Respiratory System OSCE Examination

1. Introduction
2. General Inspection
3. Hand Examination
4. Pulse and Respiratory Rate
5. Face, Eyes and Mouth
6. Neck Examination
7. Chest Inspection
8. Chest Palpation
9. Chest Percussion
10. Chest Auscultation
11. Posterior Chest Examination
12. Completing the Examination
13. Quiz

Wash your hands (or apply alcohol gel) before approaching the patient, as good hand hygiene reduces the risk of healthcare-associated infection.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient’s details taking 3 points of identification usually; full name, date of birth and NHS/hospital number.

Obtain consent for the examination, ensuring to explain what the examination will entail.

Position the patient appropriately at 45^o on the bed, as this is the standard position for assessing the jugular venous pressure later in the examination and is comfortable for breathless patients.

Expose the patient’s chest appropriately so the chest wall, neck and arms can be inspected, being mindful of patient dignity throughout.

Ask the patient if they are in any pain before you begin, particularly chest or shoulder pain, as several manoeuvres involve touching the chest wall.

Take a step back and observe the patient from the end of the bed. The aim is to form an overall impression of how unwell they are and to pick up clues before laying a hand on them.

Look at the patient’s comfort and work of breathing. A patient who is short of breath at rest, using their accessory muscles (sternocleidomastoid and scalenes) or sitting forward to fix their shoulder girdle is in respiratory distress. Pursed-lip breathing, in which the patient breathes out slowly through narrowed lips, is commonly seen in chronic obstructive pulmonary disease (COPD); it generates a small amount of positive pressure in the airways which splints them open and reduces the air trapping that occurs when floppy small airways collapse on expiration.

Listen for audible noises. A wheeze heard without a stethoscope suggests significant airway narrowing (asthma or COPD), while stridor (a harsh inspiratory sound) suggests upper airway obstruction and is a red flag. A cough may be dry or productive, and its character can point towards the underlying diagnosis.

Note the respiratory pattern. Prolonged expiration is typical of obstructive disease such as COPD, where narrowed airways slow the outflow of air. Paradoxical (abdominal) breathing, in which the abdomen moves inwards on inspiration, is a sign of diaphragmatic fatigue and impending respiratory failure. Cheyne-Stokes breathing (cyclical waxing and waning of breathing depth with apnoeic pauses) may be seen in advanced heart failure or with central nervous system pathology.

Assess the colour of the patient. Central cyanosis gives a bluish tinge to the skin and is caused by an excess of deoxygenated haemoglobin, indicating hypoxaemia. A plethoric (red, congested) complexion may indicate polycythaemia, where chronic hypoxia drives the kidneys to produce more erythropoietin and therefore more red cells, or carbon dioxide retention.

Look around the bedside for clues about the diagnosis and its severity:

• Oxygen delivery devices (nasal cannulae, masks) and the flow rate being delivered.
• Inhalers, spacers or nebulisers, suggesting asthma or COPD.
• A sputum pot – its contents are informative (purulent sputum in infection, copious volumes in bronchiectasis, frothy pink sputum in pulmonary oedema, blood in haemoptysis).
• Mobility aids, a peak flow meter, or a cigarette packet.

Pick up the patient’s hands and inspect them carefully, as they carry a surprising number of respiratory signs.

Look for tar staining of the fingers, a yellow-brown discolouration caused by the tar in cigarette smoke. It is a marker of smoking, which is the single biggest risk factor for COPD and lung cancer. (Note that nicotine itself is colourless – the staining is from tar.)

Inspect the nails for finger clubbing, in which there is soft-tissue swelling of the terminal phalanx and loss of the normal angle between the nail and nail fold. It can be confirmed with Schamroth’s window test: when the dorsal surfaces of two opposing fingers are placed together, a normal person has a small diamond-shaped window, which is obliterated in clubbing. The exact mechanism is not fully understood but is thought to involve megakaryocytes and platelet clumps bypassing the lungs and releasing growth factors in the fingertips. Respiratory causes include lung cancer, bronchiectasis, cystic fibrosis, interstitial lung disease and chronic suppurative conditions such as lung abscess and empyema.

Image - Finger clubbing showing loss of the normal nail-bed angle. In a respiratory context this raises suspicion of lung cancer, bronchiectasis or interstitial lung disease

Creative commons source by Russellpa [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]

Look at the skin of the hands and forearms. Thin, bruised skin may reflect long-term corticosteroid use in asthma, COPD or interstitial lung disease. Peripheral cyanosis – a bluish tinge confined to the fingertips – reflects sluggish peripheral perfusion rather than central hypoxaemia, although in respiratory failure the two often coexist.

