Respiratory Exam

Introduction

A safe, structured, and patient‑centred approach sets the tone for the entire respiratory examination. These first steps help learners build trust, gather essential information, and prepare both themselves and the patient for the assessment ahead.

1. Take a Full History

A thorough history provides context for everything that follows. It helps guide your observations, shape your differential thinking, and highlight areas that may need closer attention during the physical exam.

2. Wash Your Hands

Hand hygiene is essential for patient safety and professionalism.
Learners are also reminded to keep their nails short, long nails can make percussion uncomfortable for the patient and may affect technique.

3. Explain the Process & Request Consent

Before beginning the examination:

Introduce yourself
Explain what the assessment involves
Check the patient is comfortable
Request consent

Clear communication builds trust and ensures the patient feels respected and informed.

Exterior

From the end of the bed I can see…
This simple phrase anchors the start of a structured bedside assessment. Healthcare professionals often begin by observing the area around the patient to identify any visible aids, risks, or clinical clues.

Key Items to Look For Around the Bed

Oxygen tanks or delivery systems
Indicators of respiratory support needs.
Medication at the bedside
May suggest ongoing treatment or recent administration.
Mobility aids
Such as walking frames, sticks, or hoists.
Pillows and positioning supports
Helpful for understanding comfort, posture, or pressure‑relief needs.
Or note: “Nothing of notable significance”
When no relevant items are present.

Visual Inspection of the Patient

As the patient may be partially exposed during assessment, it’s important to observe respectfully and professionally for:

Scars
Which may indicate previous surgeries or injuries.
Redness
Potentially linked to irritation, pressure, or inflammation.
Swelling
A possible sign of fluid retention, injury, or infection.

These findings should always be explored sensitively with the patient, ensuring comfort, consent, and clear communication.

Legs

A structured lower‑limb assessment helps healthcare learners recognise visible changes, understand patient cues, and document findings clearly. This stage focuses on observing and gently examining the leg from lower to upper, noting any features that may require further exploration with the patient.

1. Swelling

Visible swelling may indicate a range of underlying issues. Learners are trained to observe the location, symmetry, and extent of swelling, and to discuss any discomfort or changes with the patient.

2. Checking for Oedema

Gentle pressure can help identify the presence of oedema.
If oedema is noted, it is good practice to describe how far it extends, for example:
“To the level of…” followed by the anatomical point reached.

3. Ankle Refill Time

Assessing ankle refill time provides additional insight into circulation and perfusion. This simple observation forms part of a broader lower‑limb assessment.

Wrist & Hands

A focused wrist‑and‑hand assessment provides valuable clues about circulation, respiratory effort, and systemic conditions. This stage of the examination is simple, visual, and highly teachable, perfect for learners preparing for OSCEs or clinical placements.

1. Wrist Assessment

A wrist examination often begins with evaluating the pulse, a core component of any bedside assessment.

Assessing the Pulse

When characterising the pulse, learners typically observe:

Rate – for example, “80 beats per minute”
Rhythm – such as “regularly regular”
Character – described as weak, strong, or thready

These observations help build a clearer picture of the patient’s circulatory status.

Transitioning to Respiratory Rate

In the second half of the minute, the focus shifts discreetly to the patient’s breathing.
Without drawing attention to the change, learners observe the respiratory rate, allowing for a more natural and accurate reading.

2. Hand Assessment

The hands can reveal subtle but important clinical signs. A structured approach helps learners stay consistent and confident.

Clubbing

Using the patient’s fingers, learners check for changes that may indicate long‑standing conditions.

Capillary Refill Time

A quick, gentle test that provides insight into peripheral perfusion.

Fine Tremor

Ask the patient to outstretch their hands and observe for subtle tremors.

Asterixis (30‑Second Assessment)

To assess for asterixis:

The patient holds out their hands
They extend (cock back) their wrists
The examiner observes for a flapping motion, which may be associated with CO₂ retention

Eyes

The eyes can reveal subtle but powerful indicators of a patient’s overall health. A structured eye assessment helps learners recognise early signs of systemic conditions and understand how to document findings clearly and professionally.

Conjunctival Pallor

Conjunctival pallor refers to pale or white inner eyelids, which may be associated with reduced blood colouration. Learners are trained to gently pull down the lower eyelid and observe the conjunctiva for changes in colour. This simple observation forms part of many routine clinical assessments.

