A printer friendly checklist can be found here.

Examination of any system should start with inspection. The patient should be sitting comfortably at 45° with adequate exposure of the praecordium. The room should be quiet and warm. Stand on the patient’s right hand side and, when palpating, use your right hand.

1.             INTRODUCTION

2.             INSPECTION
A.            Look for signs of breathlessness, discomfort or pain. Use of accessory muscles.
B.            Examine face, eyes and mouth for colour and central cyanosis.
C.            Look at chest shape, movement, scars and deformities.
D.             Examine hands to assess circulation for warmth and venodilation. Look for evidence of tar staining and finger clubbing. Look for flapping tremor.

3.             PALPATION
A.            Palpate radial pulse and assess rate and rhythm.
B.             Count respiratory rate.

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 INSPECTION

It is best to have the patient sitting on the bed at 45° or upright.  Observe patient generally for evidence of pain or discomfort or breathlessness.

Listen for audible inspiratory stridor (upper airway obstruction) and expiratory wheeze (asthma). As patient talks, listen for hoarseness (laryngitis, lung cancer ® laryngeal nerve palsy or laryngeal cancer) and pattern of speech e.g. interrupts speech flow to take a breath.

Observe the chest for scars, (e.g. thoracotomy scar or chest drain scars in second intercostal space mid-clavicular line or in 4th, 5th or 6th intercostal spaces axilla (possibly indicate pneumothorax, pleural effusion).
Observe chest for shape, including asymmetry, any deformity, (e.g. kyphoscoliosis) and also if increased anterior-posterior (AP) diameter (barrel shaped) as evidence of hyperinflated chest and air trapping. In air flow obstruction (e.g. COPD) there may be a large AP diameter with little lateral expansion. Prominent chest wall veins would suggest SVC obstruction.

Observe pattern of breathing, nasal flaring, use of accessory muscles of respiration, intercostal recession or indrawing (also watch abdominal muscles) and posture. Patients with respiratory distress related to airflow obstruction fix their rib cage and shoulder girdle by supporting themselves on straight arms and grasping the sides of their bed.
Ask patient to take a deep breath in through his mouth and then out. Observe for symmetry of chest movement.

Observe for spontaneous coughing. Ask patient to cough and listen to sound (dry or productive?)
Observe contents of any sputum pot, volume of sputum, smell, colour: - yellow/green, flecks of blood, (haemoptysis)

Observe face for colour. Consider if he looks polycythaemic, secondary to chronic lung disease (may have a high colour, red (or “ruddy”) complexion due to overproduction of red blood cells.)
Observe for neurological signs – look in the eyes for Horner’s syndrome (pinpoint pupil and ptosis) – destruction of the sympathetic trunk secondary to apical lung cancer (Pancoast tumour).
Observe mouth. Patients with emphysema may purse their lips on expiration to delay collapse of intrathoracic airways. Look under tongue for central cyanosis.

ASSESSMENT OF HANDS - inspection and palpation

Feel hands to assess circulation, warmth, filling of veins (venodilation). Palpate the nail bed and assess for finger clubbing - one of the signs of hypoxic pulmonary osteoarthropathy (HPOA), along with joint pain.   Commoner respiratory causes of HPOA include lung cancer, bronchiectasis (late stages), pulmonary fibrosis, empyema, cystic fibrosis, mesothelioma.

Look at hands for cyanotic discolouration of the fingers and evidence of long term smoking e.g. tar staining.
Look for flapping tremor. (CO2 retention). Ask patient to hold hands outstretched with wrists fully extended backwards and fingers spread out. Severe carbon dioxide retention can cause warm hands, a bounding pulse and a coarse irregular flapping tremor at the wrist (the movement is course and jerky).  Be sure not to confuse this with a more twitchy tremor that can be caused by liver disease.

