Respiratory Examination

Presentations

Core Respiratory Presentations

1. Interstitial Lung Disease

2. Pneumonectomy

3. Lobectomy

4. Lung Transplant

5. Pleural Effusion

6. Bronchiectasis

7. COPD

8. Normal examination

Respiratory Examination

6 minutes

Introduction + End of bed

WINDEC:

• Wash hands

• Introduce yourself

• Ask for patient's name & any pain

• Explain the examination and ask for consent, smile (!)

Exposure

• It is important to ensure adequate exposure for inspection- 45 degrees lying on bed, ask for consent for a male to be topless and female to be down to bra if they feel comfortable

Inspection

End of the bed

• Scars, chest wall asymmetry, cyanosed, work of breathing,

• Medication/ adjuncts around bed: Oxygen, nebulisers, inhalers, sputum pot

• Ask to Cough

• Deep breath in: expansion

• Breathe to calm own nerves + steady self 

Chest, abdomen and back

• Scars (!)- easily missed lateral thoracotomy on left 

Peripheral Examination

Lower limbs

• Peripheral oedema

Hands

• Tremors: fine tremor, CO2 retention tremor- hold back for 10s

• Hands & nails: finger clubbing, tar staining, Peripheral hypoxia; Inflammatory disorders for ILD

• Pulse- rate, rhythm

Arms

• Lines or fistulas

Neck

• JVP + hepatojugular reflex (patient at 45 degrees, 3cm above sternal angle

• Cervical lymphadenopathy- ?painful- virchow's node (Trossier's sign)

• Trachea- central or deviated, tracheal tug

Face

• Eyes: conjunctival pallor

• Mouth: central cyanosis (tongue)

Chest 

Easiest done posteriorly first, then should be attempted anteriorly. 

Posteriorly 

Inspection

• Scars: lateral thoracotomy, clamshell or VATs scars

• Work of breathing, equal expansion

• Cachexia, hyperinflated rib cage

Palpation

• Expansion- breath in, deeply all out: inferiorly and superiorly- thumbs move > 5cm

• Tactile vocal fremitus x3 (99) with hands on chest

Percussion

• x8

Auscultation

• Breath sounds x6

• Vocal Resonance x6

Sacral oedema

Anteriorly

Inspection

Chest expansion

• Breathe in and deep breath out

• Deep breath in whilst holding lower lobes and upper lobes

Percussion 

• 6 taps + clavicular (in between ribs)

• Tactile fremitus

Auscultation

• x6 - Right middle lobe can only be auscultated from the front (clavicle, anterior, lateral)

• Vocal resonance

Consider auscultating Heart if concerns of pulmonary hypertension if extra time ?TR. 

Conclusion

Thank patient for their time and assist them to get dressed. Wash hands. To complete my examination I would like the respiratory rate, oxygen saturations. 

Signs

End of bed

• Sputum Pot: Bronchiectasis

• Inhalers: COPD, asthma

• Young: CF

• Cough

  • Wet, productive: Bronchiectasis, pneumonia

  • Dry: ILD, lung cancer, COPD

Peripheral Examination

• Peripheral Oedema: Heart, liver, kidney failure; consider pulmonary htn

• Finger Clubbing: ILD, Lung Cancer, Bronchiectasis, TB, pulmonary abscess,

• Tobacco staining: COPD, lung cancer

• PICC/ Hickmann lines: Bronchiectasis CF

• JVP

  • Raised: Pulmonary Hypertension

  • Large v waves: Tricuspid Regurgitation

• Trachea: Deviated-

  • Pull- pneumonectomy

  • Push- pleural effusion, empyema, lung cancer, pneumothorax

  • Reduced: COPD

• Central cyanosis: COPD, ILD

• Lymphadenopathy

  • Malignancy- painless, rubbery; infection- painful

Chest

• Scars: Thorocotomy, clamshell, VATS

• Apex beat: 

  • Lateral- Mediastinal shift- collapse, effusion, tension pneumothorax

• RV Heave: Cor pulmonale

Expansion

• • Unilateral reduced: Pneumonectomy, effusion, collapse

• Percussion Dull Consolidation, collapse, pleural effusion, ILD @ bases Hyperresonant Pneumothorax

• Auscultation Bronchial breathing Pneumonia Polyphonic wheeze, COPD

• Bibasal coarse crackles: CHF, bronchiectasis

• Bibasal fine crackles: ILD

• Vocal resonance: Reduced, Pleural effusion

• Increased Consolidation, collapse, malignancy

Auscultation

• • Vesicular (normal), bronchial (thicker)

  • Added: 

    • Wheeze (insp/ exp), 

    • Crackles- fine/ coarse + location + change with coughing

Conditions

Pulmonary Hypertension

• Raised JVP

• Loud secod heart sound

Examiner Discussion

4 minutes. 

Presentation of Signs

Rough script: 

Introduction -> signs -> differentials -> negatives / severity -> complete my assessent -> investigations -> management. 

• I have performed a respiratory examination on Ms Jones [optional statement]

• [If confident, start with diagnosis] My diagnosis is interstitial lung disease, this is because my positive signs were..

• [If less confident, start with signs] My positive signs are: fine bibasal inspiratory crackles and finger clubbing; optional go into negative findings; my differentials are..

• Severity comment: there was / wasn't signs of respiratory distress/ core pulmonale / lung transplant deconditioning

• To complete my assessment I would perform a history, set of obs (RR, sats), investigations- CXR, baseline bloods, ABG/ VBG,

Key points

• Easy to forget signs

• Finishing early can give you 30s to prep your presentation

• Practice presenting (!)

• Skillful presentation can mask their inadequacies and dictate the examiner discussion favourably

Examiner Questions

Ultimately station specific and the least predictable part of any station. Learning the background, investigations and management for the core respiratory conditions is key. I believe the key part of this is to test your logic between signs and diagnosis. There simply isn't time for a deep dive into your knowledge base. 

Written in 2026