Tell me the exact questions that can be asked from a mbbs final year studentby examiner from basic to easy to moderate to hard about respiratory system and also related to the clinical findings of systematic examination along with their answers

Reading File

Finding Sources

Searching the Web

MBBS final year viva questions respiratory system clinical examination examiner questions answers

Finding Sources

Reading Web Page

https://journal-api.s3.ap-south-1.amazonaws.com/issues/artic…

Finding Sources

Reading File

Finding Sources

Reading File

Finding Sources

Reading File

Finding Sources

I now have comprehensive material from Harrison's, Goldman-Cecil, JAPI review article, and other textbooks. Let me compile the full answer.

Respiratory System - MBBS Final Year Viva Questions & Answers

Compiled from Harrison's Principles of Internal Medicine (22e), Goldman-Cecil Medicine, Murray & Nadel's Textbook of Respiratory Medicine, JAPI Review (2026), and clinical examination resources.

SECTION 1 - BASIC LEVEL

Q1. What are the cardinal symptoms of respiratory disease?

A: Dyspnea and cough are the two cardinal symptoms. Hemoptysis, chest pain (pleuritic), and wheezing are additional major complaints.

Harrison's Principles of Internal Medicine, 22e

Q2. What is the normal respiratory rate in adults?

A: 12-20 breaths per minute at rest. The normal pulse-respiratory quotient (PRQ) is 4:1 (heart rate to respiratory rate).

JAPI Respiratory Examination Review, 2026

Q3. What position should a patient be in for respiratory examination?

A: The patient should be propped up at 45° angle, comfortably reclining. For observing chest movement and paradoxical breathing, the patient should lie flat and be observed from the foot end of the bed.

JAPI Respiratory Examination Review, 2026

Q4. What are the four components of systematic respiratory examination?

A: Inspection, Palpation, Percussion, and Auscultation (IPPA).

Q5. What are the signs of respiratory distress on inspection?

Raised respiratory rate (tachypnea)
Use of accessory muscles (sternocleidomastoid, scalene, intercostals)
Intercostal retractions
Nasal flaring
Cyanosis
Sweating
Pursed lip breathing
Tripod/orthopneic position (leaning forward with hands on knees)
JAPI Respiratory Examination Review, 2026; Goldman-Cecil Medicine

Q6. Name the accessory muscles of respiration.

A: During inspiration - sternocleidomastoid, scalene, pectoralis minor, serratus anterior. During forced expiration - internal intercostals, abdominal muscles (rectus abdominis, external and internal obliques, transversus abdominis).

Q7. What is clubbing and in which respiratory conditions is it seen?

A: Clubbing is a bulbous enlargement of the terminal phalanges with loss of the normal 15° angle between the nail and nail bed (Lovibond angle >180°, Schamroth's sign positive). Respiratory causes include:

Bronchiectasis
Lung abscess
Empyema
Lung carcinoma (especially non-small cell)
Idiopathic pulmonary fibrosis (IPF)
Mesothelioma

Note: Clubbing is NOT a feature of COPD or asthma.

Barash Clinical Anesthesia, 9e; Harrison's 22e

Q8. What is cyanosis and at what saturation does it become clinically visible?

A: Cyanosis is the bluish discoloration of skin and mucous membranes due to excess deoxygenated hemoglobin (>5 g/dL reduced Hb). It becomes visible when arterial hemoglobin saturation is ≤80% (PaO2 <50-52 mmHg). Central cyanosis (tongue/mucous membranes) indicates systemic hypoxemia; peripheral cyanosis (fingers/toes) may be due to local vasoconstriction.

Barash Clinical Anesthesia, 9e

Q9. What is the anatomical landmark for the oblique fissure?

A: The oblique fissure runs from T2 spine posteriorly to the 6th rib at the mid-clavicular line anteriorly. The horizontal (transverse) fissure on the right runs from the 4th rib anteriorly to meet the oblique fissure in the mid-axillary line at the 5th rib.

JAPI Respiratory Examination Review, 2026

Q10. What are non-respiratory causes of tachypnea and bradypnea?

