Differentials
| Presenting Feature | What might it be? | What might I find? | |
| Cough |
Upper Respiratory Tract Infection (URTI) |
Short history of illness with coryza symptoms: cough, sore throat, runny nose, headache. Dry or productive cough.
Systemically well. No focal chest signs. |
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Pneumonia |
Acute illness with cough, fever, breathlessness, chest pain.
Cough generally productive of purulent sputum. May be systemically unwell with fever, tachycardia, confusion – especially in vulnerable patients e.g., elderly. Focal crackles, bronchial breathing, percussion dullness. |
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Asthma |
Typical presentation in childhood but may be older at onset.
May have other atopic illness/family history e.g., hay fever. Episodic symptoms, worse at night or w/trigger e.g., cold. Dry cough, wheeze, chest tightness, breathlessness. Widespread expiratory polyphonic wheeze. Improved with bronchodilator e.g., inhaled salbutamol. |
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Bronchiectasis |
Chronic productive cough, breathlessness, weight loss.
Recurrent chest infections. Finger clubbing, scattered wheeze and crackles to chest. |
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Lung Cancer |
Typical presentation is older smoker, persistent cough, weight loss, fatigue, haemoptysis, breathlessness.
May find finger clubbing and lymphadenopathy. Associated extra-pulmonary manifestations e.g., SIADH, RLN palsy, Horner’s syndrome, hypercalcaemia. |
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| Chronic shortness of breath |
Interstitial Lung Disease |
Progressive & persistent dry cough, breathlessness, fatigue.
Bibasal fine end-inspiratory crackles on auscultation. Finger clubbing. May be idiopathic or secondary to medication or disease. |
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Chronic Obstructive Pulmonary Disease (COPD) |
Most common in older patient with long term smoking hx.
Cough (may be productive), breathlessness, wheeze, recurrent respiratory infections. Widespread polyphonic expiatory wheeze. Progressively worsening disease. |
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| Acute shortness of breath |
Acute Exacerbation of Asthma |
Acute wheeze and shortness of breath in known asthmatic.
May be triggered by infection, exercise, cold weather. Raised rate and effort of breathing, expiratory wheeze, breathlessness, reduced air entry, difficulty speaking. May deteriorate rapidly; require quick treatment, close monitoring and rapid escalation. |
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Acute Exacerbation of COPD |
Acute wheeze and shortness of breath in known COPD.
Triggers infective and non-infective. Cough, often with purulent sputum, increased wheeze and breathlessness. May deteriorate rapidly with increased work of breathing and development of an oxygen requirement. |
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| Acute shortness of breath |
Pulmonary Embolism |
Risk factors: immobility, pregnancy, long-haul travel, malignancy, hormonal treatment e.g., COCP, HRT.
Sudden onset pleuritic chest pain, breathlessness, haemoptysis, tachypnea, hypoxia. May be co-existing signs of DVT in leg. |
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Pleural Effusion |
Shortness of breath, usually subacute onset.
RF: malignancy, CCF, infection, RA, hypoalbuminaemia. Reduced air entry, stony dullness to percussion, tracheal deviation away from the effusion (large effusions only). |
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Pneumothorax |
Typical presentation in young, tall male sporty patient.
