Expansion
Hands, face, neck, then chest front and back with the same four steps
Expansion
Position: 45 degrees, chest exposed.
- General inspection: respiratory rate, distress, accessory muscle use, pursed lips, cachexia, oxygen, inhalers, sputum pot, scars
- Hands: clubbing, tar staining, peripheral cyanosis, CO2 retention flap, fine tremor of beta agonists, wasting of the small muscles (T1 in a Pancoast tumour)
- Pulse: bounding in carbon dioxide retention, pulsus paradoxus
- Face: central cyanosis, anaemia, Horner syndrome, plethora
- Neck: tracheal position, cricosternal distance, JVP, lymph nodes (from behind)
- Chest, front then back, comparing side to side at each level:
- Inspect: shape, scars, asymmetry
- Palpate: expansion (upper and lower), apex beat, tactile fremitus
- Percuss, including the clavicles and axillae
- Auscultate: breath sounds, added sounds, vocal resonance
To finish: observations including oxygen saturation, peak flow, sputum, and a chest radiograph.
Examining the back is where most pathology is found, since the lower lobes lie posteriorly, and it is the step most often rushed.