Specifically, one must note the dynamics of the patient's facial expression in relationship to physiologic activities (inspiration and expiration) and to the questions asked by the examiner. Even as the first serious question of the fully dressed patient is asked, the inspection begins through active observation. It begins with the initial greeting and continues uninterruptedly during the entire data collection process. It is done with the eyes and the intellect. Inspection ( Table 46.1) is an active process. Auscultation, a more sensitive process, confirms earlier findings and may help to identify specific pathologic processes not previously recognized. Palpation, confirmed by percussion, assesses for tenderness and degree of chest expansion. The inspection process initiates and continues throughout the patient encounter. The pulmonary examination consists of inspection, palpation, percussion, and auscultation. By the time the physical examination is complete, even before laboratory evaluations are initiated, the diagnosis should be reasonably certain.

When using this process, it is unusual for two consecutive chest examinations to be identical.

Experienced clinicians exploit the history to help them 'look' for specific physical findings to answer questions posed by the totality of data collected previously. The history determines the examination format. The examiner extends a hand in greeting, asks about the symptoms that initiated the visit, and begins physical inspection, noting body position, assessing degree of comfort, inspecting and palpating the hands, and noting grip strength. The physical examination begins with the commencement of history taking. The setting for the chest examination must be environmentally comfortable for both clinician and patient.

Abnormal lung sounds