• Clinical science

Pulmonary examination


The examination of the pulmonary system is a fundamental part of the physical examination that consists of inspection, palpation, percussion, and auscultation (in that order). Recognition of surface landmarks and their relationship to underlying structures is essential. The physical examination of the pulmonary system begins with the patient seated comfortably on the examination table and his/her upper body completely exposed. The chest and the patient's breathing pattern are then inspected, followed by palpation of the chest wall, percussion of the thorax, and auscultation of the lung fields. A carefully recorded medical history and thorough physical examination allow for differential diagnosis and prompt initiation of therapy.

See also differential diagnoses of dyspnea.


The following should be assessed:

  1. Breathing pattern
  2. Increased effort of breathing
  3. Peripheral signs of respiratory dysfunction
  4. Abnormalities in the shape of the thorax
  5. Sputum production or secretions, if any
    • White and translucent: viral infection (for example, bronchitis that presents with a typical early-morning cough)
    • White and foamy: pulmonary edema
    • Yellow-green: bacterial infection
    • Green: an indication of a pseudomonal infection
    • Grayish: pneumoconiosis, a waning bacterial infection
    • Blackish-brown: possibly old blood; should be further investigated (can also be a harmless incidental finding)
    • Friable: tuberculosis, actinomycosis
    • Hemoptysis: see section below
  6. In newborn and infants
    • Jugular, sternal, and intercostal retraction
    • Nasal flaring or flaring of the nostrils
    • Neck extension



A chest x-ray, to determine the underlying pathology, is mandatory in all patients with hemoptysis. Patients with massive hemoptysis require stabilization before imaging!


  • Evaluate areas of tenderness or bruising
  • Symmetry of chest expansion
    • Place both hands on the patient's back at the level of the 10th ribs with thumbs pointing medially and parallel to the rib cage.
    • As the patient inhales, evaluate for asymmetric movement of your thumbs.
  • Tactile fremitus
    • Ask the patient to say “toy boat” and feel for vibrations transmitted throughout the chest wall.
    • Can be asymmetrically decreased in effusion, obstruction, or pneumothorax, among others
    • Can be asymmetrically increased in pneumonia





Physiological breath sounds

Pathological breath sounds


Overview of pulmonary examination findings

Main symptom Palpation Percussion Auscultation
Movement of the chest wall Tactile fremitus Bronchophony Breath sounds




Resonant Normal Vesicular
Pleural effusion Dyspnea may be present Asymmetric Decreased Dull Decreased Decreased
Pulmonary edema

Severe dyspnea

Symmetric Possibly increased Dull May be present Fine or coarse crackles, depending on severity
Pneumothorax Acute dyspnea Asymmetric Decreased or absent Hyper-resonant Absent or decreased

Decreased or absent breath sounds

Bronchial asthma1 Paroxysmal attacks of dyspnea, wheezing Symmetric Depends on the severity of the disease Hyper-resonant Depends on the severity of the disease

Wheeze, a prolonged expiratory phase, possibly decreased breath sounds

COPD1 Chronic cough


Possibly hyper-resonant

Wheeze, a prolonged expiratory phase when the disease is obstructive, decreased breath sounds in emphysema
Pneumonia2 Fever, dyspnea Asymmetric Increased Dull Increased

Coarse crackles


Chronic dyspnea

Symmetric but decreased Decreased Hyper-resonant



Lung fibrosis Cachexia and weakness, dyspnea Symmetric Normal, partially increased


Normal, partially increased Basal inspiratory crackles
Atelectasis Pain may be present Asymmetric Decreased Dull Decreased Decreased
Pulmonary embolism1

Acute dyspnea, pleuritic chest pain, tachypnea


Normal Normal Normal Normal

Hemoptysis, constitutional symptoms (weight loss, fever, night sweats)

Possibly asymmetric

Possibly decreased Possibly dull Possibly decreased Possibly decreased

The following conditions frequently complicate the aforementioned pulmonary disease: 1pneumonia, 2pleural effusion, 3atelectasis.

See also dyspnea.


  • 1. Walker HK, Hall WD, Hurst WJ, Silverman ME, Morrison G. Clinical Methods: The History, Physical, and Laboratory Examinations. Boston, MA: Butterworths; 1990.
  • 2. Bickley L. Bates' Guide to Physical Examination and History-Taking. Lippincott Williams & Wilkins; 2012.
  • 3. Sarkar M, Mahesh D, Madabhavi I. Digital clubbing. Lung India. 2012; 29(4): p. 354. doi: 10.4103/0970-2113.102824.
  • 4. Amirana M, Frater R, Tirschwell P, Janis M, Bloomberg A, State D. An aggressive surgical approach to significant hemoptysis in patients with pulmonary tuberculosis. Am Rev Respir Dis. 1968; 97(2): pp. 187–92. doi: 10.1164/arrd.1968.97.2.187.
  • 5. Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung auscultation. N Engl J Med. 2014; 370(8): pp. 744–751. doi: 10.1056/NEJMra1302901.
  • Herold G. Internal Medicine. Cologne, Germany: Herold G; 2014.
last updated 01/28/2020
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