5th Year Medicine

Respiratory Examination Mastery

Every step. Every trick. Every way to look like you were born doing this.

The Master Mnemonic: "I SING PPAP"

This is your entire exam. Burn it in.
I
Introduce + Inspect (general)
Consent, position 45 deg, scan bedside clues
S
Scan from End of Bed
Shape, scars, symmetry, breathing pattern, RR
I
Inspect Hands
Clubbing, tar stain, cyanosis, tremor, flap
N
Neck + Face
Anaemia, cyanosis, Horner's, JVP, trachea, cricosternal distance, lymph nodes
G
Go to Anterior Chest
Palpate, Percuss, Auscultate (always compare R vs L)
P
Posterior Chest
Sit forward → Inspect, Palpate, Percuss, Auscultate
P
Peripheral check
Sacral + ankle oedema, calves (DVT)
A
Ask to complete
"I would like to check SpO2, sputum pot, peak flow, and see the CXR"
P
Present your findings
Summarise, give differential, suggest investigations

The Golden Rule of Chest Exam

At every zone: ALWAYS compare Right vs Left before moving down

This single habit separates an average student from a polished clinician. Whether you're percussing, auscultating, or checking expansion — side-to-side, then top-to-bottom. The examiner will notice.

The "Chest PPA" Mini-Mnemonic

For both anterior AND posterior chest, do this sequence:
P
Palpate
Expansion (upper + lower), apex beat (anterior only)
P
Percuss
Supraclavicular → down, R vs L, then axillae
A
Auscultate + VR
Breath sounds, then vocal resonance ("one, one, one")
The Full Walkthrough
Tap any step to expand. Every detail you need to ace it.
0

Before You Touch the Patient

Setup, consent, positioning — this is where marks start
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What to do
  • Wash hands / gel visibly — walk to the gel dispenser so they see it.
  • Introduce: "Hello, my name is Turki, I'm a 5th year medical student. I've been asked to examine your chest today — would that be alright?"
  • Position: Reclined at 45 degrees, head on pillow, chest exposed from waist up.
  • Ask about pain before touching: "Is there any tenderness I should know about?"
Examiner loves this
Asking about pain first shows you're a safe clinician. Also, glance around the bedside and verbally note: "I can see oxygen tubing, an inhaler, and a sputum pot at the bedside" — instant marks for observation skills.
1

End-of-Bed Inspection

Stand back. This 15 seconds wins you 5+ marks.
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Scan for (mnemonic: "SCAR-BAP")
  • Scars — thoracotomy (lateral!), sternotomy, chest drain
  • Chest shape — barrel chest (COPD), pectus excavatum/carinatum, kyphoscoliosis
  • Asymmetry — one side smaller/flatter?
  • Respiratory rate — count silently for 15s × 4 (normal 12-15/min)
  • Breathing pattern — pursed-lip? I:E ratio prolonged? Cheyne-Stokes?
  • Accessory muscles — SCM, scalenes, tripod position, intercostal indrawing
  • Paraphernalia — O2, nebulisers, inhalers, sputum pot, drains
Trick: Counting RR secretly
Pretend to check the radial pulse — hold the wrist and count breaths. The patient won't consciously change their breathing pattern. Say the rate out loud: "Respiratory rate is 22 breaths per minute." Examiners love hearing you quantify.
Clinical pearl
A barrel chest (increased AP diameter) = chronic hyperinflation (COPD). If you see it, also expect: reduced cricosternal distance, loss of cardiac dullness, quiet breath sounds, and Hoover's sign on expansion.
2

Hands & Arms

Clubbing, tar, tremor, flap — a goldmine of clues
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Examination sequence (mnemonic: "Club-Tar-Cyan-TF")
  • Clubbing — look at nail profile from the side. Press nail bed: feel boggy fluctuation? Loss of the diamond-shaped window when opposing nails = Schamroth's sign.
  • Tar staining — yellow-brown on index/middle fingers = active smoker.
  • Cyanosis — peripheral cyanosis in nail beds. Also check small muscle wasting (T1 lesion → Pancoast tumour).
  • Tremor — arms out, wrists extended. Fine tremor = beta-agonist overuse (salbutamol).
  • Flapping tremor (asterixis) — wrists dorsiflexed, fingers apart, eyes closed, hold 30 seconds. Coarse flap = CO2 retention = respiratory failure.
Never forget
Respiratory causes of clubbing: lung cancer (most common!), pulmonary fibrosis, bronchiectasis, cystic fibrosis, empyema, mesothelioma. If you find clubbing, say: "I would be concerned about underlying malignancy or fibrotic lung disease."
Look smart tip
While checking flap, you're also secretly timing the respiratory rate (if you haven't already). Two birds, one stone. Mention it.
3

