Introduction

Wash hands
Introduce yourself
Confirm patient details name / DOB
Explain the examination
Gain consent
Expose the patients chest
Position patient at 45
Ask if the patient has any pain

General inspection

Treatments or adjuncts around bed O2 / inhalers /nebulisers /sputum

pots
Does patient look SOB? nasal flaring / pursed lips / use of accessory
muscles
Able to speak in full sentences?
Scars mid axillary (e.g. chest drains) / posterior chest (e.g. lobectomy)
Cyanosis bluish/purple discolouration (<85% oxygen saturation)
Chest wall note any abnormalities or asymmetry e.g. barrel chest
(COPD)
Cachexia very thin patient with muscle wasting malignancy
Cough productive or dry?
Wheeze asthma / COPD / allergy related
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General inspection
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Hands

Temperature temp peripheral vasoconstriction / poor perfusion

Tar staining smoker increased risk of COPD / lung cancer
Peripheral cyanosis bluish discolouration of nails O2 saturations
<85%
Clubbing lung cancer / interstitial lung disease / bronchiectasis
Respiratory rate normal adult range = 12-20 breaths per minute
Pulse rate & rhythm
Pulsus paradoxus pulse wave volume decreases with inspiration
asthma / COPD
Fine tremor can be a side effect of beta 2 agonist use (e.g. salbutamol)
Flapping tremor CO2 retention type 2 respiratory failure e.g. COPD
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Peripheral cyanosis

Inspect palms

Finger clubbing

Assess pulse & respiratory rate

Inspect for fine tremor

Inspect for flapping tremor

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Head & Neck

Conjunctival pallor ask patient to lower an eyelid to allow inspection
anaemia
Horners syndrome ptosis / constricted pupil (miosis) /anhidrosis on
affected side / enophthalmos
Central cyanosis bluish discolouration of the lips / inferior aspect of
tongue
Jugular Venous Pressure a raised JVP may indicate pulmonary
hypertension / fluid overload

Ensure the patient is positioned at 45

Ask patient to turn their head away from you
Observe the neck for the JVP located inline with the sternocleidomastoid
Measure the JVP number of cm from sternal angle to the upper border of
pulsation

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Inspect for central cyanosis

Inspect conjunctiva

Observe for a raised JVP

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Close inspection of thorax

Scars mid axillary (e.g. chest drains) / posterior chest (e.g. lobectomy)
Skin changes may indicate recent or previous radiotherapy erythema /
thickened skin
Asymmetry major surgery e.g. pneumonectomy / thoracoplasty
Deformities barrel chest (COPD) / pectus excavatum & carinatum
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Inspect chest wall

Inspect for scars

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Palpation

Tracheal position:

Ensure patients neck musculature is relaxed chin slightly downwards

Dip index finger into the thorax beside the trachea
Then gently apply side pressure to locate the trachea
Compare this space to the other side of trachea using the same process
A difference in the amount of space between the sides suggests deviation
Palpation of the trachea can be uncomfortable, so ensure to warn the
patient and have a gentle technique

Cricosternal distance:

Measure the distance between the suprasternal notch & cricoid cartilage
using your fingers
In normal healthy individuals the distance should be 3-4 fingers
If the distance is <3 fingers, this suggests lung hyperinflation
Keep in mind that this distance is actually based on the patients fingers
So if their fingers are significantly different in size from your own, it may be
worth checking with theirs

Apex beat:

Normal position is 5th intercostal space

Mid-clavicular line

Chest expansion:

Place your hands on the patients chest, inferior to the nipples

Wrap your fingers around either side of the chest
Bring your thumbs together in the midline, so that they touch
Ask patient to take a deep breath

Observe movement of your thumbs, they should move apart equally

If one of your thumbs moves less, this suggests reduced expansion on that
side
Reduced expansion can be caused by lung collapse / pneumonia

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Assess tracheal position

Assess crico-sternal distance

Palpate apex beat

Assess chest expansion

Assess chest expansion

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Percussion

Technique is very important!

1. Place your non-dominant hand on the chest wall
2. Your middle finger should overlie the area you want to percuss (between
ribs)
3. With your dominant hands middle finger, strike middle phalanx of your
non-dominant hands middle finger
4. The striking finger should be removed quickly, otherwise you may muffle
resulting percussion note

Percuss the following areas, comparing side to side:

Supraclavicular lung apices

Infraclavicular
Chest wall
Axilla

Types of percussion note

Resonant this is a normal finding
Dullness this suggests increased tissue density consolidation / fluid /
tumour / collapse
Stony dullness this suggests the presence of a pleural effusion
Hyper-resonance the opposite of dullness, suggestive of decreased
tissue density e.g. pneumothorax
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Supraclavicular percussion

Percussion

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Auscultation

Ask patient to take deep breaths in and out through their mouth.
Assess quality Vesicular (normal) / Bronchial (harsh sounding)
consolidation
Assess volume quiet breath sounds suggest reduced air entry
consolidation / collapse / fluid
Added sounds:

Wheeze asthma / COPD

Coarse crackles pneumonia / fluid
Fine crackles pulmonary fibrosis

Vocal resonance:

Ask patient to say 99 repeatedly & auscultate the chest again

Increased volume over an area suggests increased tissue density

consolidation/fluid/tumour

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Auscultate the chest

Assess vocal resonance

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Ask patient to sit forwards

Lymph nodes

Palpate the anterior & posterior triangles, supraclavicular and axillary

nodes.
Lymphadenopathy may indicate infective/malignant pathology TB /
Lung ca
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Palpate lymph nodes

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Assess the posterior chest

Repeat inspection, chest expansion, percussion & auscultation on the
back of the chest.
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Posterior chest expansion

Posterior chest percussion

Posterior auscultation of the chest

Posterior assessment of vocal resonance

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To complete the examination

Thank patient
Wash hands
Summarise findings
Suggest further assessments & investigations

Check oxygen saturations

Provide supplementary oxygen if indicated
Perform peak flow assessment (if asthmatic)
Request a CXR if abnormalities were noted on examination
Take an arterial blood gas if indicated (See ABG analysis)
Perform a full cardiovascular examination if indicated