Key landmarks & structures

• Ribs and intercostal spaces. The first rib passes under the clavicle and isn’t palpable.  The 2nd rib attaches to the sternum at the sternal angle and the second intercostal space is just below it.
• Costal margin.  The lower edge of the rib cage.
• Costovertebral angles.  On the back, where the lower rib cage meets the spine.
• Midclavicular line (MCL) The line that runs through the midpoint of the clavicle towards the feet.
• Midaxillary line.  The line that runs up the lateral chest through the middle of the raised arm.

 

Inspection

Observe respiratory effort.

Normal breathing should be quiet at rest, without apparent effort.  Rapid breathing, use of the muscles of the neck or abdomen to help with breathing and pulling in of the space between the ribs are all signs of respiratory distress.

Observe respiratory excursion.

Place the hands on either side of the spine and watch as your patient breathes in.  The hands should move equally because normal lungs should expand equally with inspiration.  Asymmetric expansion can be caused by weakness of the diaphragm (the muscle responsible for breathing) or by a lung problem that is limiting the intake of air.

Inspect the skin

As you perform the chest exam, move the gown to the sides to inspect the skin of the posterior and lateral chest.  Pull the gown down slightly to examine the skin of the upper anterior chest as you listen to the upper lobes.

Percussion

Percuss the lungs

Use indirect percussion, with one or more fingers of your non-dominant hand pressed firmly against the chest in the intercostal spaces. Compare the right side to the left side at each level as you percuss down the posterior chest.

Percussion creates vibrations that are transmitted to the underlying tissue and reflected back again, like radar.  The examiner can both hear and feel differences based on the density of the underlying tissue. Tissue that is filled with air, like normal lung, is described as resonant to percussion. The right and left sides of the posterior chest should be symmetric. If you percuss over your own upper right anterior chest, you should find normal resonant lung.

Lung that has been filled with fluid or displaced by fluid or solid tissue will be dull to percussion. Percuss over your liver, in the lower anterior right chest, to find a dull percussion note.

Lung that has been replaced by air will be hyperresonant to percussion. Percuss over your stomach in the left upper quadrant and compare this more resonant percussion note to the others.

Percuss the spine and costovertebral angles

Use direct percussion with the side of the fist, and moderate force.  The normal spine is not tender to percussion, but if you hit someone hard it will hurt. Tenderness of the spine can indicate injury, inflammation or cancer, while costovertebral angle tenderness suggests a kidney infection.

Auscultation

With the diaphragm of the stethoscope applied firmly to the skin, auscultate the lungs.

• • Posteriorly: from the apex to the interscapular area to the base (lower margin) of the lungs.
  • Laterally: up the midaxillary line from the base of the lungs to the axilla
  • Anteriorly: over the superior lobes and the right middle lobe.

Over the lung fields, normal breath sounds are soft and low pitched.  Inspiration is longer and more audible than expiration, which may not be heard at all.  These normal breath sounds are described as vesicular breath sounds.

Over the large airways in the anterior central chest, breath sounds are louder and higher pitched, like air rushing through a tube. The expiratory phase is also longer.  These bronchial breath sounds are normal over central airways but abnormal over peripheral lung.

Sample Documentation

Chest Exam Video

Additional Resources