Feel the temperature of the hands. Warm, well-perfused peripheries with a bounding pulse can be a sign of carbon dioxide retention, which causes peripheral vasodilatation.

With the arms outstretched, look first for a fine tremor. This is a rapid, low-amplitude shake most often caused by beta-2 agonist inhalers such as salbutamol, and its presence is a useful clue that the patient is being treated for asthma or COPD.

Then assess for asterixis (a ‘CO₂ retention flap’) by asking the patient to hold their arms out straight with the wrists cocked back for around 30 seconds. A coarse, irregular flapping tremor is caused by the effect of hypercapnia (high blood CO₂) on the brainstem, seen in type 2 respiratory failure. The same sign can occur in hepatic encephalopathy and uraemia, so it must be interpreted in context.

Palpate the radial pulse, assessing its rate and rhythm. The normal resting rate is 60–100 bpm. A tachycardia may accompany hypoxia, infection, anxiety or salbutamol use, while an irregularly irregular pulse suggests atrial fibrillation, which can be precipitated by respiratory disease such as pneumonia or pulmonary embolism. Feeling both radial pulses together to check for radio-radial delay is sometimes included; a delay between the two sides can be caused by a large mass at the lung apex compressing the subclavian artery.

A bounding pulse with warm hands again raises the possibility of carbon dioxide retention and its associated vasodilatation.

While appearing to take the pulse, discreetly count the respiratory rate over a full period of breathing. Counting it openly tends to make patients alter their breathing pattern. The normal adult rate is 12–20 breaths per minute. Tachypnoea (a raised rate) is a sensitive early marker of respiratory or systemic illness and is a key component of the NEWS2 early-warning score used throughout the NHS, while bradypnoea may indicate exhaustion, sedation or central nervous system depression.

Inspect the face generally. A plethoric appearance again suggests polycythaemia or CO₂ retention. Look for the features of Cushing’s syndrome (a rounded ‘moon’ face), which may result from long-term oral steroids.

Look at the eyes for the triad of Horner’s syndrome – ptosis (drooping eyelid), miosis (constricted pupil) and anhidrosis (loss of sweating on that side of the face). Horner’s syndrome arises when the sympathetic chain is interrupted, and in a respiratory examination the classic cause is a Pancoast tumour at the lung apex compressing the sympathetic nerves. Pull down the lower eyelids to look for conjunctival pallor, a sign of anaemia, which may contribute to breathlessness.

Inspect the mouth and under the tongue for central cyanosis, seen as a bluish discolouration of the lips, tongue and oral mucosa. Because it affects the well-perfused central mucous membranes, it specifically indicates a low arterial oxygen saturation and is a more reliable marker of hypoxaemia than peripheral cyanosis. Also look for oral candidiasis (white plaques), which is common in patients using inhaled corticosteroids who do not rinse their mouth afterwards.

Image - Bluish discolouration of the lips (central cyanosis) and fingertips. Central cyanosis indicates hypoxaemia (a low arterial oxygen saturation)

Creative commons source by Göttgens et al. [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Assess the jugular venous pressure (JVP) with the patient at 45^o and their head turned slightly to the left. The internal jugular vein lies between the two heads of the sternocleidomastoid, and the vertical height of its pulsation above the sternal angle estimates right atrial pressure. A raised JVP in a respiratory patient suggests cor pulmonale – right heart failure caused by chronic lung disease. Chronic hypoxia causes pulmonary vasoconstriction and a rise in pulmonary arterial pressure, which the right ventricle must work against; over time it fails, and the back-pressure raises the JVP. A fixed, non-pulsatile, raised JVP that does not change with respiration suggests superior vena cava obstruction, classically caused by a mediastinal tumour.

Image - The jugular venous pulse is measured vertically above the sternal angle with the patient reclined at 45 degrees. A raised JVP in a respiratory patient points towards cor pulmonale

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Palpate the position of the trachea by gently placing a finger either side of it in the suprasternal notch (warn the patient that this is briefly uncomfortable). The trachea should sit centrally. Deviation away from a lesion occurs when something pushes the mediastinum across, such as a large pleural effusion or a tension pneumothorax. Deviation towards a lesion occurs when volume is lost on that side, such as in lobar collapse or a pneumonectomy. Also assess the cricosternal distance (normally three to four finger-breadths); a reduced distance reflects lung hyperinflation in COPD.

Palpate the lymph nodes of the neck from behind, including the submental, submandibular, pre- and post-auricular, occipital, cervical chains and supraclavicular nodes. Lymphadenopathy may indicate infection or malignancy; the supraclavicular nodes are of particular concern, with the left one (Virchow’s node) classically reflecting intrathoracic or abdominal malignancy.

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