Tachypnea causes (non-respiratory): Exertion, excitement, fever, metabolic acidosis, anemia
Bradypnea causes: CNS depressants, narcotic poisoning, brain tumors, painful breathing (pleurisy)
Cushing's triad (raised ICP) = hypertension + bradycardia + bradypnea/irregular respirations
JAPI Respiratory Examination Review, 2026

SECTION 2 - EASY TO MODERATE LEVEL

PALPATION

Q11. What is Tactile Vocal Fremitus (TVF)? When is it increased and decreased?

A: TVF is the vibration felt on the chest wall when the patient speaks (say "99" or "one-one-one"). It is transmitted best through solid or consolidated tissue.

Condition	TVF	Reason
Consolidation (pneumonia)	Increased	Solid lung transmits vibration better
Pleural effusion	Decreased/Absent	Fluid dampens vibration
Pneumothorax	Absent	Air does not transmit vibration
COPD/Emphysema	Decreased	Hyperinflated lung traps sound
Fibrosis	Increased	Dense lung tissue

Harrison's 22e; Goldman-Cecil Medicine

Q12. How do you assess chest expansion and what does asymmetry indicate?

A: Place both thumbs at the midline over the lower posterior chest with hands grasping the lateral rib cage. Ask the patient to take a deep breath. Normal expansion is equal bilaterally (about 5 cm). Asymmetric chest wall expansion is the physical finding that best correlates with the presence of pleural effusion. Reduced expansion on one side suggests: pleural effusion, pneumothorax, consolidation, collapse, or fibrosis on that side.

Washington Manual of Medical Therapeutics; Harrison's 22e

Q13. What does tracheal deviation indicate?

Trachea pulled TOWARD the lesion: Lung collapse/atelectasis, pulmonary fibrosis (volume loss)
Trachea pushed AWAY from the lesion: Massive pleural effusion, large pneumothorax (tension), large mediastinal mass, large pleural tumor

A simple rule: trachea is pushed away from "space-occupying" lesions and pulled toward "volume-losing" lesions.

PERCUSSION

Q14. What are the different percussion notes and what do they indicate?

Percussion Note	Condition
Resonant	Normal lung
Hyper-resonant / Tympanitic	Pneumothorax, emphysema/COPD, large bulla
Dull	Consolidation (pneumonia), lobar collapse, lung abscess
Stony Dull	Pleural effusion (fluid transmits no vibration)

Murray & Nadel's Textbook of Respiratory Medicine; Tintinalli's Emergency Medicine

Q15. What is the significance of percussion over a large pneumothorax?

A: The percussion note becomes hyper-resonant and progresses to tympanitic when tension is present. This, combined with absent breath sounds and tracheal deviation away from the affected side, constitutes the clinical triad of tension pneumothorax - a medical emergency.

Murray & Nadel's Textbook of Respiratory Medicine

Q16. How do you percuss for diaphragmatic excursion and what is the normal range?

A: Start percussion from the upper chest downward. Ask the patient to take a deep breath and hold it - mark where resonance changes to dullness (diaphragm level on inspiration). Then ask them to breathe out fully - mark the new dullness level (diaphragm level on expiration). Normal diaphragmatic excursion is 5-6 cm bilaterally. Reduced excursion suggests pleural effusion, diaphragmatic palsy, or hyperinflation (COPD).

AUSCULTATION

Q17. What are the types of normal breath sounds?

Vesicular breath sounds - Normal over lung parenchyma. Inspiratory phase > expiratory phase. Soft, low-pitched. No gap between phases.
Bronchial/Tubular breath sounds - Normal over trachea/large airways. Expiratory phase ≥ inspiratory phase. Loud, high-pitched. Gap between phases. Pathological if heard over lung periphery (indicates consolidation).
Bronchovesicular breath sounds - Normal over the 1st and 2nd intercostal spaces anteriorly and between scapulae. Intermediate character.

Q18. What are added/adventitious breath sounds? Classify them.

