Respiratory Examination

Take note of how the patient looks generally i.e. ill, alert, well, and if they are using any accessory muscles to breathe.

This can be done by observing Schamroth's window. Respiratory causes of digital clubbing includes non-small cell lung carcinoma, cystic fibrosis, bronchiectasis, pulmonary fibrosis, lung abscesses and empyemas. It is important to note that COPD is not a cause of digital clubbing.

Tar staining (yellow-brown discolouration) along edges of fingers typically indicates the patient is a smoker, which prompts consideration of smoking-associated lung diseases.

Having the patient stetch out their arms with palms facing down and placing a piece of paper on top will allow the examiner to assess for any fine tremors, typically an adverse effect of beta-agonists.

Thenar and hypothenar muscle wasting can occur when an apical lung tumour invades the brachial plexus.

Flapping tremor is indicative of respiratory failure due to carbon dioxide retention.

Horner's syndrome (partial ptosis, miosis, facial anhidrosis) occurs when lung cancer (typically Pancoast tumours) invades and disrupts sympathetic nerve supply.

Pallor in conjunctiva can indicate severe hypoxia.

Key features to look out for include candidiasis of the tongue, cyanosis under the tongue and enlarged/suppurative tonsils.

A sustained rise of at least 4cm of the JVP from sternal notch is indicative of venous hypertension due to cardiac conditions such as right heart failure. This is a differential diagnosis of breathlessness.

Deviation of trachea away from the affected lung could be due to tension pneumothorax or massive pleural effusion while deviation of trachea towards the affected lung could be due to collapse.

Cervical lymphadenopathy can be indicative of a lung malignancy.

Apex beat may be displaced due to mass effects i.e. massive pleural effusion.

Hyper-resonant chest typically indicates excess air in the ipsilateral side of the chest i.e. due to a pneumothorax, while a dull sound on percussion typically indicate fluid in the chest i.e. pleural effusion. Always compare between the left and right side of the chest at each level of percussion.

Ask the patient to say 'ninety-nine' as you auscultate and compare both sides of the lungs. Increased vocal fremitus typically indicates lung consolidation while a decreased vocal fremitus is typically indicative of excess air in the lungs. Always compare fremitus between the left and right side of the chest at each anatomical level of auscultation.

Auscultate the chest to assess for different breath sounds i.e. bronchial, bronchovesicular and vesicular. In patients with COPD, wheezes can be heard throughout the lungs, while patients with pulmonary fibrosis will produce crepitations which sounds like Velcro coming off. Always compare breath sounds between the left and right side of the chest at each anatomical level of auscultation.

It is vital to examine the posterior aspect of the chest as well. Remember to ask the patient to hug themselves in order to expose their scapula when assessing percussion, vocal fremitus and auscultation.

Leg pitting oedema may signify fluid overload in a breathless patient as a consequence of right sided heart failure.