Clinical Skills Course, PRO365 Checklist

Respiratory System Examination

Introduction:
1. Greets the patient.
2. Introduces yourself.
3. Washes your hands, dry them and warm them.
4. Explains the procedure to the patient.
5. Takes permission and exposes the examined area.
6. Stands on the right side or at the toes of the patient except for general examination.

General Inspection (From foot end)

General appearance of patient, signs of respiratory distress including accessary muscle use,
Oxygen, lines, equipment

Examine hands for clubbing, Cyanosis, palmar erythema, wasting of small muscle of hands,
Nicotine staining, Joint deformity, Tremors – fine and flapping tremors.
Check radial pulse for rate rhythm and volume.
Examine face and neck for facial appearance, eyes, nose, central cyanosis – tongue lift
Examine for JVP – if raised measure and palpate cervical lymph node examination

Anterior Chest Examination Checklist

Inspection of chest:
1. Respiratory rate
2. Shape
3. Symmetry
4. Movement
5. Scar
6. Any Skin changes.

Palpation:
1. Palpate uniformly for any area of tenderness, or any visible abnormality like
masses.
2. Assess Tracheal Deviation: Place the right index finger and ring finger on the right
and left sternoclavicular joint respectively. Now using the middle finger try to feel
the gap/space between the sternocleidomastoid and the trachea. The space
should be symmetrical on both sides.
3. Chest Expansion: On the lower chest, place both thumbs at proximity to one
another at the midline, in a manner to create a skin fold between them. Then ask
the patient to take a deep breath while you observe for chest expansion.
4. Tactile Fremitus: By the ulnar surface of your hand feel the palpable vibrations of
the chest as you ask the patient to say “Ninety Nine” or “One-One-One.”

Reference: Lynn Bickley. Bate’s Guides to Physical Examination and History Taking 11 th edition
Prepared by CSC Team
 Clinical Skills Course, PRO365 Checklist
5. Point of Maximal Impulse (PMI): Find the apical impulse or the Point of Maximal
Impulse (PMI) at the 5th (or 4th) intercostal space around the midclavicular line.
6. Check for parasternal heave by placing palm of hand over upper sternum

Percussion:
 Hyperextend the middle finger of your left hand, known as the pleximeter finger.
Press its distal interphalyngeal joint firmly on the surfaced to be percussed. Avoid
surface contact by any other part of the hand, because this dampens out vibrations.
Note that the thumb and 2nd, 4th, and 5th fingers are not touching the chest.
 Percuss the lung fields in a uniform ladder-like order, starting from apices. Percuss
one side of the chest and then the other side at the same level. Always compare the
respective points on each side. Also percuss the lateral aspect of the chest.
 Percuss the right lung until the upper border of the liver is percussed. Appreciate the
percussion notes as resonant throughout the lung fields and dull on the liver.

Auscultation
Before auscultating the chest of patient, his upper garments are removed and he is made to
lie down on the bed in supine position.
Technique
1. Listen to the breath sounds with the diaphragm of a stethoscope after instructing the
patient to breathe deeply through an open mouth.
2. If there are hairs on chest and in thin persons due to lack of full skin contact, extra
sounds, indistinguishable from crackles or pleural rub, may be heard, bell of stethoscope
is preferred than diaphragm.
3. Chest piece of the stethoscope is put on the chest wall in a way that it is in full contact
with the skin but at the same time no extra pressure is applied over it. Care should also
be taken that chest piece should not move on the skin.
4. To start with, chest is auscultated anteriorly and then posteriorly.

Method:
1. Avoid auscultation within 2-3 cm from midline.
2. Auscultate the two sides alternately on symmetrical points.
3. Auscultate anteriorly from above the clavicles down to the sixth rib.
4. Laterally from axilla to the 8th rib.
5. If necessary repeat the auscultation after cough.
6. While auscultating, ask the patient to take deep breath with his mouth open.
7. Breathing should not be noisy.
8. Avoid prolonged deep breathing.

Reference: Lynn Bickley. Bate’s Guides to Physical Examination and History Taking 11 th edition
Prepared by CSC Team
 Clinical Skills Course, PRO365 Checklist
Objectives of auscultation – four observations must be made at each point of auscultation.
These are:
1. Intensity of breath sounds.
2. Character of breath sounds.
3. Added sounds.
4. Vocal resonances.
a. Intensity of breath sounds – intensity of breath sounds should be compared on
both sides of chest.
b. Character of breath sounds – Based on their intensity, pitch and the relative
duration of their Inspiratory or expiratory phases, there are three types of breath
sounds (Lung sounds).
i. Vesicular breathing.
ii. Bronchovesicular
iii. Bronchial breathing.

