Medically Fit For Exams
Medically Fit For Exams

Respiratory examination

Wash hands


Introduction and gaining consent

  • Explain that you will ask them to remove their top


General inspection

  • Environmental clues – oxygen, medication, inhalers, nebulisers, sputum pot, thickened fluids
  • Weight loss?
  • Breathlessness or discomfort at rest


Nature of breathing

  • Hyperventilation/high resp rate/Kussmaul respiration (acidosis)
  • Hypoventilation
  • Use of accessory muscles, leaning forward in chair, pursed lips
  • Cough, wheeze or stridor (high pitched noise normally on inspiration)


Respiratory causes of clubbing

Carcinoma of bronchus

Cystic Fibrosis



Lung abscess

Fibrosing alveolitis


  • Clubbing
  •  Peripheral cyanosis
  • Tar staining
  • Capillary refill (hold for 5 seconds, should refill in 3)
  • Tremor (excessive use of beta-agonists or bronchodilators)
  • CO2 retention flap (need to state that you would watch for 30 seconds)


Pulse and BP

  • Check radial pulse, bilaterally if possible, remark on rate, rhythm and character
  • State that you would take blood pressure



  • State that you would check the lymph nodes, including axillary nodes
  • Facial pallor
  • Conjunctival pallor
  • Pupils for asymmetry, and ptosis (eyelid drooping; sign of Horner’s syndrome – sympathetic chain interruption, usually apical tumour)
  • Lips and under the tongue for central cyanosis
  • Check mouth for thrush (secondary to oral steroids)

Causes of raised JVP

Cor pulmonale (R heart failure)

Tension pneumothorax

Severe acute asthma

SVC obstruction


Neck – JVP and trachea

  • Patient must be sat at about 45 degrees – otherwise won’t be able to see the JVP
  • Ask the patient to relax and turn their head away from you
  • Should see JVP – the point at which dilated jugular vein meets collapsed vein

Trachea towards pathology

Trachea away from pathology

Lobar collapse

Large pleural effusion


Tension pneumothorax

  •  Check for raised JVP, should be less than 3cm vertical above the sternal angle (angle of Louis)
  •  If no JVP seen, check hepatojugular reflux by pressing gently under the liver, should accentuate + raise the JVP (ask about abdominal pain first)
  •  Inform patients that you are going to check their windpipe, and warn that it may feel a little uncomfortable
  •  Assess the centrality of the trachea, using two fingers either side of trachea in the suprasternal notch


Chest inspection

  • Fully expose the chest
  • Inspect the chest, axilla and back (ideally)
  • Look for scars from surgery or drains
  • Vein dilation
  • Look for deformities of the chest (barrel chest, kyphoscoliosis, pectus excavatum, pectus carinatum)


Chest expansion

  • Place hands on front of the chest, with fingers on the ribs, and thumbs an inch apart just above the skin
  • Ask the patient to take a deep breath in and out
  • Assess for symmetry and sufficient expansion
  • Repeat for upper, middle and low zones, and the same for the back




Hyper resonant

Large air filled space:




Small pleural effusion



Organs (heart, liver etc)

Stony dull

Large pleural effusion


  • All movements should come from wrist, and tap onto the intermediate phalanx (apart from the clavicle, which can be percussed directly)
  • Start at the clavicles and work down, ensuring that all lobes are covered, and including the axilla region
  • Follow percussion on the left immediately by percussion on the right to allow for comparison between sounds at equivalent levels
  • Remember to repeat on the back



  • Ask the patient to breathe normally, through an open mouth
  • Auscultate the anterior chest wall, alternating left and right for comparison
  • Start above clavicle, and move down to below 11th rib, include the axilla
  • Repeat for the back
  • Listen for breath sound character – vesicular or bronchial
  • Listen for additional sounds, eg crackles, pleural rub (fresh snow crunch, pneumonia, PE)


Normal vesicular breathing

Rustling quality, steady increase in sound during inspiration, then rapid fall on expiration, no gap between them

Diminished vesicular breathing

Thick chest wall (pleural thickening) or emphysema, similar to normal, but quieter

Bronchial breathing

Pneumonic consolidation, pleural effusion compressing lung. Loud and blowing breath sounds, inspiration and expiration are similar in sound. Is gap between inspiration and expiration



  • The character and phase of crackles can indicate the cause


Early phase inspiration

Small airways disease such as bronchiolitis

Middle phase inspiration

Pulmonary oedema

Late phase inspiration

Fine: Pulmonary fibrosis, eg in COPD, chronic asthma

Medium: Pulmonary oedema

Coarse: Air bubbling through bronchial secretions, eg COPD, pneumonia, abscess, tubercular lung cavity


Bronchiectasis (coarse)




  • Place the lateral edge of your hands on the patients chest, with fingertips positioned laterally on their chest
  • Ask the patient to say ‘ninety nine)
  • Feel for the conducted vibration (reduced conductance indicates pleural effusion, increased conductance indicates consolidation)
  • Repeat for upper, middle and lower chest, and similarly on the back


Whispering pectoriloquy

  • An auscultatory version of conductance
  • Ask the patient to whisper ‘twenty-two’ which auscultating their chest
  • Normally (and in pleural effusion) this cannot be heard, in consolidation the sound is audible





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