Introduction

1. Greet the patient and introduce yourself
2. Confirm patient details ✍
3. Explain the procedure in a patient friendly manner
4. Get patient consent ✍
5. Wash hands ✋
6. Set the head of the bed to a 45° angle, and expose the patient’s chest and legs
7. Check the patient is not in any pain

General inspection of the patient

Identify any clinically relevant signs:

🌬 Age

🌬 Coughing: productive coughs can indicate pneumonia, bronchiectasis, COPD or CF and dry coughs can indicate asthma or interstitial lung disease

🌬 Wheezing: whistling sound which often suggests asthma, COPD, and bronchiectasis

🌬 Shortness of breath: signs include inability to speak in complete sentences, flaring of nostrils, pursed lips etc.

🌬 Stridor: when the upper airways are narrowed, air flow becomes turbulent, causing a high-pitched sound

🌬 Cachexia: ongoing muscle loss, indicates end-stage respiratory disease

🌬 Oedema: swelling of limbs when the ventricles fail

🌬 Pallor: pale skin indicative of anaemia or poor perfusion

🌬 Cyanosis: bluish skin due to poor circulation or poorly oxygenated blood

Identify any relevant objects of equipment:

🌬 Oxygen delivery devices

🌬 Prescriptions

🌬 Vital signs

🌬 Fluid balance

🌬 Sputum pot: record the colour and volume of the contents

🌬 Mobility aids ♿

🌬 Cigarettes/ vapes

🌬 Other medical equipment: ECG leads, catheters, intravenous accessories or medications

Hands

Inspection:

Observe the following characteristics:

🌬 Swelling at the joints or deformity: rheumatoid arthritis

🌬 Tar staining: smoking

🌬 Skin changes: bruising and thinning of skin due to long term steroid use

🌬 Colour: cyanosis indicative of hypoxaemia

🌬 Finger clubbing: indicative of lung cancer, interstitial lung disease, cystic fibrosis and bronchiectasis

1. Ask the patient to place the nails of their index fingers back to back
2. You should see a diamond shaped window
3. No window is known as clubbing

🌬 Fine tremor: observe the patient’s outstretched hand to identify a fine tremor

• Associated with beta-2-agonist such as salbutamol use
• Asterixis ‘flapping tremor’: flapping hands caused by irregular posture lapses, likely caused by CO₂ retention in conditions which cause type 2 respiratory failure

1. Ask the patient to move their hand backwards at the wrist for 30 seconds
2. Observe to see if there is any evidence of asterixis

Palpation:

Temperature of the hands: assess using the back of your hand

🌬 Symmetrical warmth: in healthy individuals 

🌬 Cold hands: indicates poor peripheral perfusion ❄

🌬 Warm hands: suggests CO₂ retention 

Heart rate: assess by measuring the rate for 60 seconds, and the rhythm of the radial pulse

🌬 Bounding pulse: CO₂ retention

🌬 Pulsus paradoxus: pulse volume decrease is abnormally large when the patient inspires (late sign pf cardiac tamponade, severe COPD or severe acute asthma)

Respiratory rate: assess the respiratory rate for 60 seconds, whilst simultaneously assessing the radial pulse, noting any difference between inspiration and expiration

🌬 Healthy individuals: 12-20 breaths per min

🌬 Bradypnoea: <12 breaths per min

🌬 Tachypnoea: >20 breaths per min

Jugular venous pressure (JVP)

JVP enables you to indirectly measure the central venous pressure:

🌬 The internal jugular vein (IJV) is directly connected to the right atrium, meaning there is a continuous blood column

🌬 The IJV reflects the right atrial action (e.g. raised pressure in the right atrium is reflected by the IJV becoming distended)

🌬 It is hard to visualise the IJV but the most reliable indirect measurement

Measuring the JVP:

1. Turn the patient’s head slightly left
2. Assess the IJV (visible as a double waveform pulsation, just above the clavicle, between the sternal and clavicular heads of the sternocleidomastoid muscle at the root of the neck)
3. Measure 📏 the distance between the top of the IJV pulse and the sternal angle, this gives you the JVP
   1. Healthy individuals: <3cm
   2. Raised JVP: venous hypertension

🌬 Hepatojugular reflux test: apply pressure to the liver whilst simultaneously observing for a lasting rise in the JVP

Face

Inspect the face:

🌬 Plethoric complexion: red skin can indicate polycythaemia and CO₂ retention

Inspect the eyes 👁:

🌬 Ptosis, miosis and enophthalmos: Horner’s syndrome

🌬 Conjunctival pallor: anaemia

Inspect the mouth 👄:

🌬 Oral candidiasis: fungal infection caused by steroid inhaler use (mouth red with white patches)

🌬 Central cyanosis: bluish lips/ tongue caused by hypoxaemia

Inspect the chest

Scars:

🌬 Infraclavicular scar: pacemaker insertion

🌬 Axillary thoracotomy scar: chest drain insertion

🌬 Skin changes associated with radiotherapy: xerosis, scale, hyperkeratosis, telangiectasia and hyperkeratosis

