01Principles and purposeThe professional or clinical skill and the decisions it supports.
A respiratory examination is an ordered way of sampling physiology, anatomy and illness severity. Its value comes from purposeful observation and comparison rather than from completing a memorised performance. Begin at the doorway: note posture, interaction, speech, respiratory effort, audible sounds, oxygen delivery and nearby equipment. These observations can identify a patient who needs help before a conventional sequence is safe. Explain what the examination involves, ask about pain and mobility, gain consent, clean your hands and position the patient. Exposure should permit inspection while preserving dignity and warmth. Ask before repositioning or touching painful areas, and reconsider whether examination remains appropriate when distress increases.
The central technical principle is paired comparison. Inspect the chest shape and movement; assess tracheal position only when clinically relevant and with care; palpate expansion; percuss corresponding zones; and auscultate a full breath at matching sites. Posterior and lateral areas matter because disease is not evenly distributed. Use the diaphragm of a warmed stethoscope on skin when possible, give short clear breathing instructions, and allow rest if deep breaths cause dizziness or cough. Vocal resonance or additional manoeuvres should answer a specific question, not merely prolong the sequence. Record limits such as inability to sit forward, clothing, background noise or shallow inspiration because these change confidence.
Interpretation begins with description. A percussion note is relatively resonant or dull compared with the other side; breath sounds are vesicular, bronchial, reduced or absent in a defined region; added sounds have timing, character, distribution and response to cough. Combine compatible observations. Basal inspiratory crackles with elevated respiratory rate and peripheral oedema create a different hypothesis set from unilateral reduced expansion, stony dull percussion and reduced breath sounds. Yet both patterns need history, observations and testing. Normal auscultation does not exclude pulmonary embolism, early infection or intermittent airway narrowing. Likewise, wheeze indicates airflow limitation but does not by itself identify asthma.
A clinical assessment must end in synthesis rather than a recital. State whether the patient appears stable, describe the dominant pattern, name the leading and consequential alternative explanations, and identify evidence needed next. In a PACES-style encounter, the discussion links physical findings to differential diagnosis, investigation and management while acknowledging limitations. In workplace care, unexpected instability overrides the examination script: stop, call for appropriate help, obtain observations and follow the local emergency response. Examiner feedback should focus on patient safety, technique, sign description, integration and clarity, using observable behaviours and a specific next practice target.
Key points
- Introduce yourself, confirm identity and purpose, obtain consent, offer a chaperone when appropriate, expose only what is necessary, and monitor comfort throughout.
- Before following a routine, look for distress, altered consciousness, central cyanosis, inability to speak normally, marked work of breathing or dangerous oxygenation; pause and escalate when the patient is unstable.
- Examine from the end of the bed through hands, pulse, face, neck, chest inspection, palpation, percussion and auscultation, comparing corresponding areas on both sides.
- Describe each sign before interpreting it: location, symmetry, intensity, reproducibility and technical quality determine how much diagnostic weight it deserves.
- Combine signs into anatomical and physiological patterns; a single crackle, dull note or reduced breath sound rarely proves one disease without history and observations.
- Finish with a concise synthesis, important alternatives, missing evidence, suitable bedside or formal investigations, and an explicit statement that the patient is comfortable and covered.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Inability to complete sentences, exhaustion, new confusion, central cyanosis, silent chest, severe stridor or rapidly worsening effort makes continued routine examination unsafe and requires prompt clinical assistance.
Respiratory rate, accessory muscle use, posture, recession and speech provide severity information, but anxiety, pain and exertion can alter them and should be considered.
Unilateral reduced expansion with marked dullness and diminished breath sounds supports fluid or other pleural-space processes; asymmetry and the complete pattern matter more than one finding.
Focal bronchial breathing, crackles and increased vocal resonance may support consolidation, although technique, body habitus and disease stage limit sensitivity and specificity.
Widespread expiratory wheeze and prolonged expiration suggest airflow limitation; the absence of wheeze can occur with mild disease or critically low airflow.
Fine inspiratory crackles may occur with interstitial disease or pulmonary oedema, so distribution, chronicity, cardiac findings and functional history are needed to separate mechanisms.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Physiological observations - Why
- Establish current severity before relying on detailed physical signs.
- Interpretation and limitations
- Respiratory rate, oxygen saturation, pulse, blood pressure, temperature and conscious level contextualise the examination; device, oxygen flow and baseline targets must accompany saturation.
- 02
Structured chest comparison - Why
- Localise asymmetry across inspection, expansion, percussion and auscultation.
- Interpretation and limitations
- Concordant abnormalities in the same region deserve more weight than an isolated subtle sign; limited positioning or poor inspiratory effort lowers confidence.
- 03
Peak expiratory flow when safe and appropriate - Why
- Provide an objective airflow measure in a patient able to perform the manoeuvre.
- Interpretation and limitations
- Compare with the person's best or an appropriate reference and judge effort; do not delay urgent treatment or demand forced expiration from an unstable patient.
- 04
Chest imaging selection - Why
- Test structural hypotheses suggested by history, physiology and examination.
