Preparations & Draping

• Wash hands
• Patient should be sitting up

For this exam, I need to expose your chest, so I need to lower your gown down to below your chest. Is that OK? Can you lower the gown by yourself or would you like for me to help you with that?

If you are feeling uncomfortable at any point, please let me know.

• For female patients, remove gown only in areas needed for the exam. There is no need to expose the whole chest during the examination. Seperate examinations and inspections into upper chest, lower chest, flanks and back.

Inspection

• General

  • Level of consciousness

  • Look for signs of masses, scars, bruises, lesions

    • Bruising with tenderness may indicate a fractured rib

  • Check for atrophy/hypertrophy of the chest muscles

  • Check fingers for clubbing (Schamroth sign)

    

• Respiratory Difficulty

  • Comment on comfort breathing on room air
  • Use of accessory muscles (esp. muscles of the neck)
  • Tripoding? (in severe COPD)
  • Intercostal indrawing?
  • Pursed lip breathing, heaving, wheezing?

• Cyanosis

  • Comment on color of lips, buccal mucosa, under tongue
  • Comment on fingernail color, check cap refill (normal ≤2 s)

• Chest Abnormalities

  • Spine kyphosis or scoliosis
  • Pectus excavatum or pectus carinatum
  • Barral chest

• Trachea (can combine with palpation)

  • Midline? Deviations?

• Resp Rate (estimate using 30s x2 or 15s x4)

On inspection, the patient is calm, alert, and breathing well on room air with no sign of respiratory distress. I do not see any use of accessory muscles, tripoding, intercostal indrawing, or pursed lip breathing, heaving and wheezing. [Check Schamroth Sign] I do not see any digital clubbing.

There are no visible masses, scarring, bruises, or lesions. I do not see any muscle atrophy or chest wall deformities such as pectus excavatum or pectus carinatum. The chest is not barral shaped. There is no spine kyphosis or scoliosis. I do not see any cyanosis on the lips and the fingers. [Check cap refil] Cap refil is 2 seconds, which is normal. [Ask to open mouth and lift tongue] There is no cyanosis on the buccal mucosa or on the franulum.

The trachea appears to be midline. I count about 6 breaths over the last 30 seconds, which is 12 breaths per minute and is normal.