Respiratory Examination (OSCE)

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🫁 The respiratory exam is an active, hypothesis-driven process - systematically inspect, palpate, percuss, and auscultate while thinking about underlying pathology. Time goal: 6–8 minutes; verbalise every step aloud (gains marks even if you miss something). Always finish by stating how you’d complete the exam: “To complete, I would check oxygen saturations, peak flow, temperature, sputum pot, and arrange CXR, ABG, spirometry, and bloods (FBC, CRP, U&E, D-dimer if PE suspected).”

🔑 Overall Stepwise Respiratory Exam Sequence (High-Yield OSCE Flow)

1. 🧼 Preparation & Introduction
   • Wash hands, introduce yourself, confirm name/DOB/hospital number.
   • Explain: “I’m going to examine your chest and lungs. It involves looking, feeling, tapping, and listening. It shouldn’t hurt. You can stop me anytime.”
   • Gain verbal consent, offer chaperone, expose chest to waist (preserve dignity with towel/blanket), position at 45° (or sitting if breathless).
2. 👀 General Inspection (End of Bed – 10–15 seconds)
   • Patient: dyspnoea at rest, accessory muscle use (sternocleidomastoid, scalenes), pursed-lip breathing (COPD), central/peripheral cyanosis, pallor, cachexia, clubbing (visible from distance).
   • Environment: oxygen (delivery device, flow rate), nebuliser, inhalers/spacers, sputum pot (colour, volume), peak flow meter, drains (empyema), mobility aids, ECG leads, fluid charts.
   • Verbalise: “From the end of the bed, I note the patient is breathless at rest, using accessory muscles, with 2 L oxygen via nasal prongs and a blue inhaler at the bedside.”
3. ✋ Hands & Upper Limbs
   • Inspection: clubbing (COPD, lung cancer, bronchiectasis, ILD), tar/nicotine staining, peripheral cyanosis, fine tremor (β₂ agonists), CO₂ retention flap (asterixis), small muscle wasting (thoracic outlet, cachexia).
   • Temperature & perfusion: warm/cold peripheries, capillary refill (<2 s normal).
   • Pulse: rate (tachycardia – hypoxia, infection), rhythm (AF common in COPD), bounding (CO₂ retention, sepsis).
4. 🫀 Neck & Face
   • Trachea: central (normal) / deviated (towards collapse, away from tension pneumothorax/effusion/mass).
   • Cricosternal distance: normal ≥3 fingers; <3 → hyperinflation (COPD, asthma).
   • JVP: raised in cor pulmonale (pulmonary HTN secondary to COPD/ILD).
   • Lymph nodes: cervical/supraclavicular (lung cancer, TB, sarcoid).
   • Face: plethoric (polycythaemia secondary to chronic hypoxia), conjunctival pallor (anaemia in chronic disease), Horner’s syndrome (apical lung tumour – Pancoast).
5. 👕 Chest Inspection
   • Scars: thoracotomy (lobectomy), VATS ports (minimally invasive), chest drain scars, radiotherapy tattoos, infraclavicular PPM/ICD bulge.
   • Deformities: barrel chest (COPD hyperinflation), pectus excavatum/carinatum, scoliosis/kyphosis (restrictive defect).
   • Chest movement: asymmetry (unilateral effusion/pneumothorax/collapse), use of accessory muscles, paradoxical movement (flail segment).
   • Visible pulsations or veins (SVC obstruction).
6. 🫁 Palpation
   • Trachea & cricosternal distance (repeat to confirm).
   • Chest expansion: place hands on chest wall (thumbs together midline), ask deep breath → measure separation (>2–3 cm normal; reduced in restrictive/obstructive disease; asymmetry in unilateral pathology).
   • Tactile vocal fremitus: ulnar border of hand on chest wall, ask patient to say “ninety-nine” → ↑ in consolidation, ↓ in effusion/pneumothorax/emphysema.
   • Apex beat: may be displaced by mediastinal shift or RV heave (cor pulmonale).
7. 🥁 Percussion
   • Compare side-to-side: anterior (clavicle to 6th rib), lateral (axilla), posterior (from C7 down to T10–12).
   • Technique: middle finger on chest, strike with other middle finger, listen for resonance.
   • Interpretation:
     • Resonant = normal lung
     • Hyper-resonant = emphysema, pneumothorax
     • Dull = consolidation, fibrosis
     • Stony dull = pleural effusion
8. 🎧 Auscultation
   • Ask patient to breathe deeply through open mouth; compare side-to-side (anterior, lateral, posterior zones).
   • Normal: vesicular (soft, rustling, longer inspiration).
   • Bronchial: loud, hollow, equal inspiration/expiration → consolidation (pneumonia).
   • Added sounds:
     • Coarse crackles: early = bronchiectasis, late = pulmonary oedema/fibrosis
     • Fine “Velcro” crackles: ILD/fibrosis (end-inspiratory)
     • Wheeze: expiratory (asthma/COPD), polyphonic/monophonic
     • Pleural rub: scratchy, localised (pleuritis)
   • Vocal resonance / whispering pectoriloquy / egophony: ↑ in consolidation, ↓ in effusion/pneumothorax.
9. 🔎 Additional Checks
   • Lung bases: sacral/ankle oedema (cor pulmonale), calf tenderness (DVT → PE risk).
   • Sputum pot: colour (purulent – infection, haemoptysis – cancer/TB/PE).
   • Peak flow / spirometry diary if available.
10. 🙏 Closure & Completion
    • Thank patient, help redress, wash hands.
    • Present findings clearly & concisely (e.g., “This patient has reduced expansion on the right, stony dull percussion at the right base, absent breath sounds, and reduced vocal resonance - consistent with a right-sided pleural effusion.”).
    • State: “To complete my examination, I would like to record oxygen saturations, respiratory rate, temperature, peak expiratory flow rate, examine the sputum pot, and arrange a chest X-ray, arterial blood gas, spirometry, and blood tests (FBC, CRP, U&E, D-dimer if PE suspected).”

📊 High-Yield Pathological Findings Table (OSCE Master Reference)

🚩 Red Flags & Do-Not-Miss OSCE Points

• Stridor + dysphagia + weight loss → upper airway obstruction / malignancy.
• Sudden SOB + pleuritic pain + risk factors → pneumothorax or PE.
• Clubbing + new haemoptysis → lung cancer until proven otherwise.
• Bilateral crackles + raised JVP → pulmonary oedema (cardiac failure).
• Tracheal deviation + stony dull percussion + absent breath sounds → massive effusion or tension pneumothorax (emergency).

💡 OSCE Examiner & Candidate Pearls

• Always compare both sides (symmetry is key).
• Verbalise: “I’m now percussing the left lower zone and comparing to the right...”
• Miss posterior auscultation/percussion = common fail point.
• State O₂ sats, RR, temperature early (even if not measured).
• Finish strong: “To complete my exam, I would like to record oxygen saturations, respiratory rate, peak expiratory flow rate, examine the sputum pot, and arrange a chest X-ray, arterial blood gas, spirometry, and blood tests (FBC, CRP, U&E, D-dimer if PE suspected).”

📚 References & Resources (Feb 2026)

• Talley & O’Connor – Clinical Examination (9th ed., 2025 update).
• Geeky Medics Respiratory Examination OSCE Guide (2026 revision).
• OSCEstop & PassMedicine respiratory sections.
• BTS/ERS Guidelines: Pleural Disease & Pneumothorax (2025).