Introduce yourself, confirm the patient's name and date of birth. Explain the purpose of the examination, and obtain consent. Ask the examiner to act as a chaperone and then proceed to wash hands. Adjust the bed to a 45° angle.
General inspection
Begin the examination by inspecting the patient. The patient should be exposed from the waist up. Offer a blanket to maintain the patient's dignity and inform women that they may keep their undergarments on. Ask the patient to expose their legs as well, as there may be some obvious oedema.
Ask the patient if they are in any pain and are comfortable. Check for any use of accessory breathing muscles, breathing symmetry and lung hyperexpansion as this will give a good indication of the patient's state at rest. An increased work of breathing can be due to several respiratory pathologies ranging from chronic obstructive pulmonary disease (COPD) to tension pneumothorax. Be sure to also assess the age of the patient, and note any paraphernalia around the bedside, looking for clues such as cigarettes, oxygen, inhalers, nebulisers, sputum pots or ventilators.
Carefully note the colour of the patient. They may show signs of bronchitis (cyanosis, blue lips), emphysema ("pink" complexion) or carbon monoxide poisoning (cherry red lips).
If the patient is on oxygen, then check to see how much they are currently on (4-15L), the mode of delivery (nasal cannulae or facemask) and whether or not there is positive pressure ventilation (CPAP or BPAP).
Similarly, if you observe a sputum pot by the bedside, check to see its colour and for signs of blood.
Traditionally, patients with COPD have been described as "pink puffers" or "blue bloaters."
"Pink puffers" tend to have a greater degree of emphysema, where there is destruction of the alveoli and the pulmonary capillary bed. In order to maintain a good partial pressure of oxygen, "pink puffers" hyperventilate and breathe through pursed lips.
"Blue bloaters" on the other hand tend to have a greater degree of bronchitis, and thus they have increased airway obstruction and hypoxia. "Blue bloaters" become dependant on their hypoxia for their respiratory drive. The presenting cyanosis is a result of hypoxaemia.
Hands
Inspection of the hands should be done in an intentional and noticeable way. The hands should be of a symmetrical colour and be symmetrically warm. Exceeding warm or sweaty hands could indicate carbon dioxide retention. Look at the nails carefully for clubbing (convex curvature of the nails), present in pulmonary fibrosis, cystic fibrosis and bronchiectasis. In rarer cases, it could be an ominous sign of lung cancer or mesothelioma.
Ask the patient to hold their hands outstretched and assess for a fine tremor, which can occur with the use of a beta-2 agonist (e.g. salbutamol). Next, ask them to cock their hands back at the wrist joint and hold that position for 30 seconds. This checks for asterixis, where the wrists will begin to flap as a result of increased carbon dioxide retention.
Whilst waiting for a flap, palpate the radial pulse to assess rate and character. A bounding pulse may be present with carbon dioxide retention.
Relax the patient and continue to palpate the pulse as you assess respiratory rate. Compare the inspiratory and expiratory phases; the latter may be extended in COPD.
Clubbing is not a sign of COPD.
When assessing respiratory rate, mention that you are recording their pulse, as otherwise the patient may become conscious of their breathing. Record for 30 seconds and then multiply by 2. When assessing heart rate, just like in the cardiovascular examination, measure for 15 seconds and multiply by 4.
Inspect the face in general for plethora, which can be due to carbon dioxide retention. Inspect the eyes for pallor (anaemia) and look for features of Horner's syndrome (ptosis, miosis, anhydrosis). Central cyanosis can be observed on the lips or the underside of the tongue. Check the mouth and tongue for creamy white plaques which present in oral candiadasis.
Horner's syndrome is a triad of symptoms which present when there is damage to the sympathetic trunk. This is usually due to an apical lung tumour (Pancoast tumour). The sympathetic nervous system is involved in facilitating elevation of the eyelid, pupil dilation and sweating. As a result, in Horner's syndrome there is partial ptosis, (drooping of the eyelid), miosis (pupil constriction) and anhydrosis (reduced sweating) of the forehead.
This is a result of a Candida albicans infection, which usually only occurs when the patient is immunosuppressed. Patients with respiratory disease who use steroid inhalers must ensure that they wash their mouth after use, otherwise, this could lead to local immunosuppression and candidiasis
Assess the carotid pulse. The character of the waveform should be considered. Carbon dioxide retention can be one of the causes of a bounding pulse.
Ask the patient to turn their head to the left and observe their jugular venous pressure (JVP). In normal patients, this should not be greater than 4 cm. This is measured as the distance from the angle of Louis (sternal angle) to the highest visible point where the JVP can be seen. If the JVP cannot be observed, pressure can be applied to the liver to elicit a hepatojugular reflux.
The majority of causes of a raised JVP are cardiac in origin. Pulmonary hypertension however, can lead to cor pulmonale (right heart failure in the context of respiratory disease). Cor pulmonale will in turn result in venous hypertension and this will present with a raised JVP.
Trachea
Gently palpate the trachea on either side in order to ensure that it is central. Tracheal deviation away from the lesion may be a result of a tension pneumothorax or a massive pleural effusion. Local atelectasis (collapse of lung tissue) can cause the trachea to deviate towards the side of collapse.
