Further Examination

This will largely be directed, not only by history, but by what signs have been elicited. If possible, it is important to observe the respiratory patient during exertion. The six minute walk test is a well validated tool used to assess a patients exercise capacity. If diaphragmatic paralysis is suspected then lie the patient flat and observe for paradoxical movement of the abdomen during the respiratory cycle. Performing standing and lying vital capacity using a spirometer is a more accurate assessment of this. A fall in VC from standing to lying of more than 20% is suggestive of bilateral diaphragmatic paralysis.

I would mention here briefly about spirometery and PEF. Describe their application for detecting obstructive and restrictive disease. Clearly a more detailed explanation is beyongd the scope of this chapter.
In addition it is worth mentioning that chest X ray is critical in the pulmonary assessment and the candidate should be prepared to interpret these and request them to confirm clinical findings observed on examination.