– Productive? If so, characterise sputum volume and colour, and any blood.

– Triggers? Did it start with an upper respiratory tract infection? Is it provoked by exercise or environment?

– Time pattern – nocturnal (suggests asthma or reflux)?

– On angiotensin-converting enzyme inhibitors?

• Wheeze:

– What exactly does the patient mean by ‘wheeze’?

– When does it occur – at night or during exercise?

– Provoking factors – infection, environment, contact with animals, dust, beta-blockers?

– Any relieving factors – inhalers?

– Associated respiratory symptoms – breathlessness, chest pain, fevers/rigors, weight loss.

• Ask about past respiratory diagnoses, particularly childhood wheeze or asthma, rhinitis/hay fever and prior respiratory treatments/admissions.

• Explore past non-respiratory illness: for example, eczema (suggests atopy), hypertension or angina (on beta-blockers?), other prior illnesses.

• Take a drug history – prescribed medications, including inhalers/nebulisers and recreational drugs.

• Ask about any known allergies.

• Take a social history: smoking, occupation, contact with animals.

Investigations • 91

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OSCE example 2: Respiratory examination

Mr Tate, 82 years old, reports increasing breathlessness over several weeks.

Please examine his respiratory system

• Introduce yourself and clean your hands.

• Note clues around the patient, such as oxygen, nebulisers, inhalers or sputum pots.

• Observe from the end of the bed:

• Scars, chest shape, asymmetry, pattern of breathing, accessory muscle use.

• Chest wall movement, paradoxical rib movement, intercostal indrawing.

• Examine the hands: clubbing, tar staining, muscle wasting.

• Check for tremor and flap.

• Measure respiratory rate unobtrusively.

• Examine the face: anaemia, cyanosis, Horner’s syndrome and superior vena cava obstruction.

• Examine the neck: jugular venous pressure, tracheal deviation, cricosternal distance.

• Examine the anterior chest wall:

• Palpate: apex beat, right ventricular heave, expansion of the upper and lower chest.

• Percuss: compare right with left, from top with bottom, then axillae.

• Auscultate: deep breaths; compare right with left, from top with bottom, then axillae. Repeat, checking vocal resonance.

• Examine the posterior chest wall (commonly in OSCEs, you may be directed to examine either anterior or posterior):

• Ask the patient to sit forwards.

• Inspect the back for scars, asymmetry and so on.

• Palpate:

– Cervical lymph nodes.

– Chest expansion of the upper and lower chest.

• Percuss: ask the patient to fold his arms at the front to part the scapulae; compare right with left, from top to bottom.

• Auscultate: deep breaths; compare right with left, from top to bottom, then axillae. Repeat, checking vocal resonance.

• Check for pitting oedema over the sacrum and lumbar spine.

• Thank the patient and clean your hands.

Summarise your findings

The patient has finger clubbing, a raised respiratory rate, and diminished expansion with dullness to percussion and loss of breath sounds at the right

base. A small scar suggests prior pleural aspiration.

Suggest a differential diagnosis

Signs suggest a large right pleural effusion.

(Away from patient’s bedside) A large unilateral effusion with finger clubbing suggests an underlying neoplasm. Alternatives include chronic

empyema and tuberculous effusion.

Suggest initial investigations

Chest X-ray to confirm effusion and possibly show an underlying tumour. Ultrasound to reveal pleural disease and loculation, and guide aspiration.

Pleural aspiration for cytology, culture and biochemical analysis.

OSCE example 1: Respiratory history – cont’d

• Establish whether there is a family history of respiratory disease (including asthma).

• Ask about any other patient concerns.

• Thank the patient and clean your hands.

Summarise your findings

Mrs Walker is a 55-year-old cook who gives a 6-month history of wheeze disturbing her sleep, associated with an unproductive cough. Her symptoms

vary from day to day and sometimes make climbing stairs difficult. She smokes 10 cigarettes a day and has a 20-pack-year smoking history.

Suggest a differential diagnosis

The most likely diagnosis is asthma (variable, nocturnal symptoms) and the differential is chronic obstructive pulmonary disease.

Suggest initial investigations

Spirometry and reversibility, peak-flow diary, chest X-ray, blood count for eosinophils, serum immunoglobulin E, and skin tests to common allergens.

92 • The respiratory system

Integrated examination sequence for the respiratory system

• Introduce yourself and seek the patient’s consent to chest examination.

• Position the patient: resting comfortably, with the chest supported at about 45 degrees and the head resting on a pillow.

• Carry out general observations: note any clues around the patient, such as oxygen, nebulisers, inhalers, sputum pots, etc.

• Observe from the end of the bed:

• Scars.

• Chest shape, asymmetry.

• Pattern of breathing:

– Respiratory rate.

– Time spent in inspiration and expiration.

– Pursed-lip breathing.

• Chest wall movement, paradoxical rib movement, intercostal indrawing.

• Accessory muscle use.

• Examine the hands:

• Clubbing, tar staining, muscle wasting.

• Check for tremor and flap.

• Measure respiratory rate unobtrusively.

• Examine the face:

• Check for anaemia, cyanosis, Horner’s syndrome and signs of superior vena cava obstruction.

• Examine the neck:

• Jugular venous pressure, tracheal deviation and cricosternal distance.

• Examine the anterior chest wall:

• Palpate: apex beat, right ventricular heave, expansion of upper and lower chest.

• Percuss: compare right with left, from top to bottom, then axillae.

• Auscultate: deep breaths; compare right with left, from top to bottom, then axillae. Repeat positions, asking the patient to say ‘one, one, one’ for

vocal resonance.

• Examine the posterior chest wall: ask the patient to sit forwards so that you can:

• Inspect the back for scars, asymmetry and so on.

• Palpate:

– Cervical lymph nodes.

– Expansion of the upper and lower chest.

• Percuss: ask the patient to fold their arms at the front to part the scapulae. Compare right with left, from top to bottom (see Fig. 5.16A–C for

positions).

• Auscultate: deep breaths; compare right with left, from top to bottom, then axillae. Repeat positions, asking the patient to say ‘one, one, one’ for

vocal resonance.

• Check for pitting oedema over the sacrum and lumbar spine.

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