The patient should be undressed to the waist – in the case of a female, explain the need to expose the front of the chest to examine the heart and lungs (figure 12). A patient may be lying semirecumbant, or seated with their feet hanging over the side of the bed. Initially stand back and observe the patient for evidence of dyspnea (difficulty with respiration), tachypnea (count the respiratory rate), and note the depth and regularity of respiration, the use of the accessory muscles of respiration, intercostal indrawing of the lower ribs, cyanosis and evidence of cachexia. The jugular veins may be distended and empty rapidly with changes of intrathoracic pressure, and the larynx may move forcibly up and down.

Inspect the back (at this stage if sitting up or later when the posterior aspect of the chest is examined) for evidence of scoliosis, kyphosis and other deformities, such as thoracotomy scars and prominent veins. Deformities of the anterior chest wall include pectus excavatum (indrawn sternum) and pectus carinatum (pigeon chest).

Note the position of the nipples, and whether the thoracic cavity is expanded, such as in the barrel chest of emphysema. Measure the chest expansion from inspiration to expiration, using a tape measure (figure 13a,b)

Several types of abnormal breathing patterns may be diagnosed at the bedside. In Cheyne-Stokes breathing, periods of apnea (cessation of respiratory movements) alternate with periods of hyperpnea (deep inspirations). This is due to a delay in the medullary chemoreceptor response to blood gas changes, and can occur in left ventricular failure, brain damage, chronic hypoxemia and at high altitudes

In Kussmaul breathing (air hunger), there is deep, rapid respiration due to stimulation of the respiratory center. This typically occurs in diabetic ketoacidosis and lactic acidosis. Ataxic breathing (irregular in timing and depth) occurs in brainstem damage.

Listen carefully for abnormalities in breathing, such as noise, wheezing and coughing. Stridor is a continuous rasping or croaking noise, caused by obstruction to the larynx; this is accentuated in inspiration. It may signify the presence of a foreign body, tumor or inflammatory process in the trachea.

Listen to the voice; hoarseness may signify recurrent laryngeal nerve palsy. Ask the patient to cough, to check whether there is a loose cough, a dry cough or a bovine cough. The latter occurs in recurrent laryngeal nerve palsy, when a vocal cord is paralyzed and the vocal cords cannot be approximated. Ask the patient to take a maximum inspiration and blow out as rapidly and as forcefully as possible. Listen carefully, as it may be possible to hear a wheeze and prolongation of the expiration phase, suggesting chronic airflow limitation.

Next, pick up the patient’s hands, note clubbing and evidence of peripheral cyanosis, nicotine staining and anemia. Causes of clubbing in the respiratory system include, chronic suppurative lung disease, bronchiectasis, lung abscess, empyema, bronchial carcinoma, and pleural and mediastinal tumors.

Wasting of the muscles of the hand may signify a first thoracic nerve lesion, such as caused by an apical lung tumor. It may be accompanied by damage to the cervical sympathetic chain, over the neck of the first rib, giving a Horner’s syndrome; this combination of symptoms is termed a Pancoast syndrome.

The wrist should be palpated for tenderness (caused by the symmetrical periostitis of hypertrophic pulmonary osteoarthropathy) and the radial pulse for pulsus paradoxus (page 219). Look at the face, observing the pupils for evidence of a Horner’s syndrome, anemia of the conjunctivae and central cyanosis (tip of the tongue).

The sputum should be examined as a matter of routine. The volume and type should be noted (purulent, mucoid or mucopurulent). In infection, it varies from green to yellow and rusty colored, depending on the organism; a large purulent volume suggests bronchiectasis. Pink frothy sputum occurs in pulmonary edema and eosinophilic sputum in asthma. Evidence of hemoptysis (coughing blood) should be sought, it can occur in pulmonary embolism and pulmonary malignancy.