Palpate radial pulse and assess rate and rhythm. Assess for a high bounding pulse.
A tachycardia greater than 110 /min in the context of asthma suggests a severe attack.
Count the respiratory rate (observe abdomen or chest, while holding wrist, to avoid alerting patient to your counting, which otherwise might cause him to alter his breathing.)  Opinions differ as to what is a normal breathing rate – anything from 16-25 breaths per minute may be considered normal.
Look for  Cheyne-Stokes respiration  - where tidal volume increases and decreases, interspersed with periods of apnoea (seen in patients with congestive heart failure and those with brain damage).

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4.             NECK
A.            Check position of trachea.
B.            Assess for subcutaneous emphysema if appropriate.
C.            Examine for cervical lymphadenopathy.
D.            Assess right internal jugular vein for raised JVP.
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NECK

Check position of trachea. It should be central. Place right middle finger 2 cm superior to the suprasternal notch and gently push downwards and backwards and you will feel the resistance of the trachea. Warn patient first that this may cause discomfort. Palpate the space to either side to assess if tracheal is central.
Tracheal deviation and displaced apex beat are important signs (fibrosis, (absorption) collapse of lung, pneumonectomy pull trachea towards side of pathology and pneumothorax and pleural effusion push trachea away.)

If history of injury or possible pneumothorax, assess for subcutaneous or “surgical” emphysema. This is a crackling sensation felt on palpating the skin of the neck and chest. The crackling is caused by air under the skin leaking from a pneumothorax or (rarely) a ruptured oesophagus). The neck may also be swollen.

From behind the patient examine the submental, submandibular, and tonsillar lymph nodes and the deep cervical chain of nodes in the anterior triangles of the neck.  Examine for scalene node with index or middle finger dipping behind the clavicle. Have sternocleidomastoid relaxed by asking patient to flex head towards side of examination.  Enlarged nodes feel firm and rubbery.

Assess JVP. (See notes in cardiovascular examination.)  A raised jugular venous pressure may indicate right heart failure secondary to chronic lung disease or pulmonary embolism.

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5.             PALPATION OF CHEST
A.            Locate the apex beat.
B.            Assess chest expansion anteriorly and posteriorly.
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PALPATION OF CHEST

Locate and describe the apex beat. You may not be able to feel the apex beat in patients with a hyperinflated chest. Displacement may provide evidence of mediastinal shift.

If history of injury look for seat belt abrasions, flail chest and palpate chest wall gently for tenderness and crepitus (a grinding sensation) over broken ribs.

Assess chest expansion anteriorly and posteriorly by asking the patient to take a deep breath.
Place hands on chest wall with fingers gripping lower ribcage. Bring your thumbs together to meet in the mid-line, but do not let your thumbs rest on the chest wall. Ask patient to take a big breath in and your thumbs should move apart equally.  Repeat on the back.

___________________________________________________________________________6.             PERCUSSION OF CHEST
A.            Percuss front of chest, laterally and posteriorly.
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PERCUSSION

The percussing finger is the middle finger of your right hand. Movement is at the right wrist joint and volume is increased by pushing harder on the chest with the percussed middle finger of your left hand (aim for the middle phalanx).percuss

 

Percuss the clavicles without your left hand - i.e. use the clavicle as the sounding board for the apices.

Anterior  72

Posterior72

 

 

 


Go back and forth from right to left chest comparing the percussion notes between the two sides (including the clavicles and axillae.) Percussion should be performed over intercostal spaces, moving down the chest at intervals of 3-4 cm comparing both sides. Remember to percuss laterally. Do not percuss over the scapula.
Percuss down to the 6th rib anteriorly, the 8th rib in the axilla and the 10th rib posteriorly.

 

Percussion note examples

Normal lung

Resonant

Pneumothorax

Hyper resonant

Collapse or consolidation

Dull

Pleural effusion

Abdomen

“Stony” or very dull

Tympanic

Percussion is resonant over aerated lung and dull over solid organs such as the liver and heart (except in overinflated lungs where there is aerated lung between the heart and chest wall). Increased percussion resonance occurs in emphysema, large bullae, or pneumothorax.

The percussion note is described as stony dull over a pleural effusion, and dull over areas of consolidation, collapse, pleural thickening, or fibrosis. Dullness at the base may be due to a raised diaphragm.