Risk factors: underlying lung pathology e.g., asthma. Sudden onset breathlessness , pleuritic chest pain, hypoxia. |
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Checklist
| Preparation | Wash – Name – Explain | |
| Position patient reclining 45° | ||
| Appropriate exposure of chest (bra on) | ||
| General Inspection | Systemic appearance (well/unwell) | |
| Body habitus | ||
| Respiratory rate | ||
| Work of breathing | ||
| Colour | ||
| Obvious scars | ||
| Audible respiratory sounds | ||
| Oedema | ||
| Clues in bed space | ||
| Hands | Colour | |
| Temperature | ||
| Capillary refill | ||
| Tremor | ||
| Finger clubbing | ||
| Tar staining | ||
| Bruising | ||
| Joint swelling | ||
| Radial pulse | ||
| Neck | JVP | |
| Tracheal position | ||
| Tracheal tug | ||
| Cricosternal distance | ||
| Lymphadenopathy | ||
| Face | Colour | |
| Cushingoid appearance | ||
| Eyes | Conjunctival pallor | |
| Horner’s syndrome | ||
| Mouth | Central cyanosis | |
| Candida | ||
| Chest Inspection | Fully expose chest (bra off, consider chaperone) | |
| Inspect from anterior/lateral/posterior aspect | ||
| Chest wall deformity | ||
| Scars | ||
| Skin changes | ||
| Observation of breathing | ||
| Chest Palpation | Apex beat | |
| Right ventricular heave | ||
| Chest expansion | ||
| Chest Percussion | Percuss supraclavicular to axilla, comparing left & right | |
| Tactile vocal fremitus | ||
| Chest Auscultation | Ask patient to breathe through mouth | |
| Auscultate supraclavicular to axilla, comparing left & right | ||
| Vocal resonance | ||
| Posterior Chest | Reposition patient on edge of the couch with arms folded | |
| Posterior percussion | ||
| Posterior tactile vocal fremitus | ||
| Posterior auscultation | ||
| Posterior vocal resonance | ||
| Legs | Signs of DVT | |
| Pedal oedema | ||
| Finishing | Re-cover patient | |
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the procedure and get consent
“I have been asked to examine your respiratory system. This involves looking at your hands, face, and chest and listening to your lungs. You can ask me to stop at any time. Are you happy for me to do that?”
Position the patient reclined on the examination couch at 45°.
Ask the patient to expose their chest (e.g., removing shirt).
If the patient is wearing a bra, keep it on for the initial part of the examination, and ask the patient to remove it at the point of the Chest Inspection part of the examination. You may wish to consider using a chaperone in this instance.
General Inspection
Look at the patient and around the bed space for useful signs:
- Systemic appearance (e.g., do they look unwell?)
- Body habitus (e.g., overweight or underweight)
- Respiratory rate
- Work of breathing (e.g., pursed lips, use of accessory muscles – increased work of breathing indicates respiratory distress)
- Colour – are they flushed, sweaty, plethoric, pale, or cyanosed?
- Obvious scars visible from the end of the bed
- Audible respiratory sounds (e.g., wheeze, crackles, stridor)
- Oedema
- Clues around the bed-space (e.g., oxygen, inhalers, nebuliser, cigarettes)
Hands
Examine both hands together noting:
- Colour (e.g., pale/mottled colour indicates poor peripheral perfusion, blue tinge to fingertips in peripheral cyanosis, tar-staining)
- Temperature (e.g., cold hands indicate poor peripheral perfusion)
- Capillary refill time of fingertip, if delayed >2 seconds then assess centrally at the sternum (indicates poor peripheral perfusion)
- Tremor – a flapping tremor may indicate CO2 retention; a fine tremor may indicate recent salbutamol use
- Finger clubbing – associated with respiratory conditions: bronchiectasis, lung cancer, cystic fibrosis, pulmonary fibrosis
- Tar staining – stigmata of smoking
- Bruising – may indicate frequent steroid use for treatment of respiratory conditions (e.g., COPD, pulmonary fibrosis)
- Joint swelling – some medications used to treat rheumatoid arthritis can cause pulmonary fibrosis
- Radial pulse – rate and character may help determine systemic upset
Neck
Examine the JVP by asking the patient to relax their head against the couch and turn their neck 45° to the left. Look for a visible double-pulsation of the internal jugular vein on the left side of the neck. Measure the distance of this pulsation from the sternal angle; >3-4 cm is a raised JVP and is an abnormal finding and may indicate right heart failure, cor pulmonale or pulmonary hypertension.
Examine the trachea for:
- Position – central (normal), deviation (towards a collapse; away from effusion/tension pneumothorax)
- Tracheal tug – can indicate lung hyperinflation or increased work of breathing
Examine cricosternal distance by palpating the cricoid cartilage in the midline of the neck and estimating the distance to the sternal notch, measured in the patient’s finger–breadths. <3 finger breadths is abnormal and indicates lung hyperinflation.
Examine the neck for lymphadenopathy, which may indicate infection or malignancy.
Face
Examine the patient’s face to assess:
- Colour (e.g., pallor, flushed, plethoric, central cyanosis)
- Cushingoid appearance (e.g., Moon face, puffiness, redness) – indicating frequent steroid use for treatment of respiratory conditions including COPD, pulmonary fibrosis etc.