Continuous sounds:

Wheeze - Musical, high-pitched, due to airway narrowing. Polyphonic (multiple airways - asthma) or monophonic (single airway obstruction - carcinoma, foreign body). Expiratory wheeze in asthma/COPD.
Rhonchi - Low-pitched, musical, from medium-sized airway secretions. Suggest bronchitis, bronchiectasis, COPD.
Stridor - High-pitched inspiratory wheeze, heard loudest over neck. Indicates upper airway obstruction (laryngeal edema, croup, foreign body). Surgical emergency.

Discontinuous sounds:

Crackles (Rales) - Short, non-musical. Fine crackles (Velcro-like) = pulmonary fibrosis, early pneumonia, pulmonary edema. Coarse crackles = late pneumonia, bronchiectasis. Bibasal crackles = pulmonary edema/CCF.
Pleural rub - Grating, leathery, non-musical, heard in both phases of respiration. Due to inflamed parietal and visceral pleura rubbing. Present in pleuritis/pleurisy.
Harrison's Principles of Internal Medicine, 22e

Q19. How do you differentiate pleural rub from crackles?

Pleural rub: Present in BOTH inspiration AND expiration. The expiratory component mirrors the inspiratory component. Disappears if breath is held. Not cleared by coughing. Grating, creaky character.
Crackles: Predominantly inspiratory. May clear with coughing (if due to secretions). Persist when breath is held.
JAPI Respiratory Examination Review, 2026

Q20. What are the vocal resonance tests and what do they indicate?

Vocal Resonance (VR) - Ask patient to say "99." Increased in consolidation, decreased in effusion/pneumothorax.
Whispering Pectoriloquy - Ask patient to whisper "1-2-3." Whispered sounds clearly audible = consolidation (normally only muffled sounds heard).
Egophony - Patient phonates "EEE" but examiner hears "AY/AH." Present in consolidation (pneumonia). NOT present in IPF. Due to abnormal sound transmission through consolidated parenchyma.
Bronchophony - Increased transmission of spoken voice, heard in consolidation.

Harrison's Principles of Internal Medicine, 22e

SECTION 3 - MODERATE LEVEL

Q21. Describe the complete clinical signs in a case of Pleural Effusion.

Step	Finding
Inspection	Reduced chest movement on affected side, fullness of intercostal spaces
Palpation	Reduced/absent TVF on affected side, reduced chest expansion on that side, trachea deviated AWAY (if large)
Percussion	Stony dull note on affected side. Shifting dullness. Ellis S-shaped curve (demarcates upper border). Traube's space obliterated (left-sided)
Auscultation	Absent/diminished breath sounds. Aegophony just above the effusion (E to A change). No vocal resonance

Key: "Stony dull percussion + absent breath sounds + decreased TVF + tracheal shift away" = Pleural Effusion

Washington Manual of Medical Therapeutics; Rosen's Emergency Medicine; Frameworks for Internal Medicine

Q22. What is the difference between consolidation and pleural effusion on examination?

Feature	Consolidation	Pleural Effusion
Percussion note	Dull (not stony dull)	Stony dull
Breath sounds	Bronchial	Absent/diminished
TVF	Increased	Decreased/Absent
Vocal resonance	Increased (whispering pectoriloquy +ve)	Absent
Trachea	Central (unless massive)	Deviated away (if large)
Chest expansion	Reduced on affected side	Reduced on affected side

Frameworks for Internal Medicine; Harrison's 22e

Q23. Describe the clinical findings in COPD/Emphysema.

Inspection: Barrel chest (increased AP diameter), tripod position, pursed lip breathing, cyanosis, use of accessory muscles, Harrison's sulci (indrawn lower ribs)
Palpation: Reduced chest expansion bilaterally, reduced TVF, Hoover's sign (lower costal margins move inward instead of outward on inspiration due to flat diaphragm)
Percussion: Hyper-resonant bilaterally, reduced liver dullness (pushed down), low flat diaphragm with reduced excursion
Auscultation: Diminished vesicular breath sounds, prolonged expiratory phase, polyphonic wheezes, scattered rhonchi, quiet chest in severe emphysema
Goldman-Cecil Medicine; Harrison's 22e

Q24. What is Hoover's sign?

