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Respiratory examination frequently appears in OSCEs.  You’ll be expected to pick up the relevant clinical signs using your examination skills. This respiratory examination OSCE guide provides a step by step approach to examining the respiratory system, with an included video demonstration. Check out the respiratory examination OSCE mark scheme here.



Introduction

Wash hands

Introduce yourself 

Confirm patient details – name / DOB

Explain the examination

Gain consent

Expose the patient’s chest

Position patient at 45°

Ask if the patient has any pain before you begin


General inspection

Age:

  • Young patients – more likely asthma or cystic fibrosis (CF)
  • Older patients – more likely COPD/interstitial lung disease (ILD)/malignancy

Treatments or adjuncts around bed – O2 (ILD, COPD) / inhalers or nebulisers (asthma, COPD) /sputum pots (COPD, bronchiectasis)

Does patient look short of breath? – tripod position / nasal flaring / pursed lips / use of accessory muscles / intercostal muscle recession

Is the patient able to speak in full sentences?

Scars (more details in the close inspection of the thorax section below)

Cyanosis – bluish/purple discolouration – (<85% oxygen saturation) 

Chest wall – note any abnormalities or asymmetry – e.g. barrel chest (COPD)

Cachexia – very thin patient with muscle wasting  (malignancy, cystic fibrosis, COPD)

Cough:

  • Productive (bronchiectasis / COPD if older / CF if younger)
  • Dry (asthma if younger / ILD if older)

Wheeze (expiratory) – asthma / COPD / bronchiectasis

Stridor (inspiratory) – upper airway obstruction

Hands

Inspect the hands:

  • Tar staining on fingers (or nicotine patches on body)- smoker – increased risk of COPD / lung cancer
  • Clubbing  lung cancer / interstitial lung disease / bronchiectasis
  • Peripheral cyanosisbluish discolouration of nails – O2 saturation <85%
  • Features of rheumatological disease (e.g. joint swelling/tenderness) – rheumatological diseases (e.g. rheumatoid arthritis) can be associated with pleural effusions and pulmonary fibrosis
  • Skin changes – bruising and thinning of the skin are associated with long-term steroid use (ILD / asthma / COPD)

 

Assess temperature – ↓ temperature suggests  peripheral vasoconstriction / poor perfusion

Palpate pulse – rate and rhythm

Assess respiratory rate – normal adult range = 12-20 breaths per minute

Pulsus paradoxus – pulse wave volume decreases with inspiration – asthma / COPD 

Fine tremor – can be a side effect of beta 2 agonist use (e.g. salbutamol)

Flapping tremor – CO2 retention – type 2 respiratory failure – e.g. COPD

  • Inspect for peripheral cyanosis

Head and neck

Conjunctival pallor – ask patient to lower an eyelid to allow inspection – anaemia is associated with pallor

Horner’s syndrome ptosis / constricted pupil (miosis) /anhidrosis on affected sideenophthalmos

Central cyanosis – bluish discolouration of the lips / inferior aspect of tongue

 

Jugular venous pressure (JVP) – a raised JVP may indicate pulmonary hypertension / fluid overload 

  • Ensure the patient is positioned at 45°
  • Ask patient to turn their head away from you
  • Observe the neck for the JVP – located inline with the sternocleidomastoid
  • Measure the JVP – number of centimetres measured vertically from the sternal angle to the upper border of pulsation
  • jugular venous pressure (JVP)
    Assess jugular venous pressure (JVP)

Close inspection of thorax

Scars:

  • Small mid-axillary scars (e.g. chest drains)
  • Horizontal postero-lateral scars (thoracotomy from e.g. lobectomy/pneumonectomy)

Skin changes – may indicate recent or previous radiotherapy – erythema / thickened skin

Asymmetry – major surgery:

  • Pneumonectomy (usually for cancer)
  • Thoracoplasty (rib removed / previously used to treat tuberculosis)

Deformities barrel chest (COPD) / pectus excavatum and carinatum

  • Inspect chest wall

Palpation

Tracheal position:

