There’s a good question as to why bother
examining patients nowadays, now that we have
such good investigations available. There
are several answers to that question.
The first being most obviously is that actually
the x-rays or the investigations you want
to do may not be available. And that would
happen if somebody presents with acute respiratory
distress. You don’t have time to get the
x-rays, the echocardiogram, the CT scan before
you actually have to treat the patient. So
clinical skills are essential in that circumstance.
In addition, you may not be considering doing
the test that is required until you examine
the patient and identify an unexpected finding
that might suggest something that requires
a specific investigation.
So, for example, you might hear a pleural
rub and then start thinking the patient may
have a pulmonary embolus and ask for a CT
pulmonary angiogram which, previously, you
And in addition there are signs that actually
are not identified by investigations but are
identified by examination which do have very
important implications for the patient. And
the most obvious one of that is clubbing.
Finger clubbing indicates there’s a serious
medical problem going on with the patient
and there are no tests that we do which identify
that. It’s purely on examination.
So what is the process of examination? Well,
you’ve done your history and then you move
on to examine the patient. And the idea of
doing the examination is so that you can identify
signs that might confirm the suspicions that
you have of what diagnosis might explain the
Not only that. You’re also looking for signs
which might not fit with the diagnosis you’re
thinking of and change your mind about what
is going on. So, for example, we may have
a smoker who presents with a several months’
history of breathlessness. And you think perhaps
they might have COPD – smoking-related airways
obstruction. When you examine the patient,
you hear some crackles. Now crackles means
that – it’s not a sign associated with
COPD. And therefore you need to change your
opinion of what may be happening and consider
other diseases such as interstitial lung disease.
The actual examination itself fits with the
standard format that we do for whatever medical
conditions you’re looking at, whether it
is an abdominal, a neurological, a cardiac
or a respiratory problem.
We start with a general observation of the
patient. And there are specific things that
we look for when we examine a patient which
are relevant for respiratory tract problems.
Then we move on to examine the hands where,
in particular, we’re looking for clubbing
and for two types of tremor: an essential
tremor which occurs when people have had Beta2-agonists
– a therapy for airways obstruction – and
a carbon dioxide retention tremor – asterixis.
We also look for evidence of general medical
problems which might be relevant for the lungs.
And a specific example is rheumatoid arthritis,
which has a potential multiple different lung
complications and is obvious in people’s
hands when you examine them in many patients.
We need to measure the respiratory rate, we
need to measure the pulse rate.
And then we move on to looking at the face
and the neck. And in the face, particularly
what we’re interested in is whether the
patient may have central cyanosis: blue lips,
blue tongue. In the neck there are two main
things. There’s whether the patient has
a raised JVP. And that is a sign of pulmonary
hypertension and cor pulmonale and therefore
relevant for respiratory medicine. Or whether
they have palpable cervical lymph nodes. And
that might occur in diseases such as tuberculosis
or lung cancer where involvement of the cervical
glands is relatively common.
After examining the neck, we move onto palpation
of the chest. Initially, we want to know whether
there is any mediastinal shift. To assess
that, we feel for the position of the trachea
and the apex beat.
We then see whether there’s any problem
with chest expansion, either bilaterally or
And then we percuss the chest, a method of
assessing whether there’s any material in
the chest that shouldn’t be there. Normal
percussion is clearly resonant because of
air but, if there’s any liquid or solid
material present, then it becomes dull.
We can also do tactile vocal fremitus that
I will discuss in more detail later.
Only then, after what – all we’ve done
before in the examination with palpation,
examination of the neck, the hands, the respiratory
rate – that we move on to listening, with
auscultation using a stethoscope. And with
that, we also do vocal resonance.
And at the end of the examination, it’s
important not to forget to examine other parts
of the body that might be relevant for respiratory
disease. Specifically, look for peripheral
oedema and also inspect whether there’s
any sputum present. And, if there is sputum
present, what the quality is: whether it’s
mucoid, purulent, mucopurulent or has blood
in it – haemoptysis.
Now the actual process of doing the examination
is obviously a practical thing. I’m not
going to discuss in detail exactly how we
do an examination in this lecture because
that is best described using one-to-one – well,
using a tutorial with an examiner, a subject
and then some students present by the bedside.
What we’ll discuss today are the abnormal
findings we might expect, the potential causes.
And then at the end, I will give a synthesis
of the sort of appearances – examination
findings you may get in specific, important
clinical respiratory conditions.