Face

Eyes, tongue, pupils — 30 seconds, multiple diagnoses
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Check these (mnemonic: "ACH")
  • Anaemia — pull down lower eyelid, check conjunctival pallor. (Anaemia can cause breathlessness!)
  • Cyanosis — look at the tongue (central cyanosis = blue-grey). The tongue is the best place — not lips, which can be dark naturally.
  • Horner's syndrome — ptosis + miosis + anhidrosis. Think Pancoast tumour at lung apex invading sympathetic chain.
Bonus: SVC obstruction
Dusky, swollen face with engorged neck veins + non-pulsatile raised JVP = SVC obstruction from mediastinal malignancy. If you spot it, mention it — examiners will be very impressed.
Clinical pearl
Central cyanosis is harder to detect in anaemia (less Hb to be desaturated) and easier in polycythaemia. If the patient is plethoric and cyanosed, think COPD with secondary polycythaemia.
4

Neck

JVP, trachea, cricosternal distance, lymph nodes
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Examination sequence (mnemonic: "JTC-L")
  • JVP — with tangential lighting, assess height. Raised in pulmonary hypertension, tension pneumothorax, massive PE, cor pulmonale.
  • Trachea — gently advance ONE finger into the sternal notch in midline. Is it central? Equidistant from both SCM heads?
  • Cricosternal distance — feel from sternal notch up to cricoid cartilage. Normal = 3 finger breadths. Reduced = hyperinflation (COPD).
  • Lymph nodes — from behind, palpate cervical chain. Palpable nodes = think metastatic lung cancer, TB, lymphoma.
Tracheal deviation rules
Pushed AWAY from: tension pneumothorax, massive pleural effusion.
Pulled TOWARDS: lung collapse, fibrotic scarring, post-pneumonectomy.
Remember: "Tension pushes, collapse pulls."
Look smart tip
When checking trachea, warn the patient first: "This may feel slightly uncomfortable." Then use ONE finger, gently. Examiners mark you down for being rough. Say: "The trachea is central" (or deviated).
5

Anterior Chest: Palpation

Apex beat, RV heave, expansion — the hands-on core
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Sequence
  • Apex beat — locate in 5th ICS, mid-clavicular line. Displaced? Think effusion (pushes away) or collapse (pulls towards).
  • RV heave — place heel of hand over lower sternum. A sustained lift = pulmonary hypertension / cor pulmonale.
  • Expansion UPPER zones — palms over pectoral region, thumbs opposed in midline. "Take a deep breath." Watch thumbs separate.
  • Expansion LOWER zones — cup hands around lower ribs, fingertips in mid-axillary line, pull skin medially, thumbs off skin. Watch thumbs separate.
  • Compare symmetry — asymmetry matters more than absolute excursion.
Hoover's sign
In severe COPD, the diaphragm is so flat that on inspiration it pulls the lower ribs inward instead of outward = paradoxical movement. This is Hoover's sign and is easily missed if you only check upper expansion. Always check lower ribs.
Pro technique
Keep your thumbs hovering off the skin during expansion — they act as visual pointers. The examiner can clearly see asymmetry this way.
6

Anterior Chest: Percussion

Resonant, dull, or stony dull — the story in the tap
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Technique + Sequence
  • Non-dominant middle finger pressed firmly in intercostal space, parallel to ribs.
  • Strike the middle phalanx with the flexed tip of dominant middle/index finger.
  • Movement from the wrist, NOT the elbow — like flicking water off your hand.
  • Sequence: start supraclavicular fossae → down the chest → always R vs L at same level before moving down → then axillae.
What the sounds mean
Resonant = normal air-filled lung.
Hyper-resonant = pneumothorax (air trapping).
Dull = consolidation (pneumonia), collapse.
Stony dull = pleural effusion (fluid).
Remember: left lower sternal edge is normally dull (the heart!) — this cardiac dullness is lost in hyperinflation (COPD).
Look smart tip
Percuss 5 pairs on the anterior chest. If you find dullness at one base, say: "There is dullness to percussion at the right base, which could represent a pleural effusion or consolidation — I will correlate with breath sounds." Examiners love you thinking in real time.
7

Anterior Chest: Auscultation + Vocal Resonance

Listen, compare, then get the patient to speak
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Technique
  • Diaphragm of stethoscope (unless cachectic/hairy chest → use bell).
  • "Please breathe in and out deeply through your open mouth."
  • Same sites as percussion: R vs L, top to bottom, then axillae.
  • Listen for: breath sounds (vesicular vs bronchial), added sounds (wheeze, crackles, rub).
  • Then vocal resonance: "Please say 'one, one, one' each time I place my stethoscope." Compare R vs L.
The three added sounds
Wheeze: musical, mostly expiratory. Polyphonic = asthma/COPD. Monophonic fixed = think bronchial tumour.

