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1. 1. Inspect: a) Patient's colour (central cyanosis, peripheral cyanosis, fingers, and nails) b) Count res rate 1 min(rhythm, depth and effort) c) Inspect shape of thorax from front, side and back

2. 2. Palpate lymph nodes, central, pectoral, Lateral and subscapular

3. 3. Posterior Thorax: a) position pt upright, arms crossed b) Inspect contour, shape and movement: bony deformities, lesions, bruises, masses, sinus tracts, asymmetry chest expansion, abnormal retraction of interspaces

   • c. Palpate: rib spaces for tenderness, chest expansion, tactile fremitus
     • Percuss: all lung fields and elicit a percussion note, Compare sides (ladder technique), lower loves posterior mid-axillary line
       • Auscultate: all lung fields, listen to inspiratory and expiratory at each spot, compare sides (ladder pattern) NB lower lobes in mid-axillary line
       • HEALTHY LUNGS ARE RESONNANT! Intensity, pitch, duration
         • Large pleural effusion: Flat, soft, high, short (thigh)
         • Lobar pneumonia: Dull, medium, medium, medium (liver)
         • Simple chronic bronchitis: Resonance, loud, low, long (healthy lung)
         • COPD or pneumothorax: hyper resonance, very loud, lower, longer (usually none)
         • Large pneumothorax: Loud and high (gastric air bubble/ puffed out cheek
         • Dullness: when fluid or tissue replaces air containing lung e.g. pneumonia, pleural effusion, haemothorax. Empyema or fibrous tissue or tumour
         • Hyperresonance heard over hyper inflated lungs - COPD, Asthma, Unilateral = pneumothorax
         • Diaphramatic excursion (3-5cm in adults) Percuss down whilst pt seated, boundary between lung and structure below diaphragm - high +pleural effusion/ atelectasis

4. 4. Anterior Thorax: Patient partially supine COPD pt's may prefer sit forward lips pursed exhalation

   • Inspect: a)contour, shape and movement b) bony deformities, bruises, lesions, masses or sinus tracts, asymmetry chest expansion, abnormal retraction interspaces
     • Palpate: rib spaces for tenderness, tactile remits
       • Percuss: All lung fields, compare sides (ladder), NB lower lobes posterior to mid-axillary line
         • Auscultate: all lung fields, inspiratory and expiratory, ladder patterns, NB lower lobes mid-axillary line
           • 1.Listen to breath sounds 2. Listen for added sounds 3.Listen for sound of voice transmitted through chest wall
             • Breath Sounds NORMAL
               • Vesicular: soft & low pitched: though inspiration, no pause and through expiration - fade away about 1/3 through expiration: heard over most of lungs
               • Bronchovesicular: almost equal inspiratory and expiratory may have slight interval: heard in 1st & 2nd intercostal spaces anteriorly and anteriorly between if heard in distant places suspect air filled lung replaces with fluid or solid tissue
                 • If abnormal assess transmitted voice sounds
                   • Increased transmission = normal air filled lung airless
                   • Ask pt to say EE if heard as AY (egophony) lobar consolidation e.g. pneumonia
                   • whisper 99
               • Bronchial: louder/higher in pitch short silence between I & E Expiratory longer than inspiratory Heard over Manubrium if at all if heard distant places, suspect lung replaced with fluid or solid tissue
               • Decreased when air flow decreased e.g. COPD, or muscular weakness or when sound transmission poor - pleural effusion, pneumothorax
             • Added sounds
               • Crackles: DISCONTINUOUS, INTERMITTENT, NON-MUSICAL BRIEF Sign of PNEUMONIA, fibrosis, CCF, bronchitis or bronchiectasis
                 • Fine crackles
                 • Coarse crackles
               • Wheezes and Rhonchi MUSICAL PROLONGED NOT THROUGH WHOLE CYCLE
                 • WHEEZES: Narrowed airways - asthma, COPD, bronchitis
                 • RHONCI: Secretions in large airways
               • TIMING & LOCATION CLEAR ON COUGHING?