Palpation of the trachea can be very uncomfortable, and so be sure to let the patient know that this may be the case.
Cricosternal distance
Gently place your fingers between the cricoid cartilage and the suprasternal notch. There should be a distance of approximately 3-4 fingers. If lesser than this, then this is indicative of a hyperexpanded chest. A hyperexpanded chest can suggest asthma, or - especially when accompanied with Hoover's sign (inward movement of the inferior ribs on inspiration) - COPD.
Chest
Inspection
Observe the chest for symmetrical breathing and use of accessory muscles. Inspect for a hyperexpanded chest, chest wall deformities and scars. Chest wall deformities include:
Barrel chest: A large ribcage and and hyperexpanded chest shaped like a "barrel." Most commonly associated with emphysema.
Pectus carinatum (pigeon chest): Protrusion of the sternum and ribs. This is usually idiopathic or associated with rickets.
Pectus excavatum (funnel chest): A caved in appearance of the chest. This is a congenital defect.
Kyphosis: Increased curvature of the thoracic spine.
Scoliosis: Increased sideways curvature of the spine.
Midline sternotomy: Located in the midline of the thorax. Can be due to a previous coronary artery bypass graft, valve replacement or congenital correction.
Pacemaker scar: Located superiorly on the left thorax in the midclavicular line.
Axillary thoracotomy scar: Usually located at the 5th intercostal space in the anterior axillary line. Commonly due to a previous chest drain.
Posterolateral thoracotomy scar: Usually located at the lateral and posterior intercostal space inferior to the tip of the scapula. Commonly due to a lobectomy or pneumonectomy.
Common scars following cardiothoracic surgery.
Palpation
Palpate for the apex beat. This is usually found in the left 4th or 5th intercostal space in the midclavicular line. A tension pneumothorax or pleural effusion can cause a mediastinal shift, which will result in a displaced apex beat.
Measure chest expansion by using both hands to firmly grip the patient's chest over the pectoralis major muscles. Ask the patient to take a deep breath in, and then out again. Focus on the movement of your thumbs; they should both move symmetrically upwards on inspiration, and then downwards on expiration. Repeat this process at a location inferior to the nipple, roughly at the 6th intercostal space to confirm your findings. Asymmetric reduced expansion suggests a pneumothorax or pleural effusion on that side.
Before continuing it is important to know the areas where each lobe can be individually palpated, percussed or auscultated at:
Apex of the lung: At the supraclavicular fossa.
Superior lobe: At the second intercostal space, midclavicular line.
Middle lobe (right side) + lingula (left side) : At the 5th rib, midclavicular line.
Inferior lobe: At the seventh intercostal space, midaxillary line.
Areas for auscultation on the chest.
Tactile vocal fremitus can be used to assess for consolidation or air in the pleural space. Place the lateral aspect of your hand (hypothenar eminence) horizontally in the patient's supraclavicular space. Ask the patient to quietly say "99" and feel for fremitus (internal vibration). Compare this with the other side, like for like, and repeat in the remaining three areas on both sides.
The preferred areas of auscultation differ among medical practitioners. Many advise that it is too difficult to assess each lobe individually, and therefore it is best to just listen in different lung fields. As long as you listen to four different areas bilaterally front and back, you should get a good appreciation of underlying pathology. Hence, whilst there is no middle lobe on the left side at the 5th rib, midclavicular line, it is good practise to still palpate, percuss, and auscultate in that area. This is illustrated best in the image above.
Percussion
Percuss the chest in all four areas comparing each side like for like. Percussion is hyperresonant in pneumothorax, dull when there is consolidation (e.g. with pneumonia) or atelectasis and stony dull with a pleural effusion.
Auscultation
Place the diaphragm of the stethoscope in all four areas and ask the patient to take a deep breath in and out each time. If possible, ask the patient to only breathe using their mouth. Compare each side like for like. Normal breath sounds are described as vesicular. Reduced breath sounds suggest a pneumothorax or pleural effusion, coarse crepitations suggest consolidation (e.g. due to pneumonia), fine end-inspiratory crackles suggest fibrosis and wheezing can suggest COPD or asthma. A mixed character crackle which changes with coughing suggests bronchiectasis.
Vocal resonance
If preferred, you can test vocal resonance instead of assessing tactile vocal fremitus. Place the stethoscope in all four areas and ask the patient to quietly say "99" each time. Compare each side like for like. Both tactile vocal fremitus and vocal resonance will be reduced with a pneumothorax or pleural effusion but increased with consolidation.
Coarse crepitations suggest fluid build up. This can be due to pneumonia or transiently due to normal fluid secretions. If you do hear crepitations, as the patient to cough. If due to normal secretions, the crepitations should disappear.
Back
Ask the patient to sit up. Inspection, chest expansion, percussion, auscultation, and either tactile vocal fremitus or vocal resonance should be assessed on the back as described previously, in the following four areas:
Apex of the lung: Superior to the medial angle of the scapular spine.
Superior lobe: Medial to the scapular spine.
Inferior lobe: 5cm inferomedially to the inferior angle of the scapula.
