Macleod's Clinical Examination · 4th Year Study Guide by NOVA

Respiratory System
NOVA's Examination

Systematic approach — General → Hands → Face → Neck → Chest

LookInspect
FeelPalpate
PercussPercuss
ListenAuscultate
ThinkInterpret
🎯
Session Objectives
Learning Goals
  • 01Perform a systematic respiratory examination.
  • 02Identify important abnormal respiratory signs.
  • 03Understand the mechanism behind major examination findings.
  • 04Differentiate consolidation, pleural effusion, pneumothorax, collapse and COPD clinically.
  • 05Present findings in an OSCE-style format.
  • 06Recognize important red flags requiring urgent action.
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Before You Start
Preparation
"I would like to examine the respiratory system. This will involve examining your hands, face, neck and chest." — Standard OSCE introduction phrase
Checklist
  • Introduce yourself and confirm patient's identity
  • Explain the examination and obtain consent
  • Wash hands
  • Position patient at 45 degrees on examination couch, head supported by pillow
  • Expose chest adequately while maintaining dignity
  • Examine from the patient's right side
Note 1 · Environment First

Before touching the patient, examine the environment. Look for oxygen, nebulizers, inhalers, sputum pots — these give important diagnostic clues.

Note 2 · Start Position

General examination starts from the foot of the bed. Before touching the patient — what can you already see?

👁️
General Inspection
Foot of Bed
What to look for at the foot of the bed

Asymmetry, respiratory pattern and rate, connections, signs of respiratory distress, obvious deformities.

Signs of Respiratory Distress

① Tachypnea

Normal: 12–15/min
Anxiety: ~15–20/min
Tachypnea: >20/min
Bradypnea: <12/min

② Intercostal Retraction

Inward movement between ribs on inspiration due to increased negative intrathoracic pressure and increased work of breathing.

③ Accessory Muscle Use

Activation of sternocleidomastoid & scalene muscles when normal respiratory muscles cannot meet ventilatory demand.

④ Nasal Flaring & Pursed Lips

Nasal flaring: widens nostrils, reduces airway resistance.
Pursed lips: creates positive pressure, prevents small airway collapse.

⑤ Tripod Position

Patient leans forward with hands on knees to stabilize shoulder girdle and allow accessory muscles to work more effectively.

⑥ Central Cyanosis

Bluish discoloration of tongue and oral mucosa caused by reduced oxygen saturation of arterial blood.

Respiratory distress sign Respiratory distress sign Respiratory distress sign Respiratory distress / cyanosis Central cyanosis Central cyanosis
Respiratory Patterns Reference
PatternCharacteristicsCommon Causes
Normal (Eupnea)Regular, 12–20/minHealthy individual
TachypneaRapid, shallow (>20/min)Fever, anxiety, pneumonia, hypoxia
BradypneaSlow (<12/min)Opioid overdose, brain injury, hypothyroidism
ApneaComplete cessationCardiac arrest, sleep apnea, CNS injury
HyperpneaIncreased depthExercise, metabolic acidosis
Hyperventilation↑ rate and depth → low CO₂Anxiety, sepsis, metabolic acidosis
Hypoventilation↓ ventilation → high CO₂COPD, drug overdose, neuromuscular
Cheyne–StokesCyclic waxing & waning + apneaHeart failure, stroke, brain injury
KussmaulDeep, rapid, laboredDKA, severe metabolic acidosis
🤲
Hands & Arms
Peripheral Signs
Examination Sequence
  1. 1
    Inspect hands and nails for clubbing, nicotine/tar staining, nail discoloration, and peripheral cyanosis
  2. 2
    Ask patient to extend both arms with wrists dorsiflexed
  3. 3
    Assess the radial pulse while examining the hands
  4. 4
    Palpate the distal forearms for tenderness or other abnormalities
Clubbing Clubbing / nail sign Schamroth's window Tar staining / nail Peripheral cyanosis
Key Hand Findings
Clubbing
Painless enlargement of terminal phalanx; increased nail curvature; Schamroth's window absent
Lung cancer, bronchiectasis, pulmonary fibrosis, lung abscess, empyema, cystic fibrosis, mesothelioma.
COPD does not cause clubbing.
Yellow Nail Syndrome
Yellow–brown discoloration; thickened, slow-growing nails
Yellow nails + lymphoedema + pleural effusion → Yellow nail syndrome
Tar Staining
Brownish discoloration of fingers and nails
Caused by tobacco tar (not nicotine). Brown fingers → think smoking.
CO₂-Retention Tremor (Asterixis)
Coarse, flapping tremor with arms extended and wrists dorsiflexed
Severe ventilatory failure with CO₂ retention. Coarse flapping → think hypercapnia.
4th Year Takeaway

