NB: signs are on side of lesion unless otherwise stated.

Pulmonary fibrosis

• Oxygen therapy
• Dry cough
• Tachypnoea
• Reduced expansion
• Fine end-inspiratory crepitations

Signs of aetiology: hand deformity (RA), clubbing (idiopathic pulmonary fibrosis), sclerodactyly/telangiectasia/microstomia (systemic sclerosis), butterfly rash (SLE), lupus pernio (sarcoid), radiation burns, kyphosis (ankylosing spondylitis)

Signs of complications: cushingoid/bruising (steroid use), loud P2/RV heave (pulmonary hypertension)

COPD

• Bedside inhalers/nebulisers
• Accessory muscle use
• Tar-stained fingers
• Tachypnoea
• Lip pursing
• Reduced cricosternal distance (<3 fingers)
• Tracheal tug
• Indrawing of lower intercostal muscles on inspiration
• Hyper-resonance (with obliterated cardiac and hepatic dullness)
• Quiet breath sounds/wheeze/prolonged expiratory phase

Signs of complications: cushingoid/bruising (steroid use), loud P2/RV heave (pulmonary hypertension)

Pneumonectomy

• Unilateral chest flattening
• Thoracotomy scar
• Tracheal deviation (towards)
• Reduced expansion
• Dull percussion note
• Reduced breath sounds
• Bronchial breathing in upper zone (due to deviated trachea)

Signs of aetiology: cachexia/clubbed/tar-stained fingers (lung cancer)

Lobectomy

• Thoracotomy scar
• May be no other signs due to compensatory hyperexpansion of the remaining lobes
• May be some reduced expansion, dullness to percussion and reduced air entry

Signs of aetiology: cachexia/clubbed/tar-stained fingers (lung cancer), wet cough/clubbed/coarse crepitations (bronchiectasis), signs of COPD (bullectomy)

Pleural effusion

• Reduced expansion
• Stony dull percussion note
• Reduced breath sounds
• Reduced tactile fremitus and vocal resonance

Signs of aetiology: hand deformity (RA), clubbing/radiation marks (mesothelioma/lung malignancy), butterfly rash (SLE), lymphadenopathy (malignancy), signs of chronic liver disease (cirrhosis), pulmonary/peripheral oedema(heart failure)

Bronchiectasis

• Productive cough
• Inspiratory clicks
• Clubbing
• Coarse, late expiratory crepitations

Signs of aetiology: young and thin (CF), curved yellow nails and lymphoedema (yellow nail syndrome), lymphadenopathy (malignancy), dextrocardia(Kartagener’s syndrome)

Kyphoscoliosis

• Increased thoracic forward curvature or lateral curvature of the spine
• Reduced spine flexion/extension
• Rib hump
• Reduced chest expansion

Lung cancer

• Cachexia
• Clubbing
• Tar-stained fingers
• Hard irregular lymphadenopathy
• Radiation burns

Signs of complications: pain and swelling of wrists (hypertrophic pulmonary arthropathy), ptosis/meiosis/anhidrosis (Horner’s syndrome)

Lung transplant

• Mid-sternotomy/bilateral thoracotomy scar

Signs of aetiology: signs of COPD, clubbing (CF/idiopathic pulmonary fibrosis)

Signs of complications: cushingoid/bruising (steroid use)

Try some questions to test your knowledge

Now try some OSCE stations

1. Pneumonectomy exam
2. Pulmonary fibrosis
3. Pleural effusion
4. There’s lots more!