Lung base: At the level of T10, 5cm lateral to the vertebral column.
Areas for auscultation on the back.
It is much easier to hear lung sounds in the back. Some doctors prefer to start auscultation on the back rather than the chest.
Ask the patient to cross their arms and touch their opposite shoulders with both hands. This will rotate both scapulae making the lung easier to auscultate.
Lymph nodes
Palpate the lymph nodes of the face and neck for any swelling, which can be indicative of infection or malignancy. The locations of the important lymph nodes can be found in the box below.
The lymph nodes of the head are mostly superficial and drain into the deep cervical chains of the neck. They can be located in the following areas:
Occipital: The occipital lymph nodes can be found at the back of the head.
Mastoid: The mastoid, or posterior auricular lymph nodes can be found behind and beneath the ear at the mastoid bone.
Parotid: The parotid lymph nodes encompass a large area around and anterior to the ear. Palpate just anterior to the ear for the preauricular lymph nodes and immediately posterior to the ear for the infra-auricular lymph nodes.
Submental and submandibular: The submental lymph nodes can be palpated just under the chin. The submandibular lymph nodes are more posterior and can be palpated under the jawline.
The cervical lymph nodes can be divided into anterior and posterior (or lateral), each of which can be further divided into superficial and deep. They can be located in the following areas:
Anterior cervical chain: These lymph nodes can be palpated on and anterior to the sternocleidomastoid muscle.
Posterior cervical chain: These lymph nodes can be palpated posterior to the sternocleidomastoid muscle but anterior to the trapezius muscle.
Finally, it is important the palpate the supraclavicular lymph nodes in the supraclavicular fossa. These are sometimes classified as cervical lymph nodes.
Periphery
Check the legs for peripheral pitting oedema (which can be a result of cor pulmonale). Also look for calf swelling, discolouration or increased temperature as these can be a signs of deep vein thrombosis which can precipitate a pulmonary embolism.
Completion
Complete the examination by offering to obtain a full history, and (if appropriate), obtain a sputum sample, measure peak expiratory flow rate, record oxygen saturation and temperature and ask for a chest X-ray (SPOTX). You may wish to examine the heart if you suspect cor pulmonale.
Key
Headings - items highlighted in green are important headings to cover.
Definitions
Stigmata - a clinical sign relating to a particular condition. E.g. clubbing and infective endocarditis.
Paraphenalia - equipment the patient may have by the bedside or on their person.
Presentation
Thank you for allowing me to conduct a respiratory examination on [patient's name], a [age] year old [male/female]. On general inspection, there were no inhalers, sputum pots or oxygen masks, and the patient appeared comfortable and well at rest. On examination of the hands, there were no nail changes or observable tremors. Asterixis was not elicited. Pulse was regular at [x beats per minute], and the respiratory rate was [x breaths per minute]. Examination of the head was normal, with no signs to suggest Horner's syndrome. On examination of the neck, the carotid pulse was normal, and the jugular venous pressure was not elevated (<4 cm). The trachea was central and cricosternal distance was approximately 3-4 cms.
On closer inspection of the chest, there were no obvious chest wall deformities or scars. The apex beat was in the fifth intercostal space, in the mid-clavicular line. Chest expansion was normal bilaterally. Percussion note was resonant, breath sounds were vesicular and the vocal resonance test was normal. There were no englarged lymph nodes. Finally, on examination of the periphery, there was no peripheral oedema or calf tenderness, redness or swelling. To conclude, this was a normal respiratory examination .
Interactive markscheme
When assessing each other, click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end.
We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
:
Introduction: “Hello I’m X and I am a Y. I need to examine your chest and lungs today, would that be okay? Can I confirm your name and DOB? Thank you.”
"For the purpose of this examination the examiner will act as a chaperone."
Wash hands.
Position the bed at a 45° angle and ensure adequate exposure.
Ask about pain and discomfort.
Inspect the patient (work of breathing and breathing symmetry) and their surroundings (cigarettes, oxygen, inhalers, nebulisers, sputum pots).
Inspect the hands for: warmth, clubbing and peripheral cyanosis.
Check for tremor and then test for asterixis.
Take the pulse and respiratory rate.
Offer to measure the patient's blood pressure.
Inspect the eyes for pallor and mouth for cyanosis. Check for signs of Horner's syndrome (ptosis, anhydrosis, miosis).
Assess the jugular venous pressure. If it cannot be seen, offer to test hepatojugular reflux.
Palpate the trachea for deviation and assess the cricosternal distance.
Inspect the chest again in closer detail for scars and deformity.
Palpate for the apex beat and assess its position.
Assess chest expansion at 2 places.
Percuss the apices and each lobe.
Auscultate the apices and each lobe.
Assess either tactile vocal fremitus or vocal resonance at the apices and each lobe.
Repeat steps 16-19 on the back.
Palpate the cervical lymph nodes for lymphadenopathy.
Palpate the legs for peripheral oedema.
Thank and re-cover the patient.
“To conclude, I would like to take a full history perform basic observations (SPOTX) including a sputum sample, peak flow, oxygen saturation, temperature and a chest X-ray."
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