Clubbing in an adult → serious underlying disease

Especially lung cancer or pulmonary fibrosis. Remember: COPD itself does not cause clubbing.

😮
Face
Central Signs
Examination Sequence
  1. 1
    Inspect the conjunctiva for signs of anaemia
  2. 2
    Examine the tongue for central cyanosis
  3. 3
    Check for ptosis and pupil asymmetry (Horner's syndrome)
Clinical Pearl · Cyanosis & Haemoglobin

Cyanosis may be difficult to detect in anaemic patients — visible only when sufficient deoxygenated haemoglobin is present. More apparent in polycythaemic patients, even with mild O₂ desaturation.

🔍
Neck
Trachea & JVP
Examination Sequence
  1. 1
    Position patient comfortably, supporting head to relax the sternocleidomastoid muscles
  2. 2
    Assess the JVP (jugular venous pressure)
  3. 3
    Assess tracheal position — gently place a finger in the sternal notch. Trachea should be central
  4. 4
    Assess cricosternal distance — normally three fingerbreadths between sternal notch and cricoid cartilage
JVP assessment Tracheal position Cricosternal distance Neck examination
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Thorax — Inspection
Look
What to Inspect
  1. 1
    Chest deformities & asymmetry
    Pectus excavatum (inward sternum) · Pectus carinatum (outward sternum) · Kyphoscoliosis
  2. 2
    Scars
    Midline sternotomy → cardiac surgery · Infraclavicular → pacemaker · Mid-axillary → chest tube · Lateral/posterior → thoracic surgery
  3. 3
    Chest drains — position and surrounding skin
  4. 4
    Visible masses on chest wall
  5. 5
    Dilated chest wall veins → suggest SVC obstruction
  6. 6
    Barrel chest — increased anteroposterior diameter; seen in COPD and severe asthma
  7. 7
    Chest movement with respiration — depth, pattern, symmetry of expansion
Chest inspection reference Barrel chest / hyperinflation Pectus excavatum Pectus carinatum Kyphoscoliosis Chest scars / deformities Chest inspection
Inspection Positions

Foot of bed: asymmetry, respiratory pattern & rate, connections, distress signs.
Right side: deformities, scars, visible veins/pulsations/masses — and always inspect lateral and posterior chest for thoracotomy scars or drains.

✋
Thorax — Palpation
Feel
Anterior Chest — Palpation Sequence
  1. 1
    Locate the apex beat and assess its position
  2. 2
    Assess for a right ventricular heave along the left sternal edge
  3. 3
    Palpate chest wall for tenderness, masses, or abnormalities
  4. 4
    Assess chest expansion at upper and lower chest, comparing both sides
  5. 5
    Assess TVF using palmar or ulnar aspect — should be symmetrical bilaterally
  6. 6
    Assess tracheal position for deviation
  7. 7
    Assess cricosternal distance — normally 3–4 fingerbreadths
Chest expansion palpation Chest expansion upper Chest expansion lower Palpation technique
Expected Normal Findings
  • Symmetrical chest expansion bilaterally
  • Symmetrical tactile vocal fremitus (TVF)
  • Trachea centrally positioned — no deviation
  • Normal cricosternal distance: 3–4 fingerbreadths
TVF Technique — Step by Step
  1. 1
    Use the ulnar or palmar aspect of your hand
  2. 2
    Ask patient to say "99" repeatedly while you palpate
  3. 3
    Compare both sides using a zigzag pattern
  4. 4
    Start supraclavicular → Supramammary → Mammary → Inframammary → Lateral chest
TVF technique TVF hand position TVF zigzag pattern TVF posterior TVF lateral
Important

Remember to include the lateral chest during palpation. The posterior chest follows the same sequence as the anterior chest.