Tactile vocal fremitus is most useful over areas found to be abnormal (both dull and very dull) on percussion. Use your palm or the ulnar border of your right hand. It is conventional in this country to ask the patient to say ninety nine (99). Areas found to be dull to percussion show: -
increased tactile fremitus, suggesting consolidation or fibrosis, or
reduced tactile fremitus, suggesting fluid or collapse.

If an area of dullness is found on percussion you may also wish to test to see if vocal resonance (see below, as it is usually done after initial auscultation, again patient says 99) is:- increased over solid areas for example, consolidation or fibrosis and decreased by fluid or collapse.  Compare the voice sound over the dull area to that over normal chest.

Note that vocal fremitus and vocal resonance test the same thing and it is not necessary to test both.

Also please note that some doctors prefer to complete palpation, percussion and auscultation first anteriorly, then move to the back to repeat the sequence of palpation, percussion and auscultation on the back.

Other doctors prefer to palpate anteriorly and posteriorly, then move onto percussion anteriorly and posteriorly and finally auscultate anteriorly and posteriorly.  The choice may also depend on the fitness of your patient and his ability to move backwards and forwards.

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7.             AUSCULTATION OF CHEST

A.             Auscultate front of chest.
B.            If areas of dullness on percussion test for vocal resonance or vocal fremitus.
C.            Sit patient forwards. Percuss (if not already done) and auscultate posterior chest
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Auscultation

Ask patient to breathe with mouth open and deeply (to increase tidal volume.)
Use either the bell or diaphragm. The frequency of breath sounds and added sounds is such that either can be used. If the patient’s chest is particularly hairy, the bell is preferable as it will reduce extraneous scratching sound from hair movement. Also it is preferable to use the bell in the apices to allow good contact.

Auscultate apices in supraclavicular areas with bell.
Auscultate over the front of the chest, axilla and posteriorly with diaphragm or bell.
Once again you are comparing side to side. Make sure that you auscultate over all of the lobes of the lungs.

As you auscultate ask yourself: -

  • Are breath sounds present?
  • Are breath sounds equal on both sides?
  • Are there any added sounds such as crackles, wheezes or pleural rubs?
  • Is there any bronchial breathing?

If an area of dullness has been found on percussion compare vocal resonance on both sides (see above). 

Inspiration is normally longer than expiration (I > E). Breath sounds are produced by turbulent air flow within the smaller and larger airways. They are categorised by the size of the airways that transmit the sounds to the chest wall and your stethoscope. The general rule is, the larger the airway, the louder and higher pitched the sound.

Vesicular (normal) breath sounds, produced by small airways and alveoli, are low pitched quiet and normally heard over most lung fields. The inspiratory component predominates and there is a gap between expiration and inspiration.
Bronchial sounds may be heard in certain pathologies such as when small airways or alveoli have been damaged.  They are noises from the larger airways and are harsher. In bronchial breathing the sounds gradually increase through inspiration, but stop near the end of inspiration (when air would normally be flowing round the alveoli.)  The expiratory component then dominates. Occurs in consolidation, collapse or fibrosis.

Breath sounds are decreased when normal lung is displaced by air (emphysema or pneumothorax) or fluid (pleural effusion). Breath sounds shift from vesicular to bronchial when there is fluid in the lung itself (e.g. pneumonia).

Extra lung sounds

Crackles

These are high pitched, discontinuous sounds similar to the sound produced by rubbing your hair between your fingers. (Used to be known as rales).  Can be classed as fine, medium or coarse.

Wheezes

These are generally high pitched and "musical" in quality. Due to small airway narrowing.

Friction or pleural rub

Sounds like creaking leather. Due to pleural inflammation.

 

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8.             OTHER AREAS
A.             Feel for ankle oedema.
B.            Look in sputum pot if available.
C.            Examine any observation charts available.  Pulse, BP, Temperature.
D.            Measure peak flow.

9.             CONCLUSION
A.            Thank patient and wash hands with alcohol gel or water.
B.            Summarise and present findings in patient’s notes and orally.
 
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