Features Suggestive of Horner’s Syndrome

During an eye examination, learners also stay alert for features that may be associated with Horner’s syndrome, such as:

Subtle drooping of the eyelid
Reduced pupil size on one side
Differences in facial sweating

These signs are observed visually and explored further with the patient when appropriate.

Mouth

The mouth offers important visual clues about a patient’s respiratory status, oral health, and overall wellbeing. A structured oral examination helps learners recognise subtle changes and document findings clearly and professionally.

1. Cyanosis of the Lips

Learners are trained to observe the colour of the lips, noting any bluish or dusky appearance. This visual change can be associated with reduced oxygenation and is an important part of general inspection.

2. Oral Candida

During the mouth examination, learners also look for features that may suggest oral candida, which can sometimes appear in individuals who use inhalers. This is typically identified as white patches or coating inside the mouth.

3. Tongue Positioning

To complete the assessment, the patient is asked to lift their tongue to the roof of their mouth. Look for a bluish tint, common with cyanosis.

Neck

The neck provides essential visual and tactile clues during a clinical examination. From assessing venous pressure to checking tracheal alignment, this part of the assessment helps learners build confidence in identifying subtle but meaningful signs.

1. Measuring the Jugular Venous Pulse (JVP)

A structured JVP assessment helps learners understand circulatory status and recognise abnormal findings.

How learners typically observe the JVP:

The patient is asked to turn their head slightly to the left
The leaner identifies the sternal angle and the top of the visible pulsation of the internal jugular vein
The vertical distance between these two points is estimated
A typical JVP measurement is described as not exceeding 3 cm above the sternal angle

This visual assessment forms a core component of many bedside examinations.

2. Assessing Tracheal Position

Evaluating the trachea helps learners recognise whether it appears central or deviated.

A simple, structured approach:

The learner gently places their inner three fingers along the trachea
The middle finger is used to gauge whether the trachea feels midline
Any deviation is noted and explored further with the patient when appropriate

Reasons for an asymmetrical tracheal position, include a distended lung, inflammation, or tumours.

Lymph Nodes

A structured lymph‑node examination helps learners identify inflammation, asymmetry, and other notable findings. This part of the assessment is highly teachable and often rewarded in OSCEs when performed methodically and confidently.

1. Palpating the Lymph Nodes

Learners begin by gently palpating each lymph node, noting any:

Tenderness
Swelling
Irregularity
Differences in size or texture

This hands‑on assessment helps build a clear picture of the patient’s lymphatic status.

2. Checking for Asymmetry

To complete the examination, the learner stands behind the patient and compares both sides of the neck. This position makes it easier to detect subtle differences in size, shape, or firmness.

3. Lymph Nodes to Name and Palpate

Naming each node during palpation can help learners score higher in OSCEs and demonstrate structured clinical reasoning. The key lymph nodes include:

Submental
Submandibular
Pre‑auricular
Post‑auricular
Superficial cervical
Deep cervical
Posterior cervical
Supraclavicular
Occipital

4. Safety Note

When examining the anterior cervical chain, avoid pressing too firmly over the carotid area.
A simple rule: Check one side at a time, gently.

Chest

Chest Expansion

Assessing chest expansion is a simple but powerful part of the respiratory examination. It helps learners identify symmetry, detect reduced movement, and understand how different conditions may affect one side of the chest.

1. Assessing Chest Expansion

A structured approach helps learners stay confident and consistent.

Step‑by‑step:

Place your hands around the patient’s chest, just below the nipples
Extend your thumbs outward, ensuring they do not touch
Ask the patient to take a deep breath in and out
Observe how your thumbs move apart and return during inhalation and exhalation
Compare both sides for symmetry

Understanding Asymmetrical Chest Expansion

Reduced movement on one side can be associated with several respiratory conditions:

1. Pleural Effusion

When fluid collects between the lung and chest wall, the affected lung cannot expand fully. This often results in noticeably reduced movement on that side.

2. Pneumothorax

Air trapped in the pleural space can cause the lung to collapse partially or completely. This leads to reduced or absent chest expansion on the same side.

3. Pneumonia

Infection and inflammation within the lung tissue can stiffen the affected area, limiting its ability to expand normally during breathing.

All three conditions may present with ipsilateral reduced chest expansion, making this observation an important part of clinical assessment.