🥁
Percussion
Percuss
Technique
  1. 1
    Place the middle finger of non-dominant hand firmly on an intercostal space, parallel to the ribs
  2. 2
    Strike the middle phalanx with the flexed tip of index or middle finger of dominant hand
  3. 3
    Percuss top to bottom; compare right with left at each level before moving down
  4. 4
    Avoid percussing directly over ribs or scapulae
Percussion sites diagram
Percussion sites — anterior and posterior chest
Anterior Chest
  • Percuss supraclavicular, upper, middle, and lower zones
  • Normal: resonant note over lung fields
  • Cardiac dullness just lateral to lower left sternal edge
Posterior Chest
  • Ask patient to sit forward and fold arms across chest
  • Percuss lateral to the spinal muscles
  • Avoid scapulae and spinal muscles
Percussion Note Reference
NoteSounds LikeSuggests
ResonantHollow, low-pitchedNormal lung
DullFlat, thud-likeConsolidation, collapse, or pleural effusion
Stony DullVery flat, woodenPleural effusion (classic)
HyperresonantBooming, drum-likePneumothorax or lung hyperinflation
Cardiac Dullness

Normally present just lateral to the lower left sternal edge due to the right ventricle. May be absent with lung hyperinflation as the hyperinflated lung overlies the heart.

🔊
Auscultation
Listen
Auscultation Sequence
  1. 1
    Auscultate the lung apices, comparing right and left
  2. 2
    Ask patient to take slow, deep breaths through open mouth
  3. 3
    Auscultate anterior chest top to bottom, comparing symmetrical areas bilaterally
  4. 4
    Follow the same sequence as percussion
  5. 5
    Assess quality: vesicular · reduced/absent · bronchial
  6. 6
    Listen for asymmetry and added sounds — wheeze or crackles
  7. 7
    Auscultate lateral chest along mid-axillary line, comparing both sides
Auscultation sites diagram
Auscultation sites — follow same sequence as percussion
Stethoscope Tips

Use the bell instead of the diaphragm in: (1) cachectic chest wall with sunken intercostal spaces; (2) hairy chest wall — hair movement against the diaphragm mimics lung crackles.

Vesicular vs Bronchial Breath Sounds

Vesicular

Normal sitePeripheral lung fields
CharacterSoft, low-pitched, gentle
Insp vs ExpInspiration > Expiration
GapNo pause
PitchLow
Abnormal whenReduced/absent → ↓ air entry, effusion, PTX

Bronchial

Normal siteTrachea / manubrium
CharacterLoud, harsh, tubular
Insp vs ExpExpiration ≥ Inspiration
GapDistinct pause
PitchHigher
Abnormal whenPeripherally → suggests consolidation
Added / Adventitious Sounds
Wheeze
Musical/whistling, usually expiratory, narrowed airways
Asthma, bronchitis, COPD exacerbation
Polyphonic Wheeze
Multiple simultaneous wheezes → widespread airway narrowing
Asthma, COPD
Monophonic Wheeze
Single, persistent — does not clear with coughing → fixed obstruction
Bronchial tumour / foreign body
Fine Crackles
Soft, multiple, brief inspiratory sounds — Velcro-like
Interstitial fibrosis, pulmonary oedema, viral pneumonias
Coarse Crackles
Louder, fewer crackles — changing with coughing
Bronchiectasis, bronchopneumonia, airway secretions
Pleural Rub
Harsh, grating — synchronous with respiration, superficial
Pleural inflammation + pleuritic chest pain
Vocal Resonance
  1. 1
    Ask patient to repeatedly say "one, one, one"
  2. 2
    Compare symmetrical areas bilaterally, same sequence as breath sounds
  3. 3
    Normal: voice sounds muffled and indistinct
  4. 4
    ↑ TVR: louder and clearer → consolidation or fibrosis
  5. 5
    ↓ / Absent TVR: pneumothorax or pleural effusion
  6. 6
    Whispering pectoriloquy: whispered words clearly audible over consolidated or fibrotic lung
Auscultation summary — breath sounds map
Breath sounds and auscultation summary diagram
"Bilateral symmetrical air entry with vesicular breath sounds and no added sounds." — Normal OSCE Auscultation Comment · Always comment: Air entry → Breath sounds → Added sounds → Any asymmetry
⚡
Clinical Summary & Comparison
Think
The Most Important Concept