  • Ensure patient’s neck musculature is relaxed – chin slightly downwards
  • Dip index finger into the thorax beside the trachea
  • Then gently apply side pressure to locate the trachea
  • Compare this space to the other side of the trachea using the same process
  • A difference in the amount of space between the sides suggests deviation
  • The trachea deviates away from pneumothorax and large pleural effusions
  • The trachea deviates towards lobar collapse and pneumonectomy 
  • Palpation of the trachea can be uncomfortable, so warn the patient and apply a gentle technique

 

Cricosternal distance (not commonly done in practice):

  • Measure the distance between the suprasternal notch and cricoid cartilage using your fingers
  • In normal healthy individuals, the distance should be 3-4 fingers
  • If the distance is <3 fingers, this suggests lung hyperinflation
  • Keep in mind that this distance is actually based on the patient’s fingers 
  • So if their fingers are significantly different in size from your own, it may be worth checking with theirs

 

Apex beat:

  • Normal position is 5th intercostal space – mid-clavicular line
  • Right ventricular heave is noted in cor-pulmonale (right heart failure secondary to chronic hypoxic lung diseases such as COPD or ILD)

 

Chest expansion:

  • Place your hands on the patient’s chest, inferior to the nipples
  • Wrap your fingers around either side of the chest
  • Bring your thumbs together in the midline, so that they touch
  • Ask patient to take a deep breath
  • Observe movement of your thumbs, they should move apart equally
  • If one of your thumbs moves less, this suggests reduced expansion on that side
  • Reduced expansion can be caused by lung collapse / pneumonia
  • Assess tracheal position

Percussion

Technique is very important! 

1. Place your non-dominant hand on the chest wall

2. Your middle finger should overlie the area you want to percuss (between ribs)

3. With your dominant hand’s middle finger, strike the middle phalanx of your non-dominant hand’s middle finger

4. The striking finger should be removed quickly, otherwise you may muffle resulting percussion note

Percuss the following areas, comparing side to side:

  • Supraclavicular (lung apices)
  • Infraclavicular
  • Chest wall (3-4 locations bilaterally)
  • Axilla

Types of percussion note

Resonant – this is a normal finding

Dullness – this suggests increased tissue density – consolidation / fluid / tumour / collapse

Stony dullness – this suggests the presence of a pleural effusion

Hyper-resonance – the opposite of dullness, suggestive of decreased tissue density – e.g. pneumothorax

  • Percuss the chest

Auscultation

Ask the patient to take deep breaths in and out through their mouth.

Assess quality:

  • Vesicular (normal)
  • Bronchial (harsh sounding – similar to auscultating over the trachea – inspiration and expiration are equal and there is a pause between) – associated with consolidation

Assess volume:

  • Quiet breath sounds suggest reduced air entry – consolidation / collapse / pleural effusion
  • State reduced breath sounds rather than reduced air entry when presenting

 

Added sounds:

  • Wheeze – asthma / COPD
  • Coarse crackles – pneumonia / bronchiectasis / fluid overload
  • Fine crackles – pulmonary fibrosis

 

Vocal resonance:

  • Ask patient to say “99” repeatedly and auscultate the chest again
  • Increased volume over an area suggests increased tissue density (especially if there is a dull percussion note over the same area) – consolidation / tumour / lobar collapse
  • Decreased volume over an area (especially if there is an associated dull percussion note) suggests fluid outside of the lung (pleural effusion)
  • Auscultate the chest

Ask patient to sit forwards

Lymph nodes

Palpate the following areas:

  • Anterior and posterior triangles
  • Supraclavicular region
  • Axillary region

Lymphadenopathy may indicate infective/malignant pathology – lung cancer / tuberculosis / sarcoidosis 

Assess the posterior chest

Repeat inspection, chest expansion, percussion and auscultation on the posterior aspect of the chest.

Spend more time assessing the posterior aspect of the chest as this is where you are likely to find clinical signs.

  • Assess chest expansion

 

Examine the sacrum for oedema (fluid overload in cor pulmonale)

Examine the legs:

  • Pitting oedema (fluid overload in cor pulmonale)
  • Assess the calves for signs of deep vein thrombosis
  • Inspect for evidence of erythema nodosum (associated with sarcoidosis)

To complete the examination…

Thank patient

Wash hands

Summarise findings

 

Suggest further assessments and investigations


REVIEWED BY

Dr Gareth Hynes

Respiratory Registrar


References

1. Respiratory sounds – provided by EasyAuscultation and Andy Howes


 

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