Percussion

Percussion is a core technique in the respiratory examination. By tapping the chest wall and listening to the sound produced, learners can identify differences in underlying tissue and compare lung regions with confidence.

1. What Chest Percussion Reveals

Different sounds provide different clues.

Resonant

A normal, healthy sound heard over air‑filled lung tissue.

Dullness

A quieter, heavier sound that may indicate increased tissue density beneath the percussion point.

Stony Dullness

A very flat, muted sound often associated with fluid in the pleural space, such as in a pleural effusion.

Hyper‑Resonance

A louder, more hollow sound, the opposite of dullness, which may suggest reduced tissue density beneath the chest wall.

These sound variations help learners understand how different conditions may alter the acoustic profile of the lungs.

2. Compare Both Sides

A key principle in percussion:

Percuss one point on the lung
Then compare it to the same point on the opposite side

This side‑to‑side comparison helps identify asymmetry and subtle changes.

3. How to Perform Chest Percussion

A simple, structured technique for learners:

Splay your fingers and place your middle finger firmly on the chosen point
With your dominant hand, tap the upper portion of that finger
Lift your hand quickly after each strike
Listen carefully to the sound produced and compare it across regions

Stethoscope Check

Auscultation is one of the most recognisable parts of the respiratory exam. Using a stethoscope, learners listen for breath sounds, compare both sides of the chest, and identify patterns that may suggest underlying changes in lung tissue.

1. Normal Breath Sounds

Understanding the baseline makes it easier to recognise abnormalities.

Vesicular Breath Sounds

The normal breath sound heard over healthy lung tissue
Soft, low‑pitched, with longer inspiration than expiration

2. Abnormal Breath Sounds

These sounds differ from the normal vesicular pattern and may suggest changes in lung structure.

Bronchial Breath Sounds

Harsh, high‑pitched, similar to listening over the trachea
Inspiration and expiration are equal, with a brief pause between
Often associated with lung consolidation

3. Volume of Breath Sounds

The loudness of breath sounds can provide important clues.

Quiet (Reduced) Breath Sounds

Suggest reduced movement of air in that region
May be seen in conditions such as pleural effusion or pneumothorax
When presenting findings, say “reduced breath sounds” rather than “reduced air entry”

4. Sounds that point towards concern

These sounds sit on top of the normal breath pattern and often point toward specific respiratory conditions.

Wheeze

Continuous, musical, whistling sound
Often associated with asthma, COPD, or bronchiectasis

Stridor

High‑pitched sound heard over the upper airway
Caused by turbulent airflow through a narrowed airway
May occur in acute obstruction (e.g., foreign body) or chronic narrowing (e.g., subglottic stenosis)

Coarse Crackles

Brief, popping sounds
Commonly linked to pneumonia, bronchiectasis, or pulmonary oedema

Fine End‑Inspiratory Crackles

Soft, velcro‑like sounds at the end of inspiration
Often associated with pulmonary fibrosis

Repeat On Back

A complete respiratory examination involves more than a quick listen with a stethoscope. Learners must inspect, percuss, and auscultate the front and back of the chest to gain a full understanding of breath sounds, symmetry, and underlying changes in lung tissue.

1. Inspection of the Chest

Before touching the patient, learners visually assess the chest for:

Scars
Deformities
Asymmetry
Abnormal movement

These visual clues help guide the rest of the examination.

2. Chest Percussion

Percussion helps identify differences in underlying tissue by listening to the sound produced when tapping the chest wall.

Learners compare both sides, listening for:

Resonant (normal)
Dull (increased tissue density)
Stony dull (often linked with pleural effusion)
Hyper‑resonant (suggestive of reduced tissue density)

This side‑to‑side comparison is essential for spotting subtle changes.

3. Auscultation

Using the stethoscope, learners listen for:

Normal vesicular breath sounds
Bronchial breath sounds
Reduced breath sounds
Added sounds such as wheeze, stridor, coarse crackles, or fine end‑inspiratory crackles

Each sound provides important clues about airflow and lung structure.

4. Repeat the Entire Examination on the Back

A complete respiratory assessment must include the posterior chest.

After finishing the front, learners repeat:

Inspection
Percussion
Auscultation

The back often reveals findings that may not be heard or seen from the front, especially in conditions affecting the lower lobes.

This step is frequently rewarded in OSCEs because it demonstrates thoroughness, structure, and clinical awareness.

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