Chest examination Finding to be looked on inspection, palpation, percussion and auscultation
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chest respiratory examination inspection palpation percussion auscultation clinical findings
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Chest examination: findings to look for
Examine the posterior chest first where possible. Compare corresponding areas on both sides at every step. The core sequence is inspection, palpation, percussion, and auscultation. Clinical Methods describes palpation and percussion as assessing chest expansion and underlying structures, with auscultation helping confirm the findings.
| Method | Findings to assess |
|---|---|
| Inspection | Respiratory rate, rhythm, depth and effort; chest shape and symmetry; chest movement; use of accessory muscles; intercostal or supraclavicular recession; scars, sinuses, masses, dilated veins; cyanosis; deformities such as barrel chest, pectus excavatum/carinatum, kyphoscoliosis; tracheal position; cough and sputum if present. |
| Palpation | Tracheal position; chest expansion symmetry; tactile vocal fremitus; chest-wall tenderness, rib crepitus, masses, subcutaneous emphysema; apex beat position; supraclavicular and axillary lymph nodes. |
| Percussion | Compare side to side over all lung fields. Identify resonance, dullness, stony dullness, hyperresonance, and tympany. Assess diaphragmatic excursion if indicated. |
| Auscultation | Intensity and character of breath sounds; equality on both sides; added sounds such as crackles, wheeze, rhonchi, pleural rub, stridor; vocal resonance, including bronchophony, egophony, and whispered pectoriloquy. |
1. Inspection
Look for:
- General respiratory distress: tachypnea, inability to speak full sentences, nasal flaring, sweating, agitation, cyanosis.
- Pattern of breathing: Cheyne-Stokes, Kussmaul, paradoxical breathing, prolonged expiration.
- Chest shape:
- Barrel chest: hyperinflation, often COPD.
- Pectus excavatum or carinatum.
- Kyphosis/scoliosis: may restrict ventilation.
- Chest movement:
- Reduced unilateral movement: pleural effusion, pneumothorax, collapse, consolidation, pain from rib fracture.
- Paradoxical movement: flail chest.
- Skin/chest-wall signs: scars from thoracotomy or chest drain, sinuses, herpes zoster lesions, dilated veins, bruising, visible mass.
- Tracheal deviation: may suggest major volume or pressure change in one hemithorax.
2. Palpation
Trachea
Palpate in the suprasternal notch.
- Shifted away from lesion: massive pleural effusion, tension pneumothorax.
- Shifted toward lesion: lung collapse, fibrosis, post-pneumonectomy volume loss.
Chest expansion
Place hands symmetrically on the lower posterior chest with thumbs near the midline. Ask the patient to take a deep breath.
- Reduced on one side: pleural effusion, pneumothorax, collapse, consolidation.
- Bilaterally reduced: COPD, diffuse pulmonary fibrosis, severe asthma, neuromuscular weakness.
Tactile vocal fremitus
Place the ulnar edge or palm of the hands symmetrically over the chest while the patient says “ninety-nine” or “one-one-one.”
- Increased: consolidation with a patent bronchus, for example lobar pneumonia.
- Decreased/absent: pleural effusion, pneumothorax, airway obstruction/collapse, thick chest wall, emphysema.
Other palpation
- Chest-wall tenderness: rib fracture, costochondritis, pleurisy.
- Crepitus under skin: subcutaneous emphysema.
- Apex beat: may be displaced by mediastinal shift.
- Lymph nodes: cervical and supraclavicular nodes, particularly in suspected lung malignancy.
3. Percussion
Percuss each intercostal space, comparing right with left.
| Percussion note | Likely causes |
|---|---|
| Resonant | Normal aerated lung |
| Dull | Consolidation, collapse, pleural thickening, mass |
| Stony dull | Pleural effusion |
| Hyperresonant | Pneumothorax, emphysema/hyperinflation |
| Tympanitic | Very large pneumothorax or air-filled viscus in the thorax |
Also check diaphragmatic excursion posteriorly:
- Reduced bilaterally: hyperinflation, bilateral diaphragmatic weakness.
- Reduced unilaterally: pleural effusion, lower-lobe collapse, phrenic nerve palsy.
4. Auscultation
Listen systematically over corresponding areas, ideally during deep breathing through an open mouth.
Breath sounds
- Vesicular: normal, soft inspiratory sound with shorter expiration.
- Bronchial breathing: harsh, tubular sound with expiration as long as or longer than inspiration. Suggests consolidation, provided the bronchus is patent.
- Reduced/absent breath sounds: pleural effusion, pneumothorax, severe emphysema, collapse, large airway obstruction.
- Amphoric breathing: hollow, metallic quality, classically over a large cavity or open pneumothorax.
Added sounds
- Fine late inspiratory crackles: pulmonary fibrosis, early pulmonary edema.
- Coarse crackles: bronchiectasis, pneumonia, pulmonary edema.
- Wheeze: narrowed airways, such as asthma or COPD.
- Rhonchi: secretions in larger airways, may change after coughing.
- Pleural friction rub: pleural inflammation, such as pleurisy or pulmonary embolism.
- Stridor: upper-airway obstruction, an emergency if acute or associated with respiratory distress.
Vocal resonance
Ask the patient to repeat “ninety-nine” while auscultating.
- Increased vocal resonance / bronchophony: consolidation.
- Egophony: “ee” heard as “ay,” often at the upper border of pleural effusion or over consolidation.
- Whispered pectoriloquy: whispered sounds unusually clear, supporting consolidation.
- Reduced vocal resonance: pleural effusion, pneumothorax, collapse due to bronchial obstruction.
Classic pattern recognition
| Condition | Inspection/palpation | Percussion | Auscultation/vocal resonance |
|---|---|---|---|
| Consolidation | Reduced expansion; increased fremitus | Dull | Bronchial breathing, crackles, increased vocal resonance |
| Pleural effusion | Reduced expansion; reduced fremitus; trachea may shift away if massive | Stony dull | Reduced/absent breath sounds and vocal resonance |
| Pneumothorax | Reduced expansion; reduced fremitus; trachea may shift away in tension pneumothorax | Hyperresonant | Reduced/absent breath sounds and vocal resonance |
| Lung collapse | Reduced expansion; trachea often shifts toward lesion | Dull | Reduced breath sounds and vocal resonance, unless compression collapse |
| Emphysema/COPD | Barrel chest; reduced bilateral expansion | Hyperresonant | Quiet breath sounds, prolonged expiration, wheeze |
| Pulmonary fibrosis | Reduced bilateral expansion | Often normal or dull | Fine end-inspiratory “Velcro” crackles |
Normal examination summary: Chest is symmetrical with equal bilateral expansion; trachea is central; percussion is resonant throughout; vesicular breath sounds are heard bilaterally without added sounds; vocal resonance is normal.
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