Around the bed: oxygen, medication (e.g. inhalers, nebulisers), sputum pots (look at sputum), cigarettes
Examine for tremors
Fine tremor: patient should hold arms out straight, with their fingers spread (fine tremor may be caused by β2 agonists)
Asterixis (flapping tremor): patient should hold their arms out straight, with their wrists ‘cocked back’ (flap = CO2 retention)
Look for peripheral cyanosis (hypoxia or hypoperfusion)
Check their capillary refill by pressing for 5 seconds then releasing the pressure and observe how long it takes for perfusion to return (>2 seconds is classed as hypoperfusion)
Are there hands sweaty/warm/clammy? (CO2 retention)
Look for small muscle wasting (Pancoast tumour)
Look for clubbing by asking the patient to place their two index finger nails together – Schamroth window test (idiopathic pulmonary fibrosis, lung cancer, CF, bronchiectasis)
Check for tar-stained fingers (smoker)
Pulse and respiratory rate
Calculate rate over 30 seconds and also note rhythm (tachycardia may indicate: hypoxia in severe asthma or COPD, PE or infection)
Consider if there is a bounding pulse (i.e. increased up-stroke and down-stroke; CO2 retention)
Count respiratory rate while patient still thinks you are feeling pulse: tachypnoea (lung disease, infection, hyperventilation, fever, PE), bradypnoea (central nervous system depression)
Head and neck
Look at the patient’s face
Cushingoid features (steroid use)
Plethoric (secondary polycythaemia; Cushing’s syndrome; superior vena cava obstruction if facial swelling)
Features of autoimmune disease, e.g. telangiectasia/microstomia (systemic sclerosis), butterfly rash (SLE), lupus pernio (sarcoid), lupus vulgaris (TB)
Ask permission from the patient then pull down the lower eyelid to look for conjunctival pallor (anaemia of chronic disease),
Look for Horner’s syndrome (ptosis, miosis, anhidrosis; Pancoast tumour)
Mouth: look for central cyanosis under tongue (hypoxia)
JVP: ask the patient to rest their head back and turn head slightly, then look for double pulsation of internal jugular vein – up to 3cm above sternal angle is normal (raised in cor pulmonale)
Tracheal deviation: place your right hand’s index and ring fingers on each clavicle head. Roll your middle finger over the trachea in the sternal notch. (Pneumothorax pushes to contralateral side; collapsed lung pulls to ipsilateral side.)
Cricosternal distance and tracheal tug: place your right hand’s index on the inferior border of the cricoid. Now place subsequent fingers in the midline until you reach the sternal notch (<3 fingers = lung hyperinflation). Note reduction in inspiration (‘tracheal tug’).
You should examine the front first and repeat everything on the back afterwards.
Supramammary and inframammary chest wall expansion: grip very hard around rib cage with thumbs in the air almost touching in expiration. Watch thumbs move away from each other during inspiration (normally ≥5cm).
Feel for RV heave by placing the heel of your right hand over the patient’s left lower parasternal edge with a straight elbow (pulmonary hypertension)
Percussion: compare left with right – start above clavicles and progress down to axilla
Dull = consolidation or collapse
Stony dull = pleural effusion
Hyperresonant = increased air space, e.g. in pneumothorax or emphysema
NB: the liver starts at the 5th intercostal space on the right.
How to… Percuss
Use your non-dominant hand as a firm base on the patient’s skin
Use your dominant hand’s middle finger to strike your non-dominant hand’s middle finger
Bend your dominant hand’s wrist to provide force (do not move the arm itself)
Deliver two quick blows at a time
Standard auscultation: ask patient to breathe in and out deeply through their open mouth. Compare sides in turn, starting in supraclavicular area and ending in axillae.
Vocal resonance: listen in all areas again while the patient repeats ‘ninety-nine’ (increased resonance = consolidation; decreased resonance = effusion/pneumothorax)
Listen for loud S2 over pulmonary valve area (loud pulmonary S2 = pulmonary hypertension)
Repeat all on back: now ask patient to sit over bedside with crossed arms and percuss, auscultate and assess vocal resonance again on the back
Peripheral cyanosis: 2011 James Heilman, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license
Clubbing: 2009 Desherinka, licensed under the Creative Commons Attribution-Share Alike 4.0 International, 3.0 Unported, 2.5 Generic, 2.0 Generic and 1.0 Generic license and GNU Free Documentation licence 1.2
Tar staining: James Heilman, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license
Butterfly rash: 2003. Doktorinternet. Licensed under the Creative Commons Attribution-Share Alike 4.0 International license.
Lupus pernio: M. Sand, D. Sand, C. Thrandorf, V. Paech, P. Altmeyer, F. G. Bechara: Cutaneous lesions of the nose. In: Head & face medicine Band 6, 2010, S. 7, ISSN 1746-160X. doi:10.1186/1746-160X-6-7. PMID 20525327. (Review). Open Access