Respiratory Examination — Viva

Short Case Viva Defence

Examiner instruction

"Examine this patient's respiratory system. Present your findings and offer a differential diagnosis." [1]

Candidate's model examination and presentation

"Before I begin, I would like to introduce myself, explain the examination to the patient, and obtain consent. I would ensure the patient is comfortable, exposed appropriately from the waist up, and positioned sitting upright at 45 degrees." [1]

End of bed: "On general inspection, the patient is cachectic and breathless at rest, with an increased respiratory rate of 24 breaths per minute. There is use of the accessory muscles and pursed-lip breathing. The chest has a barrel-shaped configuration with an increased anteroposterior diameter. There is oxygen tubing in situ delivering 2 litres per minute via nasal cannulae, and a salbutamol inhaler is visible on the bedside table." [1]

Hands: "In the hands, there is no finger clubbing, no peripheral cyanosis, and no asterixis. There is a fine tremor consistent with beta-agonist use. There is tar staining of the index and middle fingers of the right hand, consistent with a smoking history." [1]

Face: "In the face, there is a plethoric complexion consistent with polycythaemia secondary to chronic hypoxaemia. There is no Horner syndrome and no central cyanosis. There is no oral candidiasis." [1]

Neck: "In the neck, the JVP is elevated approximately 4 centimetres above the sternal angle. The trachea is central. The cricosternal distance is reduced at less than 3 centimetres, consistent with hyperinflation. There is no cervical or supraclavicular lymphadenopathy." [1]

Anterior chest: "On inspection of the anterior chest, there is no deformity, no scars, and the chest moves symmetrically. On palpation, chest expansion is reduced bilaterally, measuring approximately 3 centimetres. On percussion, the note is hyperresonant throughout. On auscultation, breath sounds are globally reduced with an expiratory wheeze. There are no crackles and no pleural rub. Vocal resonance is symmetrically reduced." [1]

Posterior chest: "Posteriorly, the findings are confirmed: reduced expansion bilaterally, hyperresonant percussion note, globally reduced breath sounds with expiratory wheeze, and bilateral coarse crackles at the bases. There is no sacral oedema." [1]

Legs: "In the legs, there is peripheral oedema to the mid-shin bilaterally. There is no calf swelling or tenderness to suggest a deep vein thrombosis. The peripheral pulses are present and symmetrical." [1]

Additional tests: "I would like to complete the examination by checking the oxygen saturation, a peak expiratory flow rate, the sputum pot, the inhaler technique, and ordering a chest X-ray." [1]

Summary: "In summary, this patient has the clinical features of severe COPD — the barrel chest, the pursed-lip breathing, the hyperresonant percussion note, the globally reduced breath sounds with expiratory wheeze, and the reduced cricosternal distance — complicated by an infective exacerbation (the bilateral basal coarse crackles) and cor pulmonale (the elevated JVP and the peripheral oedema). The important negative is the absence of clubbing, which would have prompted me to investigate for lung cancer, bronchiectasis, or coexisting pulmonary fibrosis. My plan is to check the arterial blood gas for CO2 retention given the drowsiness and the severe COPD, to treat the infective exacerbation with antibiotics and systemic corticosteroids, and to investigate for cor pulmonale with an echocardiogram." [1]

Examiner probing questions and model answers

Q1: "You mentioned the absence of clubbing is an important negative. What would the presence of clubbing have changed?" [1]

"Clubbing does not occur in uncomplicated COPD. If I had found clubbing in this patient, I would have been concerned about a complication — lung cancer, bronchiectasis, or coexisting pulmonary fibrosis. The lung causes of clubbing are lung cancer (especially non-small cell), bronchiectasis, pulmonary fibrosis (especially idiopathic pulmonary fibrosis and asbestosis), mesothelioma, and lung abscess or empyema [4]. I would have ordered a chest X-ray and a CT chest to look for a mass, bronchiectasis, or interstitial changes. The COPD patient who develops new clubbing has a complication until proven otherwise."

Q2: "What is the significance of the coarse crackles at the bases?" [1]

"The coarse, basal crackles suggest secretions in the medium and large airways, which in this patient with COPD is most consistent with an infective exacerbation — bronchitis or early pneumonia. Coarse crackles are mid-inspiratory, low-pitched, bubbling, and may clear with coughing. They differ from fine crackles, which are late-inspiratory, high-pitched, Velcro-like, and do not clear with coughing — fine crackles indicate interstitial lung disease or early pulmonary oedema [1]. In this patient, the crackles are bilateral and basal, which is the distribution of bronchial secretions in COPD. I would treat with antibiotics and systemic corticosteroids, and if the crackles do not resolve, I would reconsider bronchiectasis."

Q3: "How do you distinguish consolidation from a pleural effusion at the bedside?" [1]

"The two produce opposite patterns of breath sounds and vocal resonance. Consolidation produces dull percussion, bronchial breath sounds, increased vocal resonance with whispering pectoriloquy and aegophony, and coarse crackles — because the solid lung conducts sound better than air-filled lung. A pleural effusion produces stony dull percussion, absent or reduced breath sounds, and reduced vocal resonance — because the fluid blocks all sound transmission from the lung to the chest wall. The distinction between dull (consolidation) and stony dull (effusion) is the single most useful percussion finding, and I would confirm the effusion with a chest X-ray and a diagnostic pleural aspiration [3]."

Q4: "What is the significance of the elevated JVP in this patient?" [1]

"The elevated JVP in this patient with COPD indicates cor pulmonale — the right heart failure of chronic lung disease. The mechanism is pulmonary hypertension from chronic hypoxaemia (which causes pulmonary vasoconstriction) and the destruction of the pulmonary vascular bed in emphysema (which increases the pulmonary vascular resistance). The right ventricle hypertrophies and eventually fails, producing a raised JVP, a parasternal heave, tricuspid regurgitation, and peripheral and sacral oedema. I would confirm with an echocardiogram and manage with diuretics, optimised COPD therapy, and long-term oxygen therapy if chronically hypoxaemic." [1]

Q5: "What is the significance of the reduced cricosternal distance?" [1]

"The cricosternal distance — the gap between the cricoid cartilage and the sternal notch — is reduced (less than 3 centimetres) in hyperinflation. In severe COPD, the diaphragm is flattened and the chest is held in the inspiratory position, which pushes the sternum upwards and reduces the gap. A tracheal tug — the downward movement of the thyroid cartilage on inspiration — is a related sign of severe hyperinflation, produced by the flattened diaphragm pulling on the mediastinum during inspiration." [1]

Q6: "How would you manage this patient's COPD exacerbation?" [1]

"The immediate management follows the ABCDE approach. I would check the arterial blood gas given the severe COPD and the risk of CO2 retention — the oxygen target is 88 to 92 per cent, and if the pH is below 7.35 with a PaCO2 above 6 kPa, I would start non-invasive ventilation (bilevel positive airway pressure). I would give nebulised salbutamol and ipratropium, systemic corticosteroids (prednisone 30 to 40 mg daily for 5 to 7 days), and antibiotics guided by the local guideline (amoxicillin-clavulanate or doxycycline for an exacerbation with increased sputum purulence and volume). I would check the inhaler technique, optimise the maintenance therapy (confirm the dual bronchodilation and the inhaled corticosteroid regimen), enrol the patient in pulmonary rehabilitation, check the vaccination status, and address the advance care planning." [1]