By Dr. Marcus Judge

OSCE

During any examination in an OSCE it is important to understand the pathology and reasoning behind each of the signs and symptoms elicited. This applies even if the patient being examined is ‘normal’. This article explains how to perform a respiratory examination and the key findings you should look for, showing you what each sign means and what conditions it may indicate.

Contents

  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

Introduction

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 make sure you mention your grade, for example 3rd year medical student/junior doctor/consultant.

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

Obtain consent for the examination and explain what it will involve.

Position the patient appropriately at 45 degrees on the bed. This is the standard position for assessing the jugular venous pressure (the height of the pulse in the neck veins, which reflects pressure in the right side of the heart) later in the examination, and it 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.

General Inspection

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 (the sternocleidomastoid and scalene muscles in the neck, which help with breathing when it is hard work) or sitting forward to fix their shoulder girdle (steadying the shoulders so those muscles can pull on the chest) 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 (back-pressure) in the airways. This holds them open and reduces air trapping (air left behind in the lungs after breathing out), which happens when floppy small airways collapse as the patient breathes out.

Listen for audible noises. A wheeze (a high-pitched whistling sound) 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 (bringing up sputum, the phlegm coughed up from the lungs), 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 (a tiring diaphragm) and impending respiratory failure (the lungs can no longer keep blood oxygen and carbon dioxide levels normal). 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 (grey on brown or black skin) and is caused by an excess of deoxygenated haemoglobin, which usually indicates hypoxaemia (a low blood oxygen level). A plethoric (red, congested) complexion may indicate polycythaemia (too many red blood cells), where chronic hypoxia drives the kidneys to produce more erythropoietin (a hormone that stimulates red cell production) and therefore more red cells. It may also indicate carbon dioxide retention (carbon dioxide building up in the blood because it is not breathed out).

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 (devices that deliver inhaled medicine), suggesting asthma or COPD.
  • A sputum pot (a pot for phlegm coughed up from the lungs): its contents are informative (purulent sputum, which contains pus, in infection; copious volumes in bronchiectasis, where the airways are permanently widened and scarred; frothy pink sputum in pulmonary oedema, where fluid collects in the lungs; blood in the sputum, called haemoptysis).
  • Mobility aids, a peak flow meter, or a cigarette packet.

Hand Examination

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. Place the dorsal surfaces (the backs) of two opposing fingers together. A normal person has a small diamond-shaped window between them, which is obliterated in clubbing. The exact mechanism is not fully understood but is thought to involve megakaryocytes (large bone marrow cells that make platelets) and platelet clumps bypassing the lungs and releasing growth factors in the fingertips. Respiratory causes include lung cancer, bronchiectasis, cystic fibrosis, interstitial lung disease (scarring or inflammation of the lung tissue itself) and chronic suppurative (pus-forming) conditions such as lung abscess (a pus-filled cavity in the lung) and empyema (pus in the space around the lung).

Finger clubbing in respiratory disease

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 (steroid medicine) 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 both types of cyanosis often occur together.

Feel the temperature of the hands. Warm, well-perfused peripheries with a bounding pulse (a strong, forceful 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 (medicines that widen the airways) 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 (brief lapses in muscle tone, so the hands drop and then recover) can occur with hypercapnia (high blood CO2), but it is not specific to it: it is also reported with low blood oxygen alone and with some drugs. It is seen in type 2 respiratory failure (respiratory failure with a raised blood carbon dioxide level). The same sign can occur in hepatic encephalopathy (confusion caused by liver failure) and uraemia (a high blood urea level caused by kidney failure), so it must be interpreted in context.

Pulse and Respiratory Rate

Palpate the radial pulse, assessing its rate and rhythm. The normal resting rate is 60–100 beats per minute (bpm). A tachycardia (a fast heart rate) may accompany hypoxia, infection, anxiety or salbutamol use, while an irregularly irregular pulse suggests atrial fibrillation (an irregular, often fast, heart rhythm), 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. It is a key component of the NEWS2 (National Early Warning Score 2), an early-warning score used throughout the NHS to spot patients who are getting worse. Bradypnoea (a slow rate) may indicate exhaustion, sedation or central nervous system depression (slowed brain activity).

Face, Eyes and Mouth

Inspect the face generally. A plethoric appearance again suggests polycythaemia or CO2 retention. Look for the features of Cushing’s syndrome (too much of the hormone cortisol), such as a rounded ‘moon’ face. The most common cause is taking high doses of steroid medicine for a long time.

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 (the nerve pathway that supplies the eye and face) 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 (pale inner eyelids), a sign of anaemia. Anaemia may contribute to breathlessness.

Inspect the mouth and under the tongue for central cyanosis, seen as a bluish (or, on brown or black skin, grey) discolouration of the lips, tongue and oral mucosa (the lining of the mouth). Because it affects the well-perfused central mucous membranes, it usually 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.