Crackles: Fine + inspiratory + bibasal = pulmonary fibrosis. Coarse + changing with cough = secretions (bronchiectasis/pneumonia). Fine bibasal + peripheral oedema = heart failure.

Pleural rub: creaking/grating, both phases, superficial — like sandpaper. Think infection or PE with infarction.
Vocal resonance cheat sheet
Increased VR = consolidation or fibrosis (sound travels better through solid/stiff lung).
Decreased VR = effusion or pneumothorax (air/fluid blocks sound).
Whispering pectoriloquy = whispered voice heard clearly = consolidation. If you demonstrate this, you look extremely polished.
8

Posterior Chest

"Please sit forward" — now repeat the PPA sequence
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Full posterior sequence
  • Sit patient forward — "Can you lean forward for me? I'm going to examine the back of your chest."
  • Inspect — scars (thoracotomy, pleural biopsy/drain sites), asymmetry, kyphoscoliosis.
  • Palpate — cervical lymph nodes from behind. Then upper + lower expansion posteriorly.
  • Percuss — ask patient to fold arms across front (moves scapulae laterally). Percuss a few cm lateral to spine. R vs L, top to bottom.
  • Auscultate — same sites. Deep breaths through open mouth. R vs L.
  • Vocal resonance — "Say 'one, one, one'" at each site. R vs L.
Why the posterior matters more than you think
The lungs extend much lower posteriorly (approaching the 12th rib on full inspiration). Most pathology — effusions, basal consolidation, fibrosis — is best detected from behind. Never rush the posterior exam.
Look smart tip
While the patient is sitting forward, quickly check for sacral oedema by pressing over the sacrum for 5 seconds. Say: "I'm also checking for sacral oedema, which may indicate right heart failure or fluid overload." Two extra marks for one move.
9

Completing the Examination

The "I would also like to..." that seals the deal
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Say this (mnemonic: "STOP")
  • Sputum pot — "I would like to inspect the sputum pot for colour and volume."
  • Temperature & SpO2 — "I would check pulse oximetry and temperature."
  • Oedema — "I would check for ankle oedema and examine the calves."
  • Peak flow + CXR — "I would like to see the peak flow reading, a chest X-ray, and any ABG results."
The power summary
When asked to present, use this template:

"On examination, [patient name] is a [comfortable/distressed] [age]-year-old [man/woman], sitting at 45 degrees, with [oxygen/inhalers/no paraphernalia] at the bedside. Respiratory rate is [X]. On inspection of the hands, I noted [findings]. Examination of the chest revealed [findings on palpation, percussion, auscultation]. In summary, the findings are consistent with [diagnosis], and my differentials include [list]. I would like to confirm with [investigations]."
The Diagnosis Matrix
When you find X on exam, think Y. This table is OSCE gold.
Condition Expansion Trachea Percussion Breath Sounds VR Added Sounds
Consolidation (Pneumonia) Reduced (affected side) Central Dull Bronchial Increased Coarse crackles, pleural rub
Pleural Effusion Reduced (affected side) Pushed away (if massive) Stony dull Absent/reduced Decreased None (maybe crackles above effusion)
Pneumothorax Reduced (affected side) Pushed away (if tension) Hyper-resonant Absent/reduced Decreased None
Lobar Collapse Reduced (affected side) Pulled towards Dull Reduced Decreased None
COPD / Emphysema Globally reduced, Hoover's sign Central Hyper-resonant (loss of cardiac dullness) Quiet, prolonged expiration Decreased Polyphonic wheeze
Pulmonary Fibrosis Reduced bilaterally Central Normal Normal/bronchial Normal/increased Fine end-inspiratory "Velcro" crackles at bases
Asthma (acute) Reduced bilaterally Central Normal/hyper-resonant Reduced Normal Widespread polyphonic expiratory wheeze

Quick-Fire Differentiation Tricks

The 3 conditions examiners test most
Effusion vs Pneumothorax
Both have reduced breath sounds. Percussion decides it all: stony dull = effusion, hyper-resonant = pneumothorax. That's it.
Consolidation vs Collapse
Both are dull to percussion. Trachea and VR decide: consolidation = trachea central + increased VR + bronchial breathing. Collapse = trachea pulled towards + decreased VR + reduced breath sounds.
COPD vs Fibrosis
Both cause breathlessness. Percussion and crackles decide: COPD = hyper-resonant + wheeze. Fibrosis = normal percussion + fine Velcro crackles at bases + clubbing.
How to Look Like a Registrar
These are the moves that separate "pass" from "distinction."
1

