College of Medicine and Medical Sciences

Clinical skills Center

Chest Examination
Steps Done Done Not
well but done
not
well
General:-
1- Dress professionally in white coat and seek permission for
examination.
2- Introduce yourself to the patient as a medical student,
explain the procedure to patient.
3- Wash hands before and after examination with sterile
solution.
4- The examination room should be quiet and warm.
5- The patient should be lying in supine ( semi-recumbent )
position and one pillow under head with both arms at two
sides or folded across the chest .
6- Stand at the right side of the patient and use your right
hand, if you are a right handed (warm hands).
7- Expose the chest and upper abdomen of the patient.
Inspection:-
Student comments on the following :-
1-Shape of the chest:
A- Symmetrical deformity
B- Asymmetrical deformity
(bulge or retraction)
2-Respiratory movement:
A- Respiratory rate: count while you put your fingers
on the radial artery
B- Rhythm: inspiration, expiration, pause (abnormal as
Chyne-stoke & Biot's breathing)
C- Type: Observe the mode of breathing
D- Chest expansion: Student asks the patient to take
deep breath and compares the range of movement on
the both sides of the chest
E- Accessory muscles
3- Pulsation.
4-Skin pigmentation, Scars of previous surgery.
5- Dilated veins.
Palpation:
1-Student confirms the detected finding in the inspection
(respiratory movement, chest expansion and pulsation)

Revised by Internal Medicine Department. 14/4/ 2011 1

Dr / Waleed Samy
2- Student checks for chest expansion :-
A- Ask the patient lying down.
B- Place your hands firmly on the chest wall with fingers
extending around the sides of the chest & your thumbs
should almost meet in the midline and should be
slightly lifted off the chest so they are free to move
with respiration.
C- Ask patient to take deep breath and see the
movements of the thumbs. Thumbs should move apart
at least 5 cm.
D- Record the measure of maximum inspiration and
expiration in lower and middle chest .
E- Ask the patient to sit to examine upper chest.
F- Stand behind the patient and put your thumbs on
patient nuckle .
3 - Position of mediastinum :
Assess the following :-
A -Tracheal position:-
- Patient is a centralized position for the examiner or the
examiner stands in the front of the midline of the
patient.
- Student puts his index finger between the trachea and
right sternomastoid muscle and then he puts his index
finger between the trachea and left sternomastoid
muscle.
B -Apex position:-
- Student assess the position of the apex by palpation of
the apex beat
4- Tactile vocal resonance:
- Student puts the ulnar borders of both hands on the
different areas of chest wall at the same level and time
- Student asks the patient to say 44 by Arabic speaking
or 99 by English speaking.
- Student compares between the different parts of the
chest systematically ( right and left upper chest wall,
right and left lower chest wall ) .
5- Palpable adventitious sounds: rub & ronchi.
6- Points of local tenderness:
Palpate the chest wall for skin and bone (clavicle,
sternum, ribs, costochnodral junctions, spinous
process).
Percussion:
1- Move the wrist only for percussion & percus on the middle
phalanx only of the middle finger
2- Observe notes tympanic / hyperresonant / resonant /
impaired / dull / stony dull
Revised by Internal Medicine Department. 14/4/ 2011 2
Dr / Waleed Samy
3- Map out area of impaired resonance including cardiac &
hepatic dullness by percussing from a resonant to dull area
- Percus the following while patient is lying down:-
1- The precordial area (4-6 spaces)at the left side of the chest
2-The front of the chest along these lines: parasternal ,
midclavicular, anterior, middle and posterior axillary line
from 2 nd to 6th intercostals space
3-The clavicle directly
4- Traub's area
- Ask patient to sit and percuss the following:
1- The posterior wall paravertiberal and scapular line
2- Kronig's isthmus: The supraclavicular fossa
3-Tidal percussion:
- Percuss till dullness of the liver.
- Ask the patient to take a deep breath (normally the
diaphragm descent )
- Percuss at the same site ( dullness become resonance )
Auscultation :
1- Make the patient relaxed and ask him to take deep breaths
by mouth.
2- Auscultate the two sides alternatively.
3- Auscultate the following:-
- Breath sounds (types and amplitude ).
- Advetatious sounds: rhonchi, crepitation and rub.
- Conducted voice; vocal resonance & whispering
pectorlquy.
4- Cover the patient completely .

Revised by Internal Medicine Department. 14/4/ 2011 3

Dr / Waleed Samy
 Good luck .. Ahad Abdullah

Chest Examination
General
1- Introduce yourself to the patient
2- Take a permission
3- Explain Procedure
4- The patient should be lying supine position and one pillow under head with both arms
at two sides or folded across the chest
5- Stand at the right side of the patient and use your right hand, if you are right-handed.

