Respiratory examination
A respiratory examination, or lung examination, is performed as part of a physical examination, in response to respiratory symptoms such as shortness of breath, cough, or chest pain, and is often carried out with a cardiac examination. The four steps of the respiratory exam are inspection, palpation, percussion, and auscultation of respiratory sounds, normally first carried out from the back of the chest. Stages. After positioning in which the patient sits upright with their arms at the side, with the chest clear of clothing, the four stages of the examination can be carried out. In order to listen  to the lungs from the back the patient is asked to move their arms forward to prevent the scapulae (shoulder blades) from obstructing the upper lung fields. These fields are intended to correlate with the lung lobes and are thus tested on the anterior (front) and posterior (back) chest walls. Inspection. The examiner then estimates the patient's respiratory rate by observing how many times the patient breathes in and out within the span of one minute. This is typically conducted under the pretext of some other exam, so that the patient does not subconsciously change their baseline respiratory rate , as they might do if they were aware of the examiner observing their breathing. Adults normally breathe about 14 to 20 times per minute, while infants may breathe up to 44 times per minute. After obtaining the patient's respiratory rate, the examiner looks for any signs of respiratory distress, which may include: The anterior and posterior chest wall are also inspected for any abnormalities, which may include: In addition to measuring the patient's respiratory rate, the examiner will observe the patient's breathing pattern: The physician then typically inspects the fingers for cyanosis and clubbing. Tracheal deviation is  also examined. Palpation. Palpation is the use of physical touch during examination. During palpation, the physician checks for areas of tenderness, abnormalities of the skin, respiratory expansion and fremitus. Chest percussion. Percussion is the act of tapping on the surface of the body in order to assess the structures that lie beneath the skin. Percussion and resonance (the quality and feeling of sound) are used to examine lung movement and possible lung conditions. Specifically, percussion is performed by first placing the middle finger of one hand over the area of interest. The middle finger of the other hand is used  to strike the last joint of the placed finger. Percussion is performed in a systematic matter, from the upper chest to the lower ribs, and resonance is compared between the left and right sides of the chest. This is done from the front and back of the thorax. Percussion over different body tissues results in five common "notes". Auscultation. The areas of the lungs that can be listened to using a stethoscope are called the lung fields, and these are the posterior, lateral, and anterior lung fields. The posterior fields can be listened to from the back and include: the  lower lobes (taking up three quarters of the posterior fields); the anterior fields taking up the other quarter; and the lateral fields under the axillae, the left axilla for the lingual, the right axilla for the middle right lobe. The anterior fields can also be auscultated from the front. An area of thinner musculature on the back where sounds may be more audible is called the triangle of auscultation. During auscultation, deep breaths are taken through the mouth and abnormal sounds listened for. Abnormal sounds include: Lastly an assessment of transmitted voice sounds is performed.