow, heard over the trachea/mainstem bronchi | Normal only over central airways; abnormal if heard peripherally (suggests consolidation) |
| Crackles (rales) | Discontinuous popping sounds | Fluid in alveoli (pneumonia, heart failure, pulmonary edema) |
| Wheezes | Continuous high-pitched musical sounds | Airway narrowing (asthma, COPD exacerbation) |
| Rhonchi | Continuous low-pitched, snoring-like sounds | Secretions in larger airways (bronchitis) |
| Pleural friction rub | Grating, leathery sound with breathing | Pleural inflammation (pleuritis) |
Assessing Dyspnea
Dyspnea (the subjective sensation of breathing difficulty) has cardiac, pulmonary, metabolic, and anxiety-related causes, and the general physical exam is used to narrow among them:
- Orthopnea (dyspnea when lying flat, relieved by sitting up) and paroxysmal nocturnal dyspnea (waking suddenly short of breath) both point strongly toward heart failure.
- Acute dyspnea with unilateral leg swelling and pleuritic chest pain raises concern for pulmonary embolism.
- Dyspnea with wheeze and prolonged expiration suggests obstructive airway disease.
- Dyspnea with pallor and fatigue but a clear chest exam may point toward anemia rather than a primary cardiopulmonary process.
When Chest Pain Is Not Neuromusculoskeletal
Distinguishing chest wall pain from visceral chest pain is one of the most safety-critical judgments on Part III.
| Feature | Neuromusculoskeletal (e.g., costochondritis) | Cardiac / Pulmonary / Vascular |
|---|---|---|
| Reproducibility | Pain reproduced by palpation or movement | Pain not reproduced by palpation |
| Relationship to exertion | Usually unrelated to exertion | Often worsens with exertion, improves with rest (angina) |
| Associated symptoms | Localized, sometimes with recent trauma or overuse | Diaphoresis, nausea, radiation to jaw/arm, dyspnea |
| Onset | Gradual or after known strain | Sudden, severe ("tearing" pain suggests aortic dissection) |
| Fever/systemic signs | Absent | Present with pneumonia, pleuritis |
Red flags that should redirect a chest pain evaluation away from a musculoskeletal diagnosis include: pain that is not reproducible with palpation or thoracic movement; exertional pain relieved by rest; pain radiating to the jaw, neck, or arm with diaphoresis or nausea; sudden, severe, tearing pain (possible aortic dissection); and pleuritic pain accompanied by fever, productive cough, or hemoptysis (possible pneumonia or pulmonary embolism). Any of these patterns warrants urgent medical referral rather than manual therapy.
Putting It Together: Thorax and Lung Red Flags
| Finding | Suspected Process |
|---|---|
| Dull percussion + decreased fremitus + absent breath sounds | Pleural effusion |
| Dull percussion + increased fremitus + crackles + bronchial breath sounds peripherally | Pneumonia/consolidation |
| Hyperresonance + decreased breath sounds + tracheal deviation | Pneumothorax (emergency) |
| Exertional chest pain relieved by rest | Angina -- refer for cardiac evaluation |
| Chest pain not reproduced by palpation, with dyspnea and diaphoresis | Cardiac or pulmonary emergency |
Exam Tips
- Learn the percussion table (resonant/hyperresonant/dull/flat) as paired facts with their causes -- these are frequently tested directly.
- The single most useful discriminator between musculoskeletal and visceral chest pain is reproducibility on palpation: reproducible pain favors a chest wall source.
- Never assume chest pain is musculoskeletal simply because the patient also has a known spinal condition -- rule out visceral causes first.
A patient has decreased breath sounds, dull percussion, and decreased tactile fremitus over the right lower lung field. Which condition best explains this combination of findings?
Which combination of findings is most consistent with a tension pneumothorax?
A patient's chest pain is fully reproduced by palpating the costosternal joints and is unrelated to exertion. This finding most strongly supports which diagnosis?
A patient reports chest tightness that occurs during exertion and resolves within minutes of rest, without reproduction of pain on palpation. What is the most appropriate next step?