A: In advanced COPD/emphysema, the diaphragm is chronically flattened due to hyperinflation. When the patient inspires, instead of the lower ribs flaring outward, they paradoxically move inward (retract). This inward retraction of the lower rib cage with inspiration is called the Hoover sign. It indicates severe air trapping and flattened diaphragm biomechanics.

Goldman-Cecil Medicine

Q25. What are the clinical findings in Pneumothorax?

Step	Finding
Inspection	Reduced chest movement on affected side, tachypnea, distress
Palpation	Absent TVF on affected side, trachea deviated AWAY (tension)
Percussion	Hyper-resonant / Tympanitic on affected side
Auscultation	Absent breath sounds on affected side

Tension pneumothorax additionally: Hypotension, raised JVP, mediastinal shift, haemodynamic compromise - this is an immediate emergency (needle decompression at 2nd ICS, MCL).

Q26. What are abnormal breathing patterns and what do they suggest?

Pattern	Description	Cause
Cheyne-Stokes	Cyclical waxing-waning with apneic pauses	CCF, CNS disease, opioids, high altitude
Kussmaul	Deep, rapid, regular breathing	Metabolic acidosis (DKA, renal failure)
Biot's (Ataxic)	Irregular with no pattern, apneic pauses	Brainstem lesions (medullary compression)
Apneustic	Prolonged inspiration with brief expiration	Pontine lesions
Paradoxical	Abdomen and chest move in opposite directions	Diaphragmatic fatigue, flail chest

JAPI Respiratory Examination Review, 2026

Q27. What is the Trail sign? When is it seen?

A: The Trail sign (or tracheal tug) is the downward displacement of the larynx/cricoid cartilage during deep inspiration. It is typically seen in significant aortic aneurysm or mediastinal mass. Oliver's sign (tracheal tug with pulsation) specifically suggests thoracic aortic aneurysm.

SECTION 4 - HARD / EXAMINER-FAVOURITE QUESTIONS

Q28. What is the mechanism of crackles (rales)?

A: Crackles are produced by the sudden opening of small collapsed airways. During expiration, small airways collapse under the weight of dependent lung. On the next inspiration, as air rushes in, these airways reopen with a snap, causing rapid equalization of gas pressures. This produces oscillations of the gas column, generating the crackling sound. This is why crackles are predominantly inspiratory and are heard in the bases of dependent lung zones first.

JAPI Respiratory Examination Review, 2026

Q29. Why are bronchial breath sounds heard in consolidation even though the airways are filled with fluid?

A: In consolidation (e.g., lobar pneumonia), the alveoli are filled with exudate (fluid/cells) rather than air, making the lung parenchyma dense and solid. This solidified lung acts as a better sound conductor than normal air-filled lung. Sound from the large central airways (which have bronchial characteristics) is transmitted WITHOUT attenuation to the chest wall. Hence, bronchial breath sounds, bronchophony, whispering pectoriloquy, and egophony are heard at the chest wall in consolidated segments. The airways themselves must remain patent for this to occur - if the bronchus is blocked (e.g., carcinoma), no bronchial sounds are transmitted.

Harrison's Principles of Internal Medicine, 22e

Q30. A patient has complete opacification of one hemithorax on CXR. How do you differentiate clinically between massive pleural effusion vs. collapse of the entire lung?

Feature	Massive Pleural Effusion	Total Lung Collapse
Trachea	Deviated AWAY from lesion	Deviated TOWARD lesion
Mediastinum	Shifted contralaterally	Shifted ipsilaterally
TVF	Absent (fluid blocks vibration)	Absent (no air)
Percussion	Stony dull	Dull
Breath sounds	Absent	Absent
Intercostal spaces	Full/bulging	Narrow/indrawing
Chest expansion	Reduced ipsilaterally	Reduced ipsilaterally

Key distinguishing feature: Tracheal position - away in effusion, toward in collapse.

Frameworks for Internal Medicine

Q31. What is the obstructive vs restrictive pattern on spirometry and how does clinical examination suggest each?

