Respiratory Examination

Presentations

Core Respiratory Presentations

1. Medical

   1. Chronic Lung Disease

      1. Crackles

         1. Interstitial Lung Disease

         2. Bronchiectasis

      2. COPD

      3. Pulmonary HTN

   2. Reduced air entry & vocal resonance, dullness to percuss, 

      1. Pleural Effusion

      2. Differentials: Consolidation, bronchial mass, infarction

2. Surgical

   2. 1. Wedge resection, Lobectomy, Pneumonectomy, VATS procedures

      2. Lung Transplant- single, double

3. Normal examination

Respiratory Examination

6 minutes

Introduction + End of bed

WINDEC:

• Wash hands

• Introduce yourself, patients name, consent, any pain?

• Exposure, lying 45 degrees

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 remove 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

Chest, abdomen and back

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

Peripheral Examination

Lower limbs

• Peripheral oedema

Hands

• CO2 retention tremor- hold back for 10s

• Tremors: fine tremor, 

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

• Pulse- rate, rhythm;

• HR + RR

Arms

• Lines or fistulas

Face & Neck

• Trachea- central or deviated, tracheal tug

• Eyes: conjunctival pallor

• Mouth: central cyanosis (tongue)

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

• Cervical lymphadenopathy- ?painful- virchow's node (Trossier's sign)- sit forward, then onto back

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

• Deep breath 

Palpation

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

• Tactile fremitus x2 (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 optional

Auscultation

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

• Vocal resonance

Cardiac

• Pulmonary hypertension: heart sounds ?loud P2 & RVH 

Conclusion

Thank patient for their time and assist them to get dressed. Wash hands. 

Signs

End of bed

• Sputum Pot: Bronchiectasis

• Inhalers: 

  • Salbutamol inhaler- COPD, asthma

  • Double inhaler- COPD or asthma

  • Triple inhaler- COPD

• Creon + Young: CF

• Cough

  • Wet, productive: Bronchiectasis, Pneumonia, Congestive Heart Failure

  • Dry: ILD, Lung Cancer, COPD

Peripheral Examination

• Peripheral Oedema: Heart, liver, kidney failure; Core Pulmonale

• Finger Clubbing: Suppurative lung disease ( Bronchiectasis (CF), TB, Pulmonary abscess,), ILD, Lung Cancer, 

• Tobacco staining: COPD, Lung Cancer

• PICC/ Hickmann lines: Bronchiectasis CF- antibiotics; Pulmonary HTN- prosteoglandin infusion

• JVP

  • Raised: Pulmonary Hypertension

  • Large v waves: Tricuspid Regurgitation

• Trachea: 

  • Pull- pneumonectomy, atelectasis

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

  • Reduced: COPD

• Central cyanosis: COPD, ILD

• Lymphadenopathy: malignancy- painless, rubbery; infection- painful

Chest

Inspection

• Scars: VATS, Thorocotomy, Clamshell

VATS Scar 

3 scars: utility incision 6cm, 2 smaller scars for instrument & thorascope (1-3 scars possible

check under bra straps and breasts for scars as appropriate

Indications

• Wedge resection, lobectomy, 

• Lung biopsy

• Pleurectomy- recurrent pneumothoraces

• Rarer: Decortication (fibrothorax), Bullectomy, pneumonectomy

Thoractomy Scars- usually posterio-lateral

• Lobectomy, pneumonectomy

• Lung transplant

• Emergency cardiothoracic surgery- chest wall trauma + cardiac arrest

• Rarely cardiac surgery where sternotomy contraindicated- e.g. mitral valve repair

• 15-20 cm + chest drain scar

• Make sure not a breast scar

Bilateral Scars indications

• Bilateral lobectomies (Lung Cancer, TB less likely- antibiotics)

• Bilateral bullectomies (COPD- emphysema)

• Bilateral pleurectomies (Pneumothoraces- connective tissue disease)

• Dual pathology

Clamp-shell Scar

• Bilateral lung transplant

• Cardiac arrest with trauma to chest wall ?pericardial effusion

• Major cardio-thoracic surgery

• Finger clubbing: bronchiectasis (CF), ILD

Other scars

• Chest drain sites

• Portocath, Hickmann, PICC lines

• Implantable cardiac device

• 
  

Palpation

• Apex beat: 