Central cyanosis of the lips and peripheral cyanosis

Image - Bluish discolouration of the lips (central cyanosis) and fingertips. Central cyanosis usually 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)]

Neck Examination

Assess the jugular venous pressure (JVP) with the patient at 45 degrees 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 (the bony ridge where the manubrium, the top part of the sternum, meets the body of the sternum) 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 the right ventricle 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 (a tumour in the middle of the chest, between the lungs).

Location of the jugular venous pulse in the neck

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

SimpleMed original

Palpate the position of the trachea by gently placing a finger either side of it in the suprasternal notch (the dip at the top of the sternum; warn the patient that this is briefly uncomfortable). The trachea should sit centrally. Deviation away from a lesion (an abnormal area) occurs when something pushes the mediastinum (the central chest, which holds the heart and trachea) across, such as a large pleural effusion (fluid between the lung and the chest wall) or a tension pneumothorax (air trapped under pressure around the lung). Deviation towards a lesion occurs when volume is lost on that side, such as in lobar collapse (collapse of a lobe of the lung) or a pneumonectomy (removal of a whole lung). 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 (under the chin), submandibular (under the jaw), pre- and post-auricular (in front of and behind the ear), occipital (back of the head), cervical chains (along the sides of the neck) and supraclavicular (above the collarbone) nodes. Lymphadenopathy (swollen lymph nodes) 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.

Chest Inspection

With the chest fully exposed, inspect it from the front (and later from behind). Comment on the shape of the chest and any deformities:

  • Barrel chest – an increased anteroposterior diameter caused by chronic lung hyperinflation in COPD.
  • Pectus excavatum – a sunken sternum, and pectus carinatum – a protruding ‘pigeon’ chest. Both are congenital (pectus carinatum is usually first noticed in the teenage years), and severe cases can affect respiratory mechanics (the way the chest moves during breathing).
  • Kyphosis and scoliosis – spinal curvatures that can restrict chest wall expansion and lung volumes.

Look for scars, which give away the patient’s surgical history: a thoracotomy scar (from a surgical cut through the chest wall, often running below the scapula) may follow a lobectomy (removal of one lobe of the lung) or pneumonectomy, while small chest drain scars indicate previous pneumothorax or effusion drainage. Note any asymmetry of chest movement, visible pulsations, or use of accessory muscles on inspection.

Chest Palpation

Confirm the patient is not in pain, then palpate the chest systematically.

Locate the apex beat (the lowest, outermost point where the heartbeat can be felt), normally in the fifth intercostal space in the mid-clavicular line (the gap between the fifth and sixth ribs, in line with the middle of the collarbone). Displacement may reflect mediastinal shift from a large effusion or pneumothorax, or right ventricular enlargement in cor pulmonale. The apex beat can be difficult to feel in the hyperinflated chests (chests over-full of air) of patients with COPD.

Assess chest expansion. Place your hands symmetrically on the chest wall with your thumbs lifted just off the skin so they move freely, and ask the patient to take a deep breath in. Your thumbs should move apart equally. Reduced expansion on one side indicates pathology on that side (such as a large pleural effusion, pneumothorax, consolidation (lung tissue filled with pus or fluid, so that it becomes solid) or collapse), because the affected lung cannot inflate normally. Symmetrically reduced expansion is seen in conditions that stiffen both lungs, such as interstitial lung disease, or that limit airflow, such as COPD.

Assess tactile vocal fremitus by placing the ulnar border of your hand on the chest and asking the patient to repeat ‘ninety-nine’ while you compare both sides. The vibrations of speech are transmitted to the chest wall, and how well they conduct depends on what lies beneath. Increased fremitus occurs over consolidation, where solid lung tissue conducts sound better than air. Reduced fremitus occurs when something separates the lung from the chest wall, such as a pleural effusion or pneumothorax. (Tactile vocal fremitus and vocal resonance test the same principle, so in practice only one is usually performed.)

Chest Percussion

Percuss the chest by placing your non-dominant middle finger flat against the chest wall and striking its middle phalanx with the tip of your dominant middle finger. Compare like-for-like areas on both sides, working down the chest and including the axillae (armpits) and the lung apices above the clavicles. The note produced reflects what lies beneath the chest wall:

  • Resonant – the normal note over healthy, air-filled lung.
  • Dull – over increased tissue density, such as consolidation or collapse, because solid or fluid-filled tissue absorbs the percussion energy.
  • Stony dull – an especially flat, dull note that is the hallmark of a pleural effusion, where a layer of fluid lies between lung and chest wall.
  • Hyper-resonant – an unusually booming note suggesting excess air, as in a pneumothorax or a hyperinflated COPD chest.