Local Emanation:
Assessment Comment
procedure
Inspection
I will inspect the Normal (Elliptical) The shape of
Shape of the the chest
chest normal
(Elliptical)

There is no
bulge or
retraction

In case of
abnormality as
COPD (Parallel
shape chest)
Increase in
anteroposterior
diameter
I will inspect Respiratory rate: count while you put your fingers on The respiratory
your Respiratory the radial artery. rate normal
movement -Type of movement: thoracoabdomenal (female) or The respiratory
- Ask the patient abdomenothoracic ( male) movement
to take breath normal
to compare the
range of
movement.
Pulsation
Inspect for scars, There is no scars,
Skin skin
 pigmentation, pigmentation,
Dilated veins dilated veins

Palpations
There is no
I will palpate your chest limitation
expansion. Normal chest
o Ask the patient expansion
lying down to
palpate in lower
and middle chest.
o Place your hands
on the posterior
chest wall with
your thumbs at the
level of T9 or T10
and pressing
together a small
skin fold. As the
patient takes a
deep breath,
observe the
movement of your
thumbs. Thumb
should move apart
at least 5 cm.
o Ask the patient to
sit to examine the
upper chest
o Stand behind
patient and put
your thumb on
patient knuckle.
 I will palpate your Trachea in
trachea position normal
o Patient is a position there
centralized is no shifting
position for the
examiner, or the Abnormality
examiner stand in Shift to the
the front of the
same side
midline of the
collapse
patient.
Against side
o Put your index
finger between fluid (Pleural
trachea and right effusion)
sternomastoid
muscle and then
put your index
finger between
trachea and left
sternomastoid
muscle
I will Palpate your apex Apex of the lung: begin in the 2nd intercostal The apex beat
beat of the apex of the space to 5th intercostal space is normal
lung

TVF:
o Ulnar surface TVF normal
space by space
and ask the
patient to see 99
/ or 44 In Decrease in all
axilla(until 6 rib) lung diseases
and back {supra except
and infra consolidation
scapula} until the pneumonia
10 thoracic spine
o Compare the
different parts of
the chest
 systemically
(right and left
upper chest wall,
right and left
lower chest wall).

Palpate rub and rhonchi There is no rub

or rhonchi

In case of
abnormality
Rub in dry
pleurisy
I will Palpate chest wall
for skin and bone
(clavicle, sternum, ribs,
costochondral junctions.
Spinous process) to
check Tenderness
Rules for percussion;
1- Move the wrist only for percussion & percuss on the middle phalanx only of the middle
finger.
2- Observe notes tympanic/ hyper resonant/ resonant / impaired / dull / stony dull.
3- Role (resonant to dullness)
4- Area of normal dullness (bare area of the heart, liver, tidal percussion)
5- We percuss 2 lungs for comparison and special area
6- Two types of percussion light and heavy, we use light percussion for lung. And heavy in
the back due to presence of strong muscles

Percussion
o Ask the patient to lie The
down (supine position) abnormality of
then we percuss: the Traub s
o pericardial area (4-6 area become
spaces) at the left of the dullness
chest. In case of
o I will percuss the chest Mass in left
along these lines lung or
(Parasternal, splenomegaly
midclavicular, anterior, or any
middle, posterior axillary problems in
line from 2nd to 6th the borders of
intercostal space) this area
The importance of Traub s area lining the funds
o Clavicle directly of the stomach
It is very important to know the boundaries of
o Traub s area (resonant / this area
hyper resonant) Right side: left lobe of the liver
Left side: spleen
Upper: lung lower: costal margin
 o Ask the patient to sit and
percuss:
o Posterior wall
paravertebral and
scapular line
o Kronig s isthmus the
supraclavicular fossa
(represent lung apex)
above medial 1/3 of the
clavicle
o Tidal percussion
- Percuss till
dullness of the
the importance of tidal percussion to differentiate
liver between supra-diaphragmatic and infra-
- Ask the patient diaphragmatic dullness
to take a deep
breath
(normally the
diaphragm
decent)
- Percuss at the
same site
(dullness
become
resonance)

Auscultation
- Breath sounds heard on the lung
Normal normal vesicular sound (inspiration / expiration) 1:3 and no gap
- Harsh Vesicular sound
Inspiration = expiration and no gap heard in case of infection
- Bronchial breathing trachea
- Rhonchi caused by secretion in large airways (Heard in inspiration and
expiration)
- Wheeze
- Vocal resonance 44 or 99
Cover patient completely