- Interpretation and limitations
- A radiograph may clarify consolidation, collapse, oedema or pleural fluid, while other imaging depends on the clinical question; physical examination alone cannot provide anatomical confirmation.
- 05
Arterial or venous blood gas sampling when indicated - Why
- Assess ventilation, oxygenation and acid-base disturbance in selected unwell patients.
- Interpretation and limitations
- Interpret the sample type, inspired oxygen, timing and clinical state together; a number without these conditions can misrepresent severity or response.
- 06
Review of prior data - Why
- Distinguish a new physical finding from chronic baseline and test trajectory.
- Interpretation and limitations
- Previous imaging, spirometry, oxygen requirement and documented signs can refine confidence, but copied labels should not replace a fresh assessment.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked caseInterpret unilateral basal findings without overclaimingA fictional assessment case supplies progressive breathlessness, right-sided reduced chest expansion, a markedly dull percussion note and reduced breath sounds at the right base; respiratory observations are stable.+
- 1Confirm stability, consent and comfort first; position the person as tolerated, compare both sides, and verify that the asymmetry persists across expansion, percussion and auscultation rather than relying on one pass.
- 2Translate the observations into a pattern: concordant basal volume, percussion and sound changes suggest a local pleural-space or adjacent lung process, with pleural fluid an important hypothesis rather than a proven diagnosis.
- 3Build alternatives by mechanism, including consolidation, collapse, substantial pleural thickening or technical limitation; use fever, pain, malignancy risk, procedure history and tracheal position only if they were actually provided.
- 4Synthesise aloud: the patient is currently physiologically stable with a right basal pleural-pattern examination; request suitable imaging and relevant clinical tests, and escalate sooner if breathlessness or observations worsen.
- 5Verify the reasoning by checking the documented location and reproducibility, ensuring the proposed test can distinguish alternatives, explaining uncertainty in plain language, and seeking feedback on comparison technique and closure.
02Examination sequenceMove from safety survey to regional signsA patient is comfortable enough for a complete respiratory examination and has agreed to proceed.+
- 1Observe general appearance, breathing, oxygen delivery and equipment before touching the patient, then examine hands, pulse, face and neck only where each step contributes relevant information.
- 2Inspect movement and scars, palpate expansion, compare percussion and listen systematically over anterior, lateral and posterior chest, pausing between deep breaths if needed.
- 3Add vocal resonance, cough response or functional assessment only when it answers a live question and remains comfortable.
- 4Re-cover the patient, thank them, clean equipment and hands, then present the pattern, uncertainties and sensible completion steps.
03Stop and escalateRespond when examination reveals deteriorationDuring auscultation the patient becomes more breathless, can no longer speak comfortably and appears drowsy.+
- 1Stop the elective sequence, sit the patient in a position that supports breathing, summon appropriate clinical help and begin an immediate structured assessment within competence.
- 2Obtain and communicate current observations, oxygen delivery, timing of change and salient findings; do not leave the patient simply to finish documentation.
- 3Support the emergency response and follow local oxygen and resuscitation processes rather than improvising treatment from an examination script.
- 4After stabilisation, document the change, actions, response and handover, then use supervision to review whether earlier warning cues were missed.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- After practice, compare the recorded sign description with the examiner's observation: location, timing, symmetry and technical conditions should be reproducible.
- Track whether each proposed differential is supported, weakened or untouched by the findings, and identify the single next assessment most likely to separate them.
- Review recordings or supervised encounters for consent language, exposure, positioning, patient cues, auscultation coverage and the clarity of the final synthesis.
- Reassess any patient whose symptoms or physiology change; an earlier calm examination must not become a reason to discount new deterioration.
- Document the person's oxygen device and flow, limitations of examination, escalation decisions and who accepted follow-up responsibility.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Silence can be severe
A quiet chest is not reassuring when effort, exhaustion or airflow are poor; sound intensity depends on airflow as well as airway calibre.
Posterior bases carry information
Dependent fluid, basal consolidation and fine crackles may be missed by an anterior-only performance, but safe positioning takes priority over completeness.
Signs are conditional evidence
Body habitus, shallow breathing, room noise, examiner technique and disease prevalence influence the meaning of a physical sign and should temper certainty.
Completion is hypothesis driven
Saying that the examination should be completed with observations, cardiac assessment or imaging is useful only when the added step is linked to a reason.
Feedback needs observable targets
Ask a supervisor whether hand placement was symmetrical, percussion sites matched and synthesis followed from findings; vague reassurance produces little improvement.
07Common pitfallsFrequent interpretation and management errors.
- 01
Launching into the memorised sequence before noticing respiratory distress or checking whether the patient can tolerate lying back.
- 02
Calling a subtle sound 'consolidation' or 'fibrosis' instead of describing it and then presenting a weighted, uncertain interpretation.
- 03
Percussing unmatched sites, auscultating through clothing or omitting the lateral and posterior chest while claiming a normal examination.
- 04
Continuing deep-breath instructions despite dizziness, pain, coughing distress or a request to stop.
- 05
Listing every possible respiratory diagnosis without using pattern, tempo and physiology to rank the important alternatives.