Chest Auscultation

Auscultate with the diaphragm of the stethoscope, comparing both sides at each level and asking the patient to take steady breaths in and out through an open mouth. First characterise the breath sounds:

  • Vesicular breath sounds are the normal soft, rustling sounds of air moving through healthy lung, louder on inspiration with no gap before expiration.
  • Bronchial breathing is harsh and blowing, with inspiration and expiration of equal length and an audible gap between them, similar to listening over the trachea. It indicates consolidation, where solid lung transmits the central airway sounds directly to the chest wall.
  • Reduced or absent breath sounds occur when air, fluid or collapsed lung prevents sound reaching the stethoscope, as in a pleural effusion or pneumothorax.

Then listen for added sounds:

  • Wheeze – a continuous, musical, whistling sound, usually loudest on expiration, produced by air passing through narrowed airways. It is typical of asthma and COPD. A widespread polyphonic wheeze (several pitches at once) suggests diffuse airway narrowing, whereas a fixed monophonic wheeze (a single pitch) may indicate localised obstruction by a tumour or foreign body.
  • Crackles – discontinuous popping sounds caused by the sudden reopening of small airways. Fine, late-inspiratory crackles (heard at the end of breathing in) suggest pulmonary oedema (fluid in the lungs) or interstitial lung disease, while coarse crackles suggest pneumonia or bronchiectasis. Crackles that clear on coughing are usually not significant.
  • Pleural rub – a creaking, ‘leather-on-leather’ sound caused by inflamed pleural surfaces rubbing together, heard in pleurisy (inflammation of the pleura, the lining around the lung) or pulmonary embolism (a blood clot in the lung arteries).

Finally, assess vocal resonance by listening over the chest while the patient repeats ‘ninety-nine’. The findings mirror tactile vocal fremitus: increased resonance over consolidation and reduced resonance over an effusion or pneumothorax. Over consolidation, whispered words can become abnormally clear (whispering pectoriloquy).

It is worth memorising how the palpation, percussion and auscultation findings cluster together, as recognising the pattern lets you reach a diagnosis quickly in an OSCE. Consolidation gives reduced expansion, dull percussion, increased vocal fremitus and vocal resonance, bronchial breathing and crackles. A pleural effusion gives reduced expansion, stony dull percussion, reduced vocal fremitus, reduced vocal resonance and reduced breath sounds. A pneumothorax gives reduced expansion, hyper-resonant percussion, reduced fremitus and reduced breath sounds. Lobar collapse gives reduced expansion, dull percussion and reduced breath sounds, often with the trachea pulled towards the affected side.

Chest X-ray showing a large left-sided pleural effusion

Image - Chest X-ray of a large left-sided pleural effusion. On examination this would produce a stony dull percussion note, reduced breath sounds and reduced vocal resonance over the effusion

Creative commons source by Clinical Cases [CC BY-SA 2.5 (https://creativecommons.org/licenses/by-sa/2.5)]

Posterior Chest Examination

Ask the patient to sit forward and fold their arms across the chest, which rotates the scapulae out of the way and gives better access to the lung fields. The back of the chest is where most clinically significant findings are detected, because the lung bases lie posteriorly.

Repeat the full sequence on the back: inspect for scars and deformity, assess chest expansion, percuss all zones comparing side to side, assess tactile vocal fremitus or vocal resonance, and auscultate the breath sounds and any added sounds. Take care to reach the lung bases and the axillae, as basal crackles of pulmonary oedema, fibrosis or infection are easily missed if examination stops too high.

While the patient is sitting forward, press on the sacrum and palpate the ankles for peripheral oedema (swelling from fluid build-up). Pitting oedema (swelling that keeps a dent after you press on it) in a respiratory patient may be a sign of cor pulmonale, where right heart failure secondary to chronic lung disease causes fluid to accumulate in the dependent tissues (the lowest parts of the body, such as the ankles and sacrum). It is not specific to cor pulmonale, because oedema also has many other causes, including problems with the kidneys, liver or heart, and some medicines.

Pitting oedema demonstrated by pressing on the lower leg

Image - Pitting oedema, where firm pressure leaves a lasting indentation. In a breathless patient this may reflect fluid overload, for example from cor pulmonale

SimpleMed original

Completing the Examination

Thank the patient, help them to redress, and wash your hands.

Summarise your findings concisely and offer a differential diagnosis.

State that to complete the examination you would:

  • Record a full set of observations, including oxygen saturations and a NEWS2 score.
  • Measure peak expiratory flow (the fastest speed at which the patient can blow air out) when clinically relevant, for example when assessing asthma; review or sample sputum if the patient has a productive cough.
  • Perform a cardiovascular examination, as the heart and lungs are closely linked (for example in cor pulmonale).
  • Request relevant investigations, such as a chest X-ray, an arterial blood gas (a blood test measuring oxygen and carbon dioxide levels) if respiratory failure is suspected, spirometry (a breathing test measuring lung volumes and airflow), and blood tests including a full blood count and inflammatory markers.

Quiz

Preview the Respiratory System OSCE Examination quiz

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