Narrate as You Go

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The technique
Don't examine in silence. Quietly state your findings: "Expansion is symmetrical... percussion is resonant bilaterally... vesicular breath sounds with no added sounds..." This shows the examiner you're interpreting as you go, not just going through motions.
2

The "While I'm Here" Power Moves

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These take 3 extra seconds each and win you big marks
  • While at the hands → mention pack-year calculation if tar staining present: "suggesting significant smoking history — I would calculate pack-years."
  • While at the face → check for cushingoid features (long-term steroid use for COPD/asthma).
  • While at the neck → mention "I note no Pemberton's sign" (raising arms causing facial congestion = retrosternal goitre causing SVC compression).
  • While posterior → check sacral oedema.
  • At the end → mention you'd check calves for DVT (PE risk) and ankle oedema (cor pulmonale).
3

Examiner Bait: Phrases That Impress

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Drop these naturally
  • "I note no evidence of CO2 retention — no flapping tremor or bounding pulse."
  • "The cricosternal distance is reduced to approximately two finger breadths, suggesting chronic hyperinflation."
  • "There is stony dullness at the right base with absent breath sounds and absent vocal resonance, consistent with a right-sided pleural effusion."
  • "I note fine end-inspiratory crackles bilaterally at the bases, which do not clear with coughing — this is consistent with interstitial lung disease."
  • "I would like to complete my examination by checking peripheral oxygen saturations and requesting a chest radiograph."
4

The 5 Deadly Sins of Resp Exam

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Never do these
  • Forgetting to wash hands at the start AND end. (Automatic fail in some schools.)
  • Percussing without comparing sides. Top to bottom without R vs L = amateur.
  • Listening through clothing. The chest must be exposed.
  • Skipping vocal resonance. It only takes 30 seconds and confirms your auscultation findings.
  • Not saying "I would also like to..." at the end. Leaving without completing = lost marks on every OSCE.
Test Yourself
Quick-fire scenario questions. Tap to answer.

Q1: You find stony dullness at the right base with absent breath sounds and absent vocal resonance. Trachea is pushed to the left. What's the diagnosis?

Massive right pleural effusion. Stony dull + absent BS + absent VR + trachea pushed away = effusion. Pneumothorax would be hyper-resonant. Collapse would pull the trachea towards. Pneumonia would have bronchial breathing and increased VR.

Q2: A 65-year-old smoker has a barrel chest, reduced cricosternal distance, and you hear quiet breath sounds with polyphonic wheeze. You can't feel the apex beat. What's the most likely diagnosis?

COPD with hyperinflation. Barrel chest + reduced cricosternal distance + impalpable apex beat (because lingula overlies the heart) + quiet breath sounds + polyphonic wheeze in a smoker = textbook COPD. The hyperinflated lungs expand between the heart and chest wall.

Q3: You find unilateral clubbing, ptosis, and miosis on the same side. What ties these together?

Pancoast tumour. An apical lung tumour invades the sympathetic chain (causing Horner's syndrome: ptosis + miosis + anhidrosis) and can also damage the T1 nerve root (causing small muscle wasting). Clubbing is from the underlying lung cancer itself.

Q4: You percuss the left lower sternal edge and get resonance instead of the expected dullness. What does this suggest?

Hyperinflation (COPD). Normally the right ventricle causes dullness at the left lower sternal edge. In hyperinflated COPD patients, the lingula expands between the heart and chest wall, causing loss of cardiac dullness — a classic sign of severe hyperinflation.

Q5: Fine, end-inspiratory "Velcro-like" crackles at both bases that don't clear with coughing + finger clubbing. Diagnosis?

Pulmonary fibrosis. Fine inspiratory "Velcro" crackles at both bases that don't clear with coughing + clubbing is the classic presentation of idiopathic pulmonary fibrosis. Heart failure crackles are more coarse, shift with position, and wouldn't cause clubbing. Bronchiectasis has coarse crackles + productive cough.

Q6: You hear a coarse flapping tremor (asterixis) on testing the outstretched hands. What does this indicate?

CO2 retention. Asterixis (coarse flapping tremor) is a sign of hypercapnia (elevated PaCO2) seen in type 2 respiratory failure, often in COPD exacerbations. Fine tremor would suggest beta-agonist effects. Always request an ABG if you find this sign.
Rapid-Fire Checklist
Use this to practise. Tap each step as you complete it. Target: under 8 minutes.
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