Obstructive (e.g., asthma, COPD):

FEV1/FVC ratio < 0.7 (low)
FVC may be normal or reduced
Examination: wheeze, prolonged expiration, barrel chest, hyper-resonance

Restrictive (e.g., fibrosis, effusion, kyphoscoliosis, neuromuscular):

FEV1/FVC ratio > 0.7 (normal or high)
Both FEV1 and FVC are proportionally reduced
TLC reduced
Examination: reduced expansion, fine basal crackles (Velcro), kyphoscoliosis, reduced chest excursion
Harrison's Principles of Internal Medicine, 22e (Table - Obstructive and Restrictive pathophysiology)

Q32. What are the causes of monophonic vs polyphonic wheeze?

Polyphonic wheeze - Multiple airways of different sizes are obstructed simultaneously. Suggests diffuse airway disease - asthma, COPD, cardiac asthma (peribronchial edema in CCF).
Monophonic wheeze - A single airway is obstructed. Suggests focal obstruction - bronchogenic carcinoma, foreign body, endobronchial lesion, mucus plug.

Clinical implication: Not all wheeze is asthma. A persistent unilateral monophonic wheeze in a smoker must prompt investigation for lung cancer.

Harrison's Principles of Internal Medicine, 22e

Q33. What does jugular venous distension (JVD) indicate in a respiratory patient?

A: In a respiratory context, elevated JVP suggests:

Cor pulmonale (right heart failure secondary to chronic lung disease - COPD, IPF, pulmonary hypertension)
Tension pneumothorax (obstructed venous return)
Cardiac tamponade (part of Beck's triad)
Superior vena cava (SVC) obstruction (non-pulsatile elevated JVP, facial edema, dilated neck veins - seen with central lung carcinoma/lymphoma)

Symmetric pedal edema in a respiratory patient suggests cor pulmonale; asymmetric suggests DVT and possible PE.

Harrison's Principles of Internal Medicine, 22e

Q34. What is Tidal Percussion?

A: Tidal percussion is performed by percussing at the lung bases while the patient breathes normally. The percussion note alternates between resonance (inspiration) and dullness (expiration) as the diaphragm moves up and down. It allows assessment of diaphragmatic movement in a less effort-dependent manner compared to standard diaphragmatic excursion testing. The finding is obliterated when there is a large pleural effusion or diaphragmatic paralysis.

JAPI Respiratory Examination Review, 2026

Q35. What is the smell/odour of the breath clinically significant in respiratory examination?

Foul/putrid odour: Suggests anaerobic lung abscess, empyema, bronchiectasis with infected secretions
Sweet/fruity odour: Suggests Pseudomonas aeruginosa infection of skin/soft tissue or pulmonary abscess
Acetone/ketotic smell: Diabetic ketoacidosis (Kussmaul breathing)
Fetor hepaticus: Liver failure with pulmonary complications (hepatopulmonary syndrome)
JAPI Respiratory Examination Review, 2026

QUICK SUMMARY TABLE - Differential Diagnosis by Clinical Signs

Sign	Effusion	Consolidation	Pneumothorax	Collapse	Emphysema	Fibrosis
Trachea	Away (if large)	Central	Away (tension)	Toward	Central	Toward
Expansion	↓ ipsilateral	↓ ipsilateral	↓ ipsilateral	↓ ipsilateral	↓ bilateral	↓ bilateral
TVF	↓↓	↑↑	Absent	Absent	↓	↑
Percussion	Stony dull	Dull	Hyper-resonant	Dull	Hyper-resonant	Dull
Breath sounds	Absent	Bronchial	Absent	Absent	↓↓	Vesicular
Added sounds	Aegophony above	Crackles, WP	None	None	Wheeze, rhonchi	Fine crackles

(TVF = Tactile Vocal Fremitus; WP = Whispering Pectoriloquy; ↑ = increased; ↓ = decreased)

Sources:

Harrison's Principles of Internal Medicine, 22e (2025), Chapters 31 & 292
Goldman-Cecil Medicine, Chapter 76 (COPD)
Murray & Nadel's Textbook of Respiratory Medicine
Washington Manual of Medical Therapeutics
JAPI Review: Respiratory Examination for Postgraduate Residents, April 2026
Frameworks for Internal Medicine

This is a shared conversation. Sign in to Orris to start your own chat.