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

• RV Heave: pulmonary hypertension

Expansion

• Unilateral reduced: Pneumonectomy, effusion, collapse,

Percussion

• Dull Consolidation, collapse, pleural effusion, I

• Hyperresonant Pneumothorax

Ausculation

• Bronchial breathing Pneumonia 

• Polyphonic wheeze, COPD

• Crackles

  • Bi-basal coarse crackles: CHF, bronchiectasis, pneumonia

  • Bi-basal 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

Core Conditions

Categorise by

1. Are there scars?

2. Focal signs? 

Surgical

1. Scars

   • Wedge resection, Lobectomy, Pneumonectomy, VATS procedures

   • Lung Transplant- single, double

Medical

2. Focal Lung Lesion- reduced air entry & vocal resonance, dullness to percuss, 

   • Trachea away: Pleural Effusion

   • Trachea central: Consolidation, Bronchial mass, Pleural mass (unless v large), Infarction

   • Tracheal towards: Atelectasis 

3. Chronic Lung Disease

   • Crackles

     1. Interstitial Lung Disease

     2. Bronchiectasis

   • COPD

   • Pulmonary HTN

Normal examination

Core Conditions

1. Normal examination

A. Chronic Lung Disease

1. Interstitial Lung Disease

Signs

• Dry cough (end of bed)

• Finger clubbing

• Crackles

  • Bilateral

  • End inspiratory

  • Fine

  • Not change with coughing

Aetiology

• • Finger clubbing & over 50yrs- suggests ILD

  • Crackles location

    • Bi-basal - idiopathic, inflammatory ; 

    • Bi-apical - psoriatric athropathy, radiotherapy, tuberculosis (easy to miss this)

  • Connective tissue: arthralgia 

    • Systemic sclerosis- tight skin on fingers & lips, telanctasia

    • Rheumatoid arthritis findings on hand

    • Malar flush: SLE

  • AF or pacemaker: amiodarone 

  • Radiotherapy: tattoo

2. Bronchiectasis

• Bi-basal coarse crackles, change with coughing

• Finger clubbing

• Wet cough (end of bed)

Cystic Fibrosis

• Bronchiectasis- upper lobe crackles

• Liver disease: hepatomegaly, cirrhosis, ]

3. COPD

• Hyperexpanded chest

• Polyphonic wheeze

• No crackles or finger clubbing

4. Pulmonary HTN

• PICC with prostaglandin infusion

• Loud P2, RV Heave, raised JVP; cor pulmonale- peripheral fluid overload

• Cause e.g. scleroderma

B. Focal 

5. Focal Lung Lesion

• Trachea pushed (if large)

• Reduced expansion

• Dullness to percuss 

• Reduced breath sounds

• Reduced vocal resonance

• Localising

3. • Trachea away: Pleural Effusion

   • Trachea central: Consolidation, Bronchial mass, Pleural mass (unless v large), Infarction

   • Tracheal towards: Atelectasis, pneumonectomy (if scar present)

C. Scars

6. Pneumonectomy

• Tracheal pulled to side of pneumonectomy

• Reduced expansion

• Dullness to percuss

• Absent breath sounds

• Absent vocal resonance

7. Lobectomy

• Posterio-lateral thoracotomy scar or VATS scars

• Trachea, expansion, percussion can be normal due to compensation of other lobes

• Can have subtle signs same as pneumonectomy

• Indications

  • Commonest: Lung cancer, usually NSCLC- 80% lung cancer, SCLC presents late (rarely for surgery

  • Bronchiectasis, lung abscess

8. Lung Transplant

Notes for all transplants

• Examination

  • Other scars: tracheostomy, portacath/ Hickmann/ PICC

  • Examination may be normal +- finger clubbing

  • Signs of medication: 

    • Fine tremor (tacrolimus), gum hypertrophy (cyclosporin- renal failure), diabetes - moon face, libra (pred), 

• Aetiology

  • COPD, ILD, CF/ bronchiectasis, Pulmonary HTN

    • Commonest- COPD 40% improves QoL > quantity, BODE index > 7yrs

    • Finger clubbing: CF/ bronchiectasis, ILD

• Indications

  • Severe lung disease: > 50% risk of death in 2yrs without transplant

  • Functional reserve

    • > 80% Survive 90 days post transplant

    • > 80% of 5yr post transplant survival (with functioning transplant)

• Contraindications

  • Malignancy within 5 yrs

  • Organ vital failure- liver, renal, lung, brain, cardiac (unless 

  • Severe infection- e.g. mycobacterium abscessus, burkhodelia

  • Frailty, BMI > 30, smoking/ recreational drugs

  • Compliance issues- psychosocial issues,

  • Relative: age > 65 yrs

• Complications:

  • Acute rejection, opportunistic infections

  • Chronic rejection: Bronchiolitis obliterans- terminal event

  • Infections

  • Malignancy: post transplant lymphoproliferative disease, skin

  • Median survival 6 yrs

• Referral early to transplant centre

Single

• Postero-lateral thorocotomy scar

• Indications: ILD, COPD, 

• Examine other lung ?COPD/ ILD

Double 

• Examination

  • Clampshell anterior scar 

  • Normal expansion, percussion, auscultation if working

• Indications: classically suprarutive disease- CF/ bronchiectasis, generalised bronchiectasis

