This document provides guidance on performing a respiratory examination, including inspection, palpation, percussion, and auscultation of the lungs and chest. Key steps include observing general appearance and respiratory status, assessing hand features like clubbing, feeling the chest for tracheal position and expansion, tapping the chest for dull or hyperresonant areas, and listening to breath sounds and added sounds like wheezes or crackles. Specific clinical conditions can be associated with certain exam findings, such as decreased breath sounds in pneumonia or coarse crackles in bronchiectasis.

1. Respiratory examination
• Batch 45
• Group B

2. • Introduce yourself
• Identify patient by name and IC number
• Explain what you are about to do and why
• Ensure confidentiality
• Obtain informed consent
• Sanitize hand
• Positioning and Exposure of patient
Build up rapport
with patient

3. General observation
1. Next look from the end of the bed and take in all of the patient’s
surroundings, including whether or not they have :
• Oxygen
• Nebulizer
• Inhaler
• Sputum pot
2. Look closely at the patient for signs of respiratory distress:
- Cough, nasal flaring, wheeze ,stridor, labored breathing

5. 3. General appearance : Built and nourishment
Pale/Cyanosed/Plethoric

6. Central Cyanosis

7. Assess Hand
Check for :
• Pallor
• Flapping tremors
• Cyanosis
• Tar staining
• Clubbing
• Pulse : Rate, Rhythm, Volume, Vessel wall thickening
• Arm sitting position / bed at 45 degree measure Blood pressure

8. Flapping Tremors

9. Clubbing

12. Respiratory causes of finger clubbing
● Bronchial carcinoma (non-small cell)
● Intrathoracic suppuration
● Bronchiectasis
● Empyema
● Cystic fibrosis
● Pulmonary abscess
● Fibrosing alveolitis (usual interstitial pneumonia)

13. Peripheral Cyanosis

14. DVT
Supra clavicular and Cervical Lymph nodes

15. P- Pallor
I - Icterus
C- Cyanosis + Anthropometry + Vitals
C- Clubbing
L- Lymphadenopathy
E - Edema
General Examination

16. INSPECTION

17. INSPECTION
The chest
• Skin
• Abnormality of skin to look for evidence of metastatictumour nodules,
sarcoidosis, cutaneous sarcoid and any systemic features of collagen vascular
disorders such as the rash of SLE, herpetic vesicles or depigmentated scars in
the distribution of a dermatome
• Any scars in the chest – e.g. thoracoplasty, other surgical scars
• Subcutaneouslesions – metastatictumour nodule, lipomas
• Abnormal blood vessels – superior vena caval obstruction

18. INSPECTION
The chest
• Shape of Chest
• Ensure adequate exposure
• Commonestabnormality of shape is
‘barrel-chested’
• Pigeon chest deformity (pectus
carinatum)
• Funnel chest deformity (pectus
excavatum)

19. INSPECTION
The spine
• Curvature of spine
• Kyphosis
• Kyphoscoliosis
• Protrusion of ribs

20. INSPECTION
Breathing
• Depth and regularity
• Respiratory rate
• Mode of breathing
• Any use of accessory muscles

21. PALPATION
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22. Palpation
Position of trachea
★ Check for deviated trachea; relationship between centre point of trachea to the insertion points of
sternal head of SCM muscle.
★ Common causes of tracheal deviation:
Position of apex beat
★ Normally located at left fifth intercostal space in midclavicular line.
★ Causes of displaced apex beat:

23. Palpation
Chest wall expansion
★ Normal chest expansion is 3-5cm.
★ Place both hands at each sides of patient’s body, with thumbs projected horizontally and remaining
fingers placed at each lateral side of the body. Then, ask patient to breath in and out. Observe if
both thumb moves away bilaterally symmetrical from midline of body during inhalation.
★ Chest expansion reduction:
○ Symmetrical reduction: Overinflated lungs, pulmonary fibrosis
○ Asymmetrical reduction: Absent expansion (e.g. emphysema and pleural effusion), reduced
expansion (e.g. pulmonary consolidation and collapse)

24. Palpation
Vocal fremitus
★ Place ulnar border of hand on corresponding areas on both sides
of chest and ask patient to say ‘99’ repeatedly. Check both sides
one after the other for comparison. Vibrations should be felt the
same on both sides.
★ Interpretation of vocal fremitus:
○ If increased: indicate better conduction of sound through
chest wall seen in consolidation.
○ If decreased: indicate reduced conduction seen in lung
collapse, pleural effusion or pneumothorax.

25. PERCUSSION

26. PERCUSSION
• Place one hand firmly on the chest wall with
the fingers separated and then use the middle
finger of your dominant hand to tap the finger
with a hammer effect.
• Compare equivalent sites on both sides of the
chest.
• Mid-clavicular line and mid-axillary line on
both sides; anteriorly.
• Posteriorly; position the patient sitting
forwards with their arms folded infront to
move the scapula laterally.
• Percuss a few centimetres lateral to the spinal
muscles, taking care to compare positions the
same distance from the midline on right and
left.
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27. SIGNS
DULLNESS
• Consolidation
• Pulmonary
collapse
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STONY DULLNESS
• Pleural effusion
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HYPERRESONANCE
• Emphysema
• Pneumothorax
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**3rd to 5th interspaces dullness: Cardiac dullness

29. Auscultation
Batch 45, B

30. Types of breath sounds

31. Clinical Conditions and Breath Sounds

32. Clinical Conditions and Breath Sounds
CONDITION BREATH SOUNDS AIR ENTRY
Lung collapse Decreased Decreased
COPD Decreased vesicularbreath sounds with
prolongedexpiration
Decreased
Emphysema Decreased Significant
Pneumothorax Decreased
Hammond’ssign: Click on auscultation
in time with the heart sounds ( left
sided pneumothoraxonly)
Decreased

33. Added Pulmonary Sounds
• Rhonchi or wheezes : Continuous musical type sounds, Inspiratory / expiratory
• Crepitations or crackles: Distinct clicking sounds and discontinuous,Inspiratory
• Pleural sounds: Consist of a pleural rub, discontinuous

34. 1. Wheeze
• Divided into,
a) Monophonic:Eg: COPD, Asthma
b) Polyphonic: Eg: Bronchial carcinoma

35. 2. Crackles/ Crepitations

36. 2. Crackles/ Crepitations
• Fine crackles
• Seen when alveoli collapse due to excess water impeding role of surfactant
• Eg: Pulmonary edema
• Coarse crackles
• Seen due to secretions moving around the airway
• Low pitch, high amplitude
• Fine- Medium coarse crackles: Pulmonary fibrosis ( pulling Velcro)
• Medium -Coarse crackles: Severe bronchiectasis, TB, pneumonia
• Crackles can be fixed ( does not move on inspirartory cycle or coughing) or mobile
• Mobile crackles are due to sputum

37. 3. Pleural Rub
• A leathery or creaking sound produced by the movement of the visceral pleura
over the parietal pleura when the surfaces are roughened, usually by fibrinous
material
• Seen in Pleural effusion

38. Vocal Resonance
• While listening to the breath sounds from a stethoscope ask the
patient to say “ twenty –two”
• Increased: Consolidation , Fibrosis
• Decreased: Lung collapse, pleural effusion, Pneumothorax