Posterior Chest Examination

Inspection:
7. Shape - deformities
8. Symmetry
9. Movement
10. Scar
11. Any Skin changes

Palpation:
1. Ask the patient to cross his arms with his hands on the opposite shoulders.

2. Palpate uniformly for any area of tenderness, or any visible abnormality like
masses.

3. Chest Expansion: On the lower posterior chest, at the position of 10th rib, place
both thumbs at proximity to one another at the midline, in a manner to create a
skin fold between them. Then ask the patient to take a deep breath while you
observe for chest expansion

4. Tactile Fremitus: By the ulnar surface of your hand feel the palpable vibrations of
the chest as you ask the patient to say “Ninety Nine” or “One-One-One”. Always
compare with other side and check for areas with increased, decreased or absent
fremitus.
Percussion:
1. Hyperextend the middle finger of your left hand, known as the pleximeter finger.
Press its distal interphalyngeal joint firmly on the surfaced to be percussed. Avoid
Reference: Lynn Bickley. Bate’s Guides to Physical Examination and History Taking 11 th edition
Prepared by CSC Team
 Clinical Skills Course, PRO365 Checklist
surface contact by any other part of the hand, because this dampens out
vibrations. Note that the thumb and 2nd, 4th, and 5th fingers are not touching
the chest.

2. Percuss the lung fields in a uniform ladder-like order, starting from apices.
Percuss one side of the chest and then the other side at the same level. Always
compare the respective points on each side.

3. Identify the percussion note as Resonant, Hyperesonant, Dull or Flat

4. Diaphragmatic Excursion: Ask the patient to exhale (breath out) and hold breath

a. Percuss on the posterior chest downwards until dullness is noted. Mark

that level with a pen

b. Next ask the patient to take a full breath (inhale), percuss downwards to
the level of dullness and mark it

c. Assess similarly on the other side

d. Measure the distance between dullness on inhalation and exhalation

(Normal 3–5.5 cm)
Posterior Auscultation
Before auscultating the chest of patient, his upper garments are removed and he is made to
sit in an upright position.
Technique
5. Listen to the breath sounds with the diaphragm of a stethoscope after instructing the
patient to breathe deeply through an open mouth.
6. If there are hairs on chest and in thin persons due to lack of full skin contact, extra
sounds, indistinguishable from crackles or pleural rub, may be heard, bell of stethoscope
is preferred than diaphragm.
7. Chest piece of the stethoscope is put on the chest wall in a way that it is in full contact
with the skin but at the same time no extra pressure is applied over it. Care should also
be taken that chest piece should not move on the skin.
8. To start with, chest is auscultated anteriorly and then posteriorly.

Method:
9. To auscultate the back patient is made to sit. However if patient is weak, then roll him
first to one side and then to the other.
10. Avoid auscultation within 2-3 cm from midline.
11. Ask patient to cross their arms.
12. Auscultate posteriorly from the apices down to the level of 11th rib.
13. Auscultate the two sides alternately on symmetrical points.
Reference: Lynn Bickley. Bate’s Guides to Physical Examination and History Taking 11 th edition
Prepared by CSC Team
 Clinical Skills Course, PRO365 Checklist
14. If necessary repeat the auscultation after cough.
15. While auscultating, ask the patient to take deep breath with his mouth open.
16. Breathing should not be noisy.
17. Avoid prolonged deep breathing.

Objectives of auscultation – four observations must be made at each point of auscultation.

These are:
5. Intensity of breath sounds.
6. Character of breath sounds.
7. Added sounds.
8. Vocal resonances.
a. Intensity of breath sounds – intensity of breath sounds should be compared on
both sides of chest.
b. Character of breath sounds – Based on their intensity, pitch and the relative
duration of their Inspiratory or expiratory phases, there are three types of breath
sounds (Lung sounds).
i. Vesicular breathing.
ii. Bronchovesicular
iii. Bronchial breathing.

Check for pedal edema

Thank the patient and cover up

Reference: Lynn Bickley. Bate’s Guides to Physical Examination and History Taking 11 th edition
Prepared by CSC Team