  • Also ILD with pulmonary HTN

Cardiac and lung transplant

• Scar: midline sternotomy + lateral Thoracotomy

• Indications

  • Lung disease (ILD/ Bronchiectasis/ COPD) with core pulmonale

  • Congenital heart & lung disease: Eisenmenger Syndrome

  • Systemic diseases such as Sarcoidosis

1. Cystic Fibrosis

• Lung transplant- clampshell scar

• PICC / Hickmann with IV antibiotics

• Creon

• Bronchiectactic exam, may be normal- upper zones

• Young

• Finger clubbing

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]

• Start with positive signs (rarely signs are fully diagnositic)

• Give differentials with qualification

• Evidence of respiratory distress or complications- e.g. pulmonary hypertension, 

  • Medication side effects (transplant)- cyclosporin gum hypertrophy, tacrolimus tremor, MMF abdo pain, pred- diabetes

• Underlying aetiology- e.g. ILD- nil signs of inflammatory condition

• 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. 

Core Condition Scripts

1. Interstitial Lung Disease

I've examined Mr Jones' respiratory system. I auscultated bibasal, end expiratory, fine crackles which did not change on coughing. This would be consistent with interstitial lung disease. Mr Jones was comfortable at rest and there were no signs of hypoxia, however he was mildly tachypnoeic with a respiratory rate of 24. There were no signs of pulmonary hypertension - such as a raised JVP, loud P2 or right parasternal heave. I did not elicit any signs of an underlying cause, for example there was no arthralgia or skin changes, therefore the commonest cause of bibasal ILD in the UK is idiopathic. 

To complete my assessment I would like to take a history and ask about exposure to asbestos or silicosis, medication history for amiodarone or methotrexate or ask about exposure to pigeons. Smoking would also be relevant, particularly when looking for home oxygen. I would like an oxygen probe and a full set of observations. My investigations would start at the bedside- ECG- signs of pulmonary hypertension- right axis deviation, baseline bloods FBC, U&Es, CRP, LFTs before starting medications and too look for signs of infection, a sputum pot would also but useful for culture. In terms of imaging I would start with a CXR to look for a reticular pattern or honey combing. A high resolution CT would be necessary for making the diagnosis. My management would start with an MDT approach led by a respiratory consultant with a specialty interest in ILD, physio- chest physio & chest rehab, OT - home adjustments, dietician- nutrition, solicitors- compensation for exposure. Lifestyle factors- smoking cessation, light exercise, healthy eating. Medications- nintedanib (antifibrotic), vaccinations- pneumococcal, flu & covid, treat underlying cause. Surgical- very rarely single or double lung transplants are offered. 

Questions

• Spirometry: restrictive pattern

• Investigations

  • Diagnosis: HRCT with ground glass opacity (inflammation- for steroids)

  • Bronchoscopy

  • Biopsy: alveolar or surgical

• Management: antifibrotic agents

2. Pneumonectomy

3. Lobectomy

Surgery

VATS vs open thoracotomy

• Reduced post operative complications: pain, wound complications, length of hospital stay

• Preserved benefit

Indications

1. Main- Lung Cancer

2. Other: Aspergilloma, TB, Lung Abscess, Bronchiectasis

Lung Cancer Investigations

1. CT CAP ?site to biopsy + staging

2. Biopsy: bronchoscopy, EBUS, CT guided biopsy

3. MDT Discussion ?treatment plan

Fitness for surgery

1. Lung function tests with transfer factor

   1. Lobectomy- FEV1 1.5L

   2. Pneumonectomy- FEV1 2L

   3. Good prognosis post op- VO2 Max 15ml/kg

2. Cardiopulmonary exercise testing

Lung Cancer

1. SCLC- 20%, aggressive, lates present- rarely surgical intervention

2. NSCLC- aim surgical 

   1. Adenocarincoma

   2. SCC

   3. Rarer- large cell carcinoma, neuro-endocrine tumours

4. Lung Transplant

5. Pleural Effusion

6. Bronchiectasis

7. COPD

8. Normal examination

I examined Mr Jones' respiratory system today. My examination was normal and I did not elicit any positive signs. [Pause]. Mr Jones was comfortable at rest and his respiratory rate was 14. There was no signs of central or peripheral cyanosis. Expansion, percussion and ascultation were normal. I didn't identify any signs of underlying respiratory disease or other disease. [Pause again.]

To complete my assessment I'd like to take a history, asking about the respiratory symptoms of shortness of breath, cough, haemoptysis and chest pain. I would like to widen my examination and obtain a set of observations. The history and examination would guide my investigations. 

Written in 2026