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Instructions to Candidate: Please examine this patientโs respiratory system. You have 7 minutes. Present your findings at the end.
- ๐งผ Preparation: Wash hands, introduce yourself, confirm patientโs name + DOB. Explain exam, gain consent, expose chest (with dignity), position at 45ยฐ, offer a chaperone.
- ๐ General / End-of-bed Inspection:
Look for signs of distress (accessory muscles, pursed-lip breathing, cyanosis). Note cachexia, oxygen therapy, inhalers, sputum pots, mobility aids, chest drains.
Examiner tip: Verbalise โ โFrom the end of the bed, I seeโฆโ
- โ Hands:
- Clubbing (lung cancer, bronchiectasis, fibrosis).
- Nicotine/tar stains.
- Peripheral cyanosis, temperature, cap refill.
- Tremor (fine = ฮฒโ agonists, flapping = COโ retention).
- ๐ซ Pulses & Neck:
- Radial pulse โ rate, rhythm, volume.
- JVP (pulmonary HTN, cor pulmonale).
- Tracheal position (central/pulled/pushed).
- Cervical & supraclavicular lymph nodes (malignancy, TB).
- ๐ Chest Inspection:
- Scars: thoracotomy, VATS, drains, pacemaker.
- Deformities: pectus, scoliosis, barrel chest.
- Chest expansion symmetry, accessory muscles.
- ๐ซ Palpation:
- Trachea (again) + cricosternal distance.
- Chest expansion (upper/mid/lower zones).
- Tactile vocal fremitus (โ consolidation, โ effusion/pneumothorax).
- Apex beat (displaced by cardiomegaly or mediastinal shift).
- ๐ฅ Percussion:
Compare side-to-side, anterior, lateral, posterior (โฅ3 zones).
Interpret:
- Dull = consolidation/effusion
- Stony dull = effusion
- Hyperresonant = pneumothorax
- ๐ง Auscultation:
- Anterior, lateral, posterior zones.
- Normal vesicular vs bronchial breathing.
- Added sounds: crackles (fibrosis/oedema/bronchiectasis), wheeze (asthma/COPD), pleural rub.
- Vocal resonance (egophony, whispering pectoriloquy).
- ๐ Other Checks:
- Leg oedema (cor pulmonale, RHF).
- Sacral oedema (if immobile).
- DVT signs (if PE suspected).
- ๐ Closure: Thank patient, reposition, wash hands.
To complete my exam I would:
- Check sputum pot, peak flow diary.
- Examine ENT (e.g. for clubbing/cyanosis links), cardiovascular exam.
- Order investigations: CXR, ABG, Spirometry/PFTs, Sputum culture, Bloods (FBC, CRP, U&E).
Present findings clearly to examiner.
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