1. Wash hands
2. Greet examiner
3. Place briefcase in safe place and take stethoscope out, hang around neck
4. Introduce and thank the patient
   1. Hello Mr/ Mrs ..., my name is Dr ... Thank you for letting me examine you today
5. Position the patient sitting over the bed
6. Expose the patient to the waist 
7. Modestly ask female patient to remove bra
8. Step back from patient and make a show to the examiners that your examining the patient
   1. Look for obvious features (RA, SLE, pectus excavatum, ank spond, heliotrope rash, shawl sign, work of breathing)
   2. Look for lines
   3. Look for oxygen tank
   4. Look for sputum cup and examine contents
9. Re-cover female patient until you get back to thorax
10. Hands
    1. Do not focus on RA/ SLE/ Scleroderma  - make movements to let the examiner know that you acknowledge the presence of peripheral signs and be happy that you are aware of what you are going to find on the clinical examination
    2. Start at nails
       1. yellow nail syndrome " primary lymphedema associated with yellow nails and pleural effusion, 40% develop bronchiectesis"
       2. leukonychia
       3. splinter haemorrhages
    3. Inspect for clubbing (remember multiple causes not just resp)
       1. look at nails from top
       2. Look from side
       3. Shammroth sign
    4. Inspect for cyanosis
    5. Inspect palms
       1. palmar erythema of hypercarbia
       2. anaemia
11. Look for T1 lesion by testing finger abduction. Also tests integrity of small hand muscles
    1. Pancoast tumour
12. Look for evidence of acute CO2 retention
13. Squeeze the wrists gently to look for evidence of hypertrophic pulmonary osteoarthropathy
14. Palpate pulse and measure RR
15. Check for pembertons sign
    1. Can you please raise you arms above your head
    2. This should take 60s to elicit, during this time, proceed with the rest of the examination of the face
    3. Looking for distended neck veins, facial flushing, inspiratory stridor
16. Inspect the face - look for peripheral signs of connective tissue disease
17. Examine for horners syndrome
    1. Palpate each side of the brow with the index finger
    2. Look in the eye for miosis and ptosis
18. Examine the mouth
    1. Look for central cyanosis
    2. Peripheral signs eg ulcers
    3. Tonsilitis/ tonsilar adenopathy
    4. Pharyngeal crowding, retnognathia, large tongue (signs of risk of OSA)
    5. Oral hairy leukoplakia
    6. Oral candidiasis associated with long term steroid use
19. Ask patient to drop their arms
20. Inspect neck and check for scars
21. Check patients lymph nodes from the back
22. Inform patient that you will feel their windpipe and they may experience some discomfort
23. Examine for tracheal tug and deviation (volume loss eg tuberculosis scarring)
24. Examine the patient from the back 
    1. Inspect for scars under both arms
    2. Visually inspect chest expansion
25. Check for chest expansion, noting normal is >5cm
26. Percuss lung fields
    1. include the axillae 
       1. RML is only heard near the axilla
    2. include the lateral lung fields
27. Auscultate the lung fields
    1. Ask the patient to take big deep breaths in and out with their mouth
    2. Listen for noises, time them
       1. early, mid, late, pan --> inspiratory or expiratory
28. Assess for vocal resonance
    1. Ask the patient to say '99' each time the stethescope touches their chest
29. Now move to the front of the patient
30. Inspect patient for radiation tattoos, scars etc
31. Check for chest expansion from the front
32. Percuss the clavicles
33. Percuss the anterior chest
34. Auscultate the anterior chest
35. Assess for vocal resonance
36. Ask the patient to lie flat on the bed positioned at 45 degrees
37. Assess for signs of pulmonary hypertension
    1. JVP + hepato-abdominal reflex + pulsatile liver
    2. palpate for left parasternal heave, parasternal thrill, palpable P2
    3. Auscultate for functional TR, loud P2
38. Ask to complete the examination by performing bedside spirometry and a formal cardiovascular examination