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Respiratory Examination OSCE Guide

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 clear concise, step by step approach to examining the respiratory system, with an included video demonstration.

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Sam James
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321 views14 pages

Respiratory Examination OSCE Guide

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 clear concise, step by step approach to examining the respiratory system, with an included video demonstration.

Uploaded by

Sam James
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Respiratory examination – OSCE Guide

geekymedics.com /respiratory-examination-2/

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 clear concise, step by
step approach to examining the respiratory system, with an included video demonstration.

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

General inspection

Treatments or adjuncts around bed – O2 / inhalers /nebulisers /sputum pots


Does patient look SOB? – nasal flaring / pursed lips / use of accessory muscles
Able to speak in full sentences?
Scars – mid axillary (e.g. chest drains) / posterior chest (e.g. lobectomy)
Cyanosis – bluish/purple discolouration – (
Chest wall – note any abnormalities or asymmetry – e.g. barrel chest (COPD)
Cachexia – very thin patient with muscle wasting – malignancy
Cough – productive or dry?
Wheeze – asthma / COPD / allergy related
General inspection

Hands

Temperature – ↓ temp – peripheral vasoconstriction / poor perfusion


Tar staining – smoker – increased risk of COPD / lung cancer
Peripheral cyanosis – bluish discolouration of nails – O2 saturations
Clubbing – lung cancer / interstitial lung disease / bronchiectasis
Respiratory rate – normal adult range = 12-20 breaths per minute
Pulse – rate & rhythm
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

Peripheral cyanosis
Inspect palms

Finger clubbing

Assess pulse & respiratory rate


Inspect for fine tremor

Inspect for flapping tremor

Head & Neck

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


Horner’s syndrome – ptosis / constricted pupil (miosis) /anhidrosis on affected side / enophthalmos
Central cyanosis – bluish discolouration of the lips / inferior aspect of tongue

Jugular Venous Pressure – 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 cm from sternal angle to the upper border of pulsation
Inspect for central cyanosis

Inspect conjunctiva

Observe for a raised JVP


Close inspection of thorax

Scars – mid axillary (e.g. chest drains) / posterior chest (e.g. lobectomy)
Skin changes – may indicate recent or previous radiotherapy – erythema / thickened skin
Asymmetry – major surgery – e.g. pneumonectomy / thoracoplasty
Deformities – barrel chest (COPD) / pectus excavatum & carinatum

Inspect chest wall

Inspect for scars

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 trachea using the same process
A difference in the amount of space between the sides suggests deviation
Palpation of the trachea can be uncomfortable, so ensure to warn the patient and have a gentle technique

Cricosternal distance:

Measure the distance between the suprasternal notch & 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

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


Assess crico-sternal distance

Palpate apex beat

Assess chest expansion


Assess chest expansion

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 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
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
Supraclavicular percussion

Percussion

Auscultation

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

Assess quality – Vesicular (normal) / Bronchial (harsh sounding) – consolidation

Assess volume – quiet breath sounds suggest reduced air entry – consolidation / collapse / fluid

Added sounds:

Wheeze – asthma / COPD


Coarse crackles – pneumonia / fluid
Fine crackles – pulmonary fibrosis

Vocal resonance:
Ask patient to say “99” repeatedly & auscultate the chest again
Increased volume over an area suggests increased tissue density – consolidation/fluid/tumour

Auscultate the chest

Assess vocal resonance

Ask patient to sit forwards

Lymph nodes

Palpate the anterior & posterior triangles, supraclavicular and axillary nodes.
Lymphadenopathy may indicate infective/malignant pathology – TB / Lung ca
Palpate lymph nodes

Assess the posterior chest

Repeat inspection, chest expansion, percussion & auscultation on the back of the chest.

Posterior chest expansion


Posterior chest percussion

Posterior auscultation of the chest

Posterior assessment of vocal resonance

To complete the examination…


Thank patient
Wash hands
Summarise findings

Suggest further assessments & investigations

Check oxygen saturations


Provide supplementary oxygen if indicated
Perform peak flow assessment (if asthmatic)
Request a CXR – if abnormalities were noted on examination
Take an arterial blood gas if indicated
Perform a full cardiovascular examination if indicated

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