Inspection and peripheral examination

Patient should be lying at 45°.

End of bed
● Comfortable breathing? Accessory respiratory muscle use?
● Abnormal sounds: stridor, wheeze.
● Look for sputum pots and oxygen supply around bed.

Hands and wrist

Signs:
● Tar stains.
● Clubbing
● Peripheral cyanosis: compare colour with your hand.
● Muscle wasting: lung cancer mets causing T1 root compression.
● Salbutamol can cause a fine tremor.
● Hypercapnia can cause flapping tremor: ask them to stick hands out and cock
wrists. The co-ordinated extensor contraction and flexor relaxation required is
not maintained, and as the hand drops they consciously jerk it back,
producing an irregular, coarse flap. Similar mechanism and appearance to
hepatic flap.

Respiratory causes of clubbing:

● Suppurative lung disease: bronchiectasis, empyema, abscess.
● Cancer: lung cancer, mesothelioma.
● Interstitial lung disease (ILD).
● TB

Check pulse at wrist. Also a good time to check the respiratory rate.
Pulsus Paradoxus:
● ↓SBP with inspiration, making the radial pulse intermittently hard to palpate on
inspiration.
● Pulmonary causes: COPD, asthma, obstructive sleep apnoea.
● Pericardial causes: pericarditis, cardiac tamponade.

Head and neck

Jugular venous pressure (JVP): (optional)
● Ask patient to look up and to the left.
● May be raised in right heart failure, and raised and fixed in SVC
obstruction, a sign of lung cancer.

Face:
● Check for pallor in conjunctiva by pulling down lower eyelid.
 ● Horner's syndrome: look for ptosis, miosis, and anhidrosis, checking for
anhidrosis with back of hands. Seen in lung cancer, lymphoma, and Marfan's.
● Mouth: central cyanosis, oral candida (from inhaled steroids).

Palpation

Chest
First, do a closer inspection:
● Any scars?
● Hyperinflated in COPD and asthma: barrel shaped, ↑anterio-posterior
diameter, and raised shoulders.
● Ask to breath in and out: symmetrical?
● Hoover's sign: paradoxical inspiratory retraction of lower ribs and intercostal
spaces. Seen in COPD due to diaphragm flattening.

Neck
● Check position of trachea using middle finger, with 2nd and 4th finger either
side of it. May be deviated towards collapse, lobe/pneumectomy, and fibrosis,
or away from tension pneumothorax or massive effusion.
● Check cricosternal distance: may be >3 fingerbreadths (≈ cm) in
hyperexpansion (e.g. COPD).
● Feel the posterior lymph nodes from the front: occipital, postauricular,
posterior cervical, and axillary. (optional)

Palpation:
● Chest expansion: ask them to breath out fully and wrap your hands around
their upper, middle and lower chest. Hover thumbs above chest, then ask
them to breath in deeply. Reduced expansion seen in pneumonia,
pneumothorax, effusion, and PE.
● Apex beat: displaced in LVF, which may present with respiratory symptoms.
Percussion:
● Do at 5-6 points on both sides.
● Start supraclavicular then just below clavicle, then supra mammary,
inframammary, 2 more points at the sides for lower lobes.
● Findings: Resonant is normal. Hyper-resonant = pneumothorax or
emphysema. Dullness = consolidation, collapse, or pleural thickening. Stony
dullness = effusion.

Auscultation
Front
Overview:
● Ask them to breath in and out deeply with their mouth open.
 ● Start supraclavicular, then just below clavicle at the mid-clavicular line, then 2
more points further down, then the sides.
● Normal breath sounds (BS) are 'vesicular'.
Abnormal sounds (aka adventitious sounds):
● Bronchial breath sounds: loud, hollow whoosh sound, with clear pause
between inspiration and expiration. Heard in consolidation or fibrosis.
● Reduced breath sounds: effusion, pneumothorax, obesity, COPD, or lobar
collapse.
● Wheeze: asthma, COPD, HF. Usually expiratory, but can be inspiratory if
there is airway obstruction or hypersensitivity pneumonitis.
● Crackles
● Ronchi (aka sonorous wheeze): continuous low-pitched noise, like snoring or
gargling. Heard in COPD and CF.
● Pleural rub: like the sound of treading on snow. Heard in pleurisy, PE,
pneumonia, and effusion.

Types of crackles (aka crepitations, rales):

● Fine: fine to medium mid inspiratory crackles in oedema, fine end inspiratory
crackles in interstitial lung disease. Bilateral in both cases.
● Coarse: inspiratory and expiratory in bronchiectasis, and late inspiratory in
pneumonia.
Vocal resonance: have them say 99 while you listen. An alternative to TVF.

Back
Ask them to sit forward with elbows on knees.
Repeat parts of front exam:
● Feel anterior lymph nodes from behind: sub-mental, sub-mandibular, anterior
cervical, and clavicular.
● Chest expansion.
● Percuss: 3 points either side. Make sure to do it between the scapulae.
● Auscultate: again, between scapulae (around mid-clavicular line).

Completing the examination

Feel lower anterior shin for pitting oedema.
Example comment of normal chest findings: "Chest was resonant to percussion, and
clear on auscultation with vesicular breath sounds throughout".
Further tests:
● Bedside spirometry.
● O2 sats.