Inspection
General inspection
Preferably standing up, if necessary sitting down or lying down
Posterior, lateral thorax, anterior
Always compare left and right
Assess:
- The breathing
- type of breathing (chest and/or abdominal breathing)
- breathing rate
- respiratory depth
- respiratory regularity
- the ratio between inspiration and expiration
- cough or audible breathing
- the presence of dyspnoea (breathlessness)
- The presence of a preferred posture and/or use of accessory breathing muscles
- The presence of blue/grey lips and tongue (central cyanosis)
- The presence of peripheral cyanosis, clubbed fingers and hourglass nails.
Inspection of the thorax
Assess:
- The skin of the thorax
- The thoracic subcutis
- The breasts
- The musculature (muscle layer)
- The skeleton
- the skeletal landmarks
- the shape and symmetry of the thorax.
- The presence and symmetry of the respiratory excursions
- at rest
- following maximum inspiration
- presence of intercostal retraction or bulging
- if necessary, measure the thoracic circumference with a measuring tape, both at rest and during deep inspiration.
Palpation
- Palpate the lymph node stations: submandibular, in front of and behind the sternocleidomastoid muscle, supraclavicular and axillary areas.
If indicated:
- Examine the symmetry of the thoracic excursions during rest and deep respiration
Each time, place your hands left and right:- high on the anterior side of the thorax
- on anterior side of the thorax, following the movements of the costal triangle with your thumbs
- laterally
- with one hand on the sternum and the other on the spine: the sternal lift
- low down on the posterior side of the thorax
- Check the thorax for bipolar and local pain upon palpation
- Compare the vocal fremitus of an area with suspected abnormalities with a non-suspect (preferably contralateral) area.
Percussion
The posterior thorax
Start with topographic percussion
- The preferred position is standing directly behind the patient or alternatively on the right-hand side of the examination table. Ask the patient to sit down.
- Determine the lung boundaries at the posterior side of the thorax:
- percuss along the scapular line, working downwards
- determine the transition from resonant percussion to dull percussion (mark this border, if possible, with a marking pencil)
- Note the location of this border by making use of anatomical reference points
- Repeat the procedure on the other side
- Compare the findings.
Subsequently test the mobility of the lung boundaries if indicated
- Place the pleximeter finger below the posterior lung border indentified above
- Ask the patient to breathe in deeply and to hold their breath
- Percuss downwards from here, along the scapular line, and the resonant percussion sound disappears (mark with a skin pencil if possible)
- Ask the patient to breathe normally again
- Determine the distance between the border found in this situation with the previously determined lung border
Express this distance in centimetres or finger widths - Repeat the procedure on the other side.
Next, carry out comparative percussion on the posterior thorax.
- Start above lung apices, working downwards, preferably percussing in the intercostal spaces, medially near the scapulae, then returning to the midscapular line, comparing the symmetrical locations on the left and right side.
- If required, complete the examination with percussion of a larger area.
The lateral thorax
Carry out the comparative percussion
- Start in the axilla, working downwards
- Examine symmetrical locations, preferably by percussing in the intercostal spaces, and comparing the left and right sides
- If required, complete the examination with careful percussion of a larger area.
The anterior thorax
Start with topographic percussion
- Ask the patient to lie in supine position
- Determine the relative and absolute lung-liver border on the anterior aspect of the thorax:
- percuss along the right midclavicular line, in a downwards direction
- mark the position where the clear resonant percussion tone starts to become dull: the relative lung-liver border
- then percuss more gently, continuing downwards until an absolute dull tone is audible: the absolute lung-liver border
- note the location of this border by making use of anatomical reference points.
If indicated:
- Determine the relative cardiac dullness:
- percuss gently; note where the resonant tone becomes dull
- to percuss the right-hand heart border, start from the right side of the thorax just above the lung–liver border and percuss towards the left with the pleximeter finger in a vertical position
- to percuss the left heart border, start from the left anterior axillary line and continue to percus towards the right side of the thorax, with the pleximeter finger in a vertical or horizontal position
- to percuss the upper border of the heart, preferably in the intercostal spaces, start on the left side of the thorax and percus downwards (caudally), from the midclavicular line to the parasternal line, with the pleximeter finger perpendicular to the direction of percussion
- note the location of this border by making use of anatomical reference points
- Percuss Traube’s space.
Proceed with the comparative percussion of the anterior thorax
- Start in the supraclavicular fossa
- percuss along the midclavicular line, in a downwards direction, and compare symmetrical locations on the left and right side
- Percuss the clavicle without the pleximeter finger
- Thereafter, preferably percuss in the intercostal spaces
- If required, complete the examination with percussion of a larger area.
Auscultation
- Ensure that the stethoscope is warm and use the membrane-side
- Instruct the patient to:
- sigh deeper than usual, with the mouth opened
- with the tempo being indicated by placement of the stethoscope
- Systematically auscultate all pulmonary fields
- examine the posterior aspect (medial at the level of the scapulae and then along the scapular line), the lateral thorax (along the axillary line) and the anterior aspect (along the midclavicular line)
- start above lung apices
- work downwards
- immediately compare symmetrical locations on the left and right sides
- listen to a complete cycle of inspiration and expiration at each position
- avoid the patient hyperventilating by – if necessary – pausing the examination
- Assess the presence and nature of the breath sounds
- Assess the presence and nature of possible adventitious sounds.
If indicated:
- Examine the transmission of the vocal sounds (bronchophony)
- ask the patient to say “ninety-nine”
- listen to the transmission of the vocal sound across the pulmonary field where, based on percussion and/or auscultation, abnormalities are expected and if possible compare these areas with the healthy contralateral pulmonary field or, alternatively, with another area that is not suspected for abnormalities.