A basic heart and lung examination is a normal component of the physical examination of even a well patient. A focused examination is also an essential part of the diagnosis of any patient who presents with signs or symptoms arising from the cardiovascular or respiratory systems.

Proper examination of the heart or lungs will require inspection and possibly palpation of the chest. As discussed in previous lessons, it is wise to inform a patient of your intentions, and seek their permission before touching them. If you are uncertain of a patient's understanding of your oral explanations, gestures will help you to explain the procedures which you need to perform.

In addition to inspection and palpation, the clinician will auscultate the chest for heart and lung sounds. You will also percuss the chest to locate the boundaries between organs, and to determine the densities of underlying tissues. For example, percussion will be used to determine the size of the heart in a patient with congestive heart disease, or to locate areas of consolidation in the lungs of a patient with pneumonia.

The proper examination therefore necessitates appropriate exposure of the chest, which requires at least partial disrobing of the patient. As discussed previously, this may create difficulty for some patients depending upon their culture, religion and previous experience. You may need to explain the need for disrobing to the patient and seek their understanding. Additionally, it may be necessary to modify your examination if a patient is reluctant to disrobe.

As with other aspects of physical examination, such as the orthopedic examination, you will require the cooperation of the patient. In particular, you may need the patient to modify their breathing to accentuate particular heart or lung sounds. If you demonstrate what you want the patient to do, as you give corresponding verbal cues, you will have little difficulty in your communications.

Situation 1: A doctor is examining a middle-aged woman who seems to be experiencing episodes of orthostatic hypotension. She is wearing an examination gown and is seated on an examination table.

Doctor: Alright Mrs. Brown, I would like to listen to your heart. Can you just open the top of your gown so that I can listen here. (The doctor gestures to indicate the upper chest.)

Mrs. Brown: (opening her gown to expose her upper chest.) Is that okay?

Doctor: That's fine. Just breathe normally. (The doctor auscultates the aortic and pulmonic areas.) Now, I will get you to lean forward a little bit and take a deep breath. (The doctor repeats the auscultation.) Good.

Mrs. Brown: Is everything okay?

Doctor: Yes, you seem fine. Now, can I get you to hold up the bottom of your gown a little bit so I can listen here. (The doctor gestures to indicate his lower chest.)

Mrs. Brown: (Raising her gown a little.) Will that do?

Doctor: Just a bit more. That's good. (The doctor auscultates the tricuspid and mitral areas.) And now, I want you to lie on your left side while I listen again.

Mrs. Brown: Is anything wrong?

Doctor: There are no murmurs. Everything seems normal.

Mrs. Brown: That's a relief, but why have I been feeling dizzy?

Doctor: We will perform an ECG right now to be sure, but I doubt that there is anything serious wrong with your heart.

Mrs. Brown: Then what is making me feel dizzy?

Doctor: There is no major problem. This sort of thing is often caused by lifestyle, for example, not enough sleep or too much stress.

Patterns:

* I would like to
... listen to your heart

* Can you just
... open the top of your gown

* Can I get you to
... hold up the bottom of your gown a little

* I will get you to
... lean forward a little bit

* I want you to
... lie on your left side

* Is that okay
* Is everything okay
* Is anything wrong

* You seem fine
* Everything seems normal
* I doubt that there is anything serious wrong
* There is no major problem

* Why have I been feeling dizzy
* What is making me feel dizzy

* This sort of thing is often caused by
... lifestyle
... not enough sleep
... too much stress

Situation 2: A nurse is examining the chest of an elderly man with a chronic cough. The nurse is seated behind the man, who has removed his shirt.

Nurse: Mr. Wilson, I am going to listen to your chest. Just breathe normally for me. (The nurse auscultates the patient's posterior chest wall.) That's good.

Mr. Wilson: (Joking) Boy, that thing is cold! (Referring to stethoscope)

Nurse: Sorry, we'll be finished in just a minute. Now, I want to listen to your chest again. This time, take a deep breath for me - in and out. Again - in and out. That's fine. (The nurse auscultates the left and right lungs.) You sound quite congested on the left side.

Mr. Wilson: Yes, that feels really congested. When I cough, it's as if I can't clear my chest on the left side.

Nurse: Okay, Mr. Wilson. I need to listen to your chest again. This time, I want you to repeat the number "99" as I am listening. "99, 99 ..." (The nurse coaches Mr. Wilson.) That's the way.

Mr. Wilson: 99, 99 ... I'm getting out of breath.

Nurse: Almost finished. Okay, you can relax and breathe normally. Now, I am just going to tap the back of your chest lightly. This shouldn't hurt at all, but you can tell me if it is uncomfortable. (The nurse begins to percuss the posterior chest wall.)

Mr. Wilson: That's a little tender. (As nurse percusses left lung fields)

Nurse: Yes, you probably strained the muscles with your coughing. Okay, we're all done. You can put your shirt back on now if you like.

Mr. Wilson: So, what's the verdict?

Nurse: There's a congested area on the left. The doctor has already ordered an X-ray for you. So, we'll do that next.

Mr. Wilson: But what do you think it is?

Nurse: Don't worry. In a few minutes we'll have the X-rays. Then we'll know exactly what is going on.

Patterns:

* I am going to ... listen to your chest
* I want to ... listen to your chest
* I need to ... listen to your chest

* Just breathe normally for me
* Just relax and breathe normally
* Take a deep breath for me

* That's good
* That's fine
* That's the way

* We'll be finished in just a minute
* Almost finished
* We're all done

* You sound quite congested
* That feels really congested
* There is a congested area on the left

* What's the verdict
* What do you think it is

Discussion:

1. In situation 1, why does the doctor use gestures to show where he wants to auscultate? Does it seem as if the patient doesn't understand his spoken instructions?

2. In situation 1, the doctor seems to discount any serious disease even before he has finished his examination. Why do you think he does this?

3. What are the four classical steps in physical examination of the chest?

4. In situation 2, the nurse does not seem willing to offer the patient a diagnosis. Why do you think she is hesitating?

5. What are some common causes of chronic cough in adults?