Unlike the cardiac and neurological systems, physical exam of the pulmonary system is crude. In cardiology one can precisely say which chamber is enlarged, what type of work it is doing, the status of valves, etc. Similarly in neurological exam, precise localization of lesion is possible. Unfortunately, physical exam is not precise in pulmonary exam.
In general, physical exam, is good for acute and subacute illness. It is poor for chronic illness. If there is normal lung surrounding a large cavity it will be completely missed on exam. Mediastinal masses are rarely picked up by physical exam.
Many modern day physicians in advanced countries have abandoned physical exam and totally rely on chest x-ray and CT scan. As a result, most of them have not been taught or have not developed the necessary physical exam skills.
It should be recognized that with certain diseases e.g., asthma, COPD, pulmonary vascular disease and DIF, chest x-ray can be completely normal. These diseases can be recognized only by physical exam. However, it is difficult to think of making a competent pulmonary consultation without a chest x-ray. They should be thought of as complimentary information.
Since it is not anticipated that one should accurately detect all of the abnormalities on exam, we should learn to accept not detecting lesions. We should also learn to be honest in our elicitation of findings. Prejudice can influence the results easily. If one pays close attention to history, one can anticipate findings in the chest. Clinical exam is more like detective work. Information gathered during general exam will help you anticipate problems. Then focused or prejudiced exam can be done to elicit an abnormality.
I divide pulmonary exam into screening and focused or prejudiced exam. Screening exam should be done in all cases. Focused physical exam is conducted in selected cases after history and screening exam have identified certain problems. This can be reviewed under the lesson entitled "Problem Specific Exam".