Eyes
Look at the patient’s eyes examining for:
- Conjunctival pallor indicating anaemia
- Horner’s syndrome – unilateral partial ptosis, miosis, anhidrosis
Mouth
Examine inside the mouth to inspect for any central cyanosis of the tongue and for any oral candidiasis, which may indicate immunocompromise (e.g., from frequent oral steroid use, or poor oral hygiene after steroid inhaler use).
Chest Inspection
If the patient is wearing a bra, at this point ask them to remove it and consider a chaperone.
Fully expose the chest and perform a closer inspection, making sure to inspect anteriorly, posteriorly and laterally looking for:
- Chest wall deformities including pectus carinatum (asthma), barrel chest (lung hyperinflation in COPD), severe scoliosis affecting respiratory function
- Scars (e.g., thoracotomy scar from previous thoracic surgery)
- Skin changes (e.g., post-radiotherapy)
- Observation of breathing (e.g., respiratory effort, accessory muscle use, symmetry of chest expansion)
Chest Palpation
Examine for:
- Apex beat
- Right ventricular heave
- Chest expansion
Locate and palpate the apex beat, assessing its location and character. It is normally located in the mitral area, i.e. in the 5th intercostal space, mid-clavicular line. Locate this area by counting down the ribs from the 2nd rib (level of the sternal angle) to the 5th intercostal space (space between the 5th and 6th ribs) and moving across to where this level intersects the vertical mid-clavicular line. The apex beat may be displaced (i.e moved away from the normal location (e.g., cardiomegaly, mediastinal shift due to collapse/effusion) or non-palpable (i.e. obstructive layer e.g., fat, air, fluid).
Palpate for a right ventricular heave (with the heel of the hand) over the left lower sternal edge. If a heave is present, the doctor’s hand is lifted off the chest wall and indicates right ventricular hypertrophy which can occur with cor pulmonale and pulmonary hypertension.
Examine chest expansion feeling for symmetry of movement on both sides of the chest. Ask the patient to breathe out, place your hands palms–down on patient’s chest with thumbs touching in the midline. Ask the patient to take a deep breath in and observe your hands; thumbs should move apart symmetrically. Asymmetrical movement indicates unequal chest expansion, with likely underlying lung disease.
Chest Percussion
Percuss the anterior chest starting in the supraclavicular area comparing right and left sides. Continue percussing at intervals down to the level of the axilla, comparing right and left sides before moving on. Percussion notes indicate the following:
- Resonant – normal
- Dull – consolidation, collapse, mass
- Stony dull – effusion
- Hyper–resonant – pneumothorax
Assess further for tactile vocal fremitus; feeling the chest wall vibration in the areas indicated above whilst asking the patient to say ‘ninety–nine’.. An increase in vibration indicates solid tissue within the underlying lung (e.g., consolidation or masses) whereas reduced fremitus indicates fluid or air (e.g., Effusion, pneumothorax).
Chest Auscultation
Ask the patient to take some deep breaths in and out through their mouth – this is important to try to eliminate any upper airway sounds from your examination.
Auscultate the anterior chest from the supraclavicular area to the axilla in the same areas as you percussed, comparing right and left sides before moving on. Assess the following:
- Presence of breath sounds
- Character of breath sounds – vesicular (normal) or bronchial (consolidation)
- Presence of added sounds – wheeze, crackles, stridor, pleural rub
- Pattern of added sounds – inspiratory or expiratory
Assess further for vocal resonance; listening in the areas indicated above whilst asking the patient to say ‘ninety–nine’. An increase in resonance of the voice in a specific area indicates solid tissue within the underlying lung (e.g., consolidation or masses) whereas reduced resonance indicates fluid or air (e.g., Effusion, pneumothorax).
Posterior Chest
Ask the patient to change their position, sitting forward on the edge of the bed with their arms folded.
Repeat the following as for the anterior chest on the posterior chest:
- Palpation
- Tactile vocal fremitus
- Auscultation
- Vocal resonance
Legs
Examine the legs for:
- Signs of DVT – unilateral red, hot, tender swollen calf
- Pedal oedema – may indicate cor pulmonale
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the respiratory examination findings, you may wish to carry out further investigations, including blood gas sampling, chest X-ray, blood tests, peak flow assessment, lung function tests, or further imaging such as CT scan.
[*Illustrations – coming 2025]
Last updated Dec 2024
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