Ask the patient to remove his/her shirt/blouse and position the patient on the bed at an angle of approximately 45°. Once the patient is comfortable, commence the examination. Ensure that you have washed your hands and that they are at a temperature appropriate for palpation.

General inspection

1. ▪ Look around the bed for sputum pot, peak flow metre and inhalers.

2. ▪ Look for general abnormalities, such as cachexia, pallor and cyanosis.

3. ▪ Is the patient on supplementary oxygen.

4. ▪ Look for gross distension of the neck veins.

5. ▪ Look for scars – do they correlate with the surgical history?

6. ▪ Count respiratory rate noting dyspnoea, tachypnoea, laboured breathing, stridor or wheeze, or cough.

7. ▪ Note the breathing pattern (e.g. Cheyne-Stokes respiration).

8. ▪ Note chest shape. In normal subjects the AP diameter of the chest is less than the lateral diameter; in hyperinflation or ‘barrel chest’ states – seen in states of chronic airflow limitation – the reverse may be true. Look for other chest wall deformities, for example pectus excavatum (funnel chest), or pectus carinatum (pigeon chest) where the sternum and costal cartilages project inwards and outwards, respectively.

9. ▪ Look for any marked kyphosis or scoliosis.

Hands

1. ▪ Inspect the hands looking for any digital clubbing (bronchial carcinoma, chronic pulmonary sepsis, cryptogenic fibrosing alveolitis, asbestosis), or peripheral cyanosis.

2. ▪ Look for CO2 retention tremor.

JVP

1. ▪ With the patient lying supine at 45°, assess the jugular venous pressure and the jugular venous pulse form. Remember the JVP may be raised in cor pulmonale (right heart failure due to lung disease).