Respiratory examination


  • Wash hands
  • Introduce self
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent
  • Expose and sit patient at 45⁰

General inspection

  • Observe from the foot of the patient’s bed
  • Do they look well/unwell?
  • Consider if they are alert, comfortable, breathless
  • Look for cachexia (malignancy, emphysema) and cushingoid features (steroid use)
  • Observe the patient’s breathing
    • Note any use of accessory muscles (COPD, pleural effusion, pneumothorax, severe asthma)
    • Pursed-lip breathing (prevents bronchial wall collapse by keeping airway pressure high in severe airway obstruction/emphysema)
  • Listen for breathing noises

Abnormal breathing noises

  • Speech abnormalities (e.g. in recurrent laryngeal nerve palsy)
  • Stridor (large airway obstruction e.g. mediastinal masses, bronchial carcinoma, retrosternal thyroid)
  • Wheeze
  • Cough (dry/productive/bovine)
  • Prolonged expiratory phase (asthma, COPD)
  • Clicks (bronchiectasis)
  • Gurgling (airway secretions)
  • 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)
  • Check perfusion
    • 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)
  • Nails
    • Look for clubbing by asking the patient to place their two index finger nails together – Schamroth’s window test (idiopathic pulmonary fibrosis, lung cancer, CF, bronchiectasis)
    • Check for tar-stained fingers (smoker)

Pulse and respiratory rate

  • Radial pulse
    • 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)
  • Eyes
    • 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)
  • Neck
    • 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.


Chest wall

  • Scars (look under arms as well as on back)
  • Skin changes, trauma
  • Deformities (pectus carinatum may be related to childhood respiratory disease; pectus excavatum may be related to connective tissue disease; barrel chest in emphysema or COPD)
  • Kyphosis/scoliosis (restrict chest movements)
  • Radiotherapy tattoos

Chest wall movements

  • Mainly upwards (emphysema)
  • Asymmetrical (fibrosis, collapsed lung, pneumonectomy, pleural effusion, pneumothorax)


  • In-drawing of intercostal muscles (generalised = hyperinflation; localised = bronchial obstruction)
  • Powerful expirations (asthma, COPD)
  • Hyperexpanded chest (COPD)



  • Examine for 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)

RV heave

  • 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)


  • Compare left with right – start above clavicles and progress down to axilla
    • Normally resonant
    • 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

Suggested percussion/auscultation positions
Decreased air entryEmphysema, pneumothorax, pleural effusion, collapse
WheezeAsthma, COPD
Coarse crepitationsBronchiectasis, consolidation
Fine inspiratory crepitationsPulmonary oedema
Fine end-inspiratory crepitations (like Velcro)Pulmonary fibrosis
Bronchial breathing (harsh breath sounds)Consolidation
Pleural rub (grating sound)Pleurisy, pulmonary infarction, pneumonia, pleural malignancy


  • Cervical lymph nodes: examine for cervical lymphadenopathy from posteriorly while the patient is still sitting forward (infection, carcinoma, lymphoma, sarcoidosis)
  • Legs
    • Examine for peripheral oedema by pushing over the tibia for 10 seconds, then run finger over feeling for indent (cor pulmonale)
    • Feel calves (swollen/tender = DVT)

To complete

  • Thank patient and restore clothing
  • ‘To complete my examination, I would like to review the observations chart (particularly to see oxygen saturations), and measure peak flow (if asthmatic).’
  • Summarise and suggest further investigations you would consider after a full history

Why don’t you test your knowledge on examination findings?

Describe the chest examination findings you may find in each of the following conditions:
1. Pneumothorax
2. Pneumonia
3. Pleural effusion
4. Lobar collapse

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What are the stages and causes of digital clubbing?

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What findings would you expect when examining a patient after a pneumonectomy?

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How about some advanced signs?

What is Kussmaul’s sign and which conditions could cause it?

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What is pulsus paradoxus and what are the causes?

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Here are some questions on some of the conditions you may see

What are the causes of bronchiectasis?

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What are the indications for a pneumonectomy/lobectomy?

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What are the causes of upper and lower zone pulmonary fibrosis?

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How would you categorise the severity of COPD?

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Now it’s time for you to try some OSCE stations

  1. Start with a normal respiratory exam
  2. Now try some pathology
  3. Here’s a pneumonectomy station
  4. And a patient with pulmonary fibrosis
  5. Let us help you! Hundreds of stations available here.

Picture references

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

Cushing’s facial appearance: 2012. Ozlem Celik, Mutlu Niyazoglu, Hikmet Soylu and Pinar Kadioglu. Licenced under Creative Commons Attribution 2.5 Generic license

Horner’s syndrome: Nautiyal A, Singh S, DiSalle M, O’Sullivan J (2005) Painful Horner Syndrome as a Harbinger of Silent Carotid Dissection. PLoS Med 2(1): e19 doi:10.1371/journal.pmed.0020019

Pectus excavatum: 2006 Ahellwig, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license and GNU Free Documentation licence 1.2

Pectus carinatum: 2010 Tolson411, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license, edited

Barrel chest: 1912. Cabot R, Clarke R. Physical diagnosis. New York William Wood and Company

Peripheral oedema: James Heilman, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license

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