History
- • Cough (dry/productive, sputum colour, haemoptysis)
- • Dyspnoea — onset, exertion, orthopnoea, wheeze
- • Chest pain, fever, weight loss, night sweats
- • Smoking pack-years, occupational/asbestos, pets, travel
Examination sequence
- • WIPE — patient at 45°, fully expose chest
- • End-of-bed: respiratory rate, accessory muscles, pursed lips, O₂
- • Hands: clubbing, tar staining, peripheral cyanosis, CO₂ flap, fine tremor (β-agonist)
- • Face: central cyanosis, Horner's, anaemia, pursed lips
- • Neck: trachea, cricosternal distance, lymph nodes, JVP
- • Anterior chest: inspect, palpate (expansion, TVF), percuss, auscultate (breath sounds + added)
- • Repeat posteriorly + vocal resonance
- • Sacral/pedal oedema, peak flow, sputum pot
Positive findings
- • Reduced expansion + dull percussion + bronchial breathing — consolidation
- • Stony dull + absent breath sounds — effusion
- • Hyper-resonance + absent breath sounds — pneumothorax
- • Bilateral fine end-inspiratory crackles — pulmonary fibrosis
Differentials
- • Acute SOB: PE, pneumothorax, pneumonia, APO, exacerbation
- • Chronic: COPD, ILD, bronchiectasis, lung cancer, HF
Viva questions
Q. How do you confirm a pleural effusion clinically?
A. Reduced expansion, stony dull percussion, absent breath sounds + tactile/vocal resonance on the affected side.
Q. Bedside investigations?
A. SpO₂, peak flow, ABG, ECG, CXR, sputum culture.
Common mistakes
- • Skipping the back exam
- • Not comparing both sides side-by-side
- • Missing trachea before percussion