Think about what is between your hand/ear and the bronchial tree:

Solid lung → transmits vibrations well → ↑ TVF + ↑ TVR

Fluid/air in pleural space → blocks transmission → ↓ TVF + ↓ TVR

🫁 Consolidation (patent bronchus)
TracheaNo deviation
Expansion↓ affected side
TVF↑
PercussionDull
Breath soundsBronchial + fine crackles
TVR↑
🚬 COPD
TracheaNo deviation
Expansion↓ bilaterally
TVF↓
PercussionResonant → Hyperresonant
Breath sounds↓ air entry ± wheeze
TVR↓
🫁 Collapse
TracheaToward lesion
Expansion↓ affected side
TVF↓
PercussionDull
Breath sounds↓ / Absent
TVR↓
🫁 Pulmonary Fibrosis
TracheaToward lesion
Expansion↓ affected side
TVF↑ over dense fibrosis
PercussionDull
Breath soundsBronchial ± fine crackles
TVR↑
💧 Pleural Effusion / Hemothorax
TracheaAway (if large)
Expansion↓ affected side
TVF↓ / Absent
PercussionStony Dull
Breath sounds↓ / Absent
TVR↓ / Absent
💨 Pneumothorax
TracheaAway (if tension)
Expansion↓ affected side
TVF↓ / Absent
PercussionHyperresonant
Breath sounds↓ / Absent
TVR↓ / Absent
Tracheal Deviation — The Easiest Rule

Volume loss → pulls trachea TOWARD · Pressure/volume → pushes AWAY

→ Trachea TOWARD the lesion

  • Collapse (volume loss)
  • Pulmonary Fibrosis (volume loss)

← Trachea AWAY from lesion

  • Massive Pleural Effusion
  • Tension Pneumothorax
No Deviation

Consolidation and COPD → usually no major tracheal deviation.

TVF & TVR Cheat Sheet
ConditionTVFTVRPercussionBreath Sounds
🫁 Consolidation↑↑DullBronchial breathing
🫁 Fibrosis↑↑DullBronchial ± fine crackles
💧 Pleural Effusion↓↓Stony dull↓ / Absent
💨 Pneumothorax↓↓Hyperresonant↓ / Absent
🫁 Collapse↓↓Dull↓ / Absent
🚬 COPD↓↓Hyperresonant↓ air entry + wheeze
Rapid Pattern Recognition
Pattern → Diagnosis
↑ TVF + ↑ TVR + Dull + Bronchial breathing
🫁 Consolidation
Pattern → Diagnosis
↓ TVF + ↓ TVR + Stony Dull
💧 Pleural Effusion
Pattern → Diagnosis
↓ TVF + ↓ TVR + Hyperresonant
💨 Pneumothorax
Pattern → Diagnosis
↓ TVF + Dull + Trachea toward lesion
🫁 Collapse
Pattern → Diagnosis
↑ TVF + ↑ TVR + Dull + Fine crackles
🫁 Fibrosis
Pattern → Diagnosis
Hyperresonant + ↓ air entry + Global ↓ expansion
🚬 COPD