🌬 Median sternotomy scar: cardiac valve replacement and coronary artery bypass

🌬 Posterolateral thoracotomy scar: lobectomy, oesophageal surgery or pneumonectomy

Deformities:

🌬 Hyperexpansion

🌬 Pectus excavatum: ‘caved’ appearance

🌬 Pectus carinatum: protruding sternum/ ribs

🌬 Asymmetry

Tracheal position and cricosternal distance

Assess the position of the trachea:

1. Ask the patient to put their chin down to relax the neck muscles
2. Use your index fingers to assess the 2 tracheal borders
3. Identify a tracheal deviation if present

🌬 Can be caused when the trachea deviates away from large pleural effusions and tension pneumothorax or towards pneumonectomy and lobar collapse

Measure cricosternal distance:

🌬 Using your fingers measure the distance between the cricoid cartilage and the suprasternal notch

                Healthy individuals: 3-4cm

                < 3 fingers: can indicate lung hyperinflation e.g. asthma or COPD

Palpate the chest

Palpation of the apex beat:

Place your fingers across the chest horizontally, and palpate the apex beat

🌬 Healthy individuals: located in the 5h intercostal space in the midclavicular line

🌬 Displaced apex beat: caused by large pleural effusion, tension pneumothorax, right ventricular hypertrophy

Assess the chest expansion:

1. Place your hands below the nipples, wrap your fingers ✋ around the sides of the chest so your thumbs meet in the middle

2. Assess how your thumbs move

🌬 Healthy individuals: thumbs will move symmetrically up and out

🌬 Unsymmetrical movement: the thumb that moves less suggests chest expansion is reduced on that side

🌬 Symmetrical reduced chest expansion: lung elasticity is reduced by pulmonary fibrosis

🌬 Asymmetrical reduced chest expansion: caused by pneumonia/ pleural effusion/ pneumothorax

Chest percussion

Listen to volume and pitch of chest percussion:

1. With your non-dominant hand ✋ on the chest wall, press your middle finger where you are percussing
2. With the middle finger of your dominant hand ✋  quickly strike the middle of the finger pressing on the chest

Where to percuss?

🌬 Axilla

🌬 Chest wall

🌬 Supraclavicular region

🌬 Infraclavicular region

What will it sound 👂 like?

🌬 Stony dullness: pleural effusion

🌬 Dullness: increased tissue density

🌬 Hyper-resonance: decreased tissue density

🌬 Resonant: normal

Tactile vocal fremitus:

Palpate the chest wall in a range of locations as the patient repeats a word e.g. “99”

🌬 Increased vibration: increased tissue density

🌬 Decreased vibration: fluid or air outside lung

🌬 Vocal ? resonance: alternative method to assess sound, using a stethoscope

Auscultate the chest

1. Ask the patient to breathe in and out through the mouth
2. Use the diaphragm of your stethoscope to listen to the patients breathing
3. Assess quality, volume, and any additional sounds you observe
4. Assess different areas of the chest on both sides to compare them

Breath sounds 👂:

🌬 Vesicular: normal sounds in healthy individuals

🌬 Bronchial: harsh sounding, associated with consolidation

🌬 Quiet: entry of air into lungs restricted

Additional sounds 👂:

🌬 Stridor

🌬 Wheezing

🌬 Fine end inspiratory crackles

🌬 Coarse crackles

Assess vocal resonance:

Auscultate the chest wall in a range of locations as the patient repeats a word e.g. “99”

🌬 Increased volume: increased tissue density

🌬 Decreased volume: fluid or air outside of the lung

Tactile fremitus: alternative method, feeling for vibrations when the patient speaks with your hands

Lymph nodes

Palpation ? of the lymph nodes:

1. Examine the patient from behind as they sit upright
2. Assess for neck irregularity or lymphadenopathy
3. Palpate the neck from behind

Use your fingers to assess the lymph node characteristics (size, consistency and mobility), assessing all areas:

🌬 Pre-auricular: located just in front of the ear👂  

🌬 Post-auricular: located just beneath the ear👂 

🌬 Superficial cervical: located close to the surface of the neck

🌬 Deep cervical: located near to the IJV

🌬 Submental: located along the external jugular vein

🌬 Supraclavicular: located on both sides, above the clavicle, close to the sternoclavicular joint

🌬 Submandibular: located beneath the mandible

Lymphadenopathy: caused by tuberculosis/ lung cancer/ sarcoidosis

Assess the back of the chest

🌬 Ask the patient to sit forward and fold their arms across their chest

🌬 Assess the posterior aspect of the chest following the same steps as you did for the front

Final assessments

🌬 Assess for sacral and pedal oedema as can be indicative of congestive heart failure

🌬 Assess the calves to identify deep vein thrombosis presence

🌬 Assess for erythema nodosum which can indicate sarcoidosis

Completion of the examination

1. Thank the patient and inform them the examination is complete ✅
2. Wash hands ✋
3. Summarise what the examination has revealed ✍