Resp — MRCS Part B Physical examination

What you need to know for the Resp station

What are you asked at the Resp station?

The station runs to 15 questions over nine minutes. These are the questions as they are put to you; the model answers are in the question bank.

1. Please examine his respiratory system as appropriate and discuss your findings with the examiner. The patient is comfortable, you have washed you hands, introduced yourself and explained what you are going to do. Examination: Resp
2. Explain how you would introduce yourself
3. Explain how you would expose this gentleman and how you would begin your examination
4. What features of general inspection may indicate that the patient is short of breath?
5. What would you do after general inspection?
6. How would you assess tracheal deviation and cricosternal distance?
7. What peripheral features link to respiratory disease?
8. Skin Changes and Discolouration Smoker: Tar staining on the fingers, nicotine patches on the body or a strong smell of smoke carries an increased risk of COPD and lung cancer Clubbing: lung cancer, interstitial lung disease and bronchiectasis Peripheral cyanosis: bluish discolouration of the nails evident at O2 saturations of Pulses and Breathing Respiratory rate: normal adult range = 12-20 breaths per minute Pulsus paradoxus: pulse wave volume decreases with inspiration seen in asthma and COPD Fine tremor: can be a side effect of beta 2 agonist use (e.g. salbutamol) Flapping tremor: CO2 retention is seen in type 2 respiratory failure e.g. COPD Question 7 What features might you look for when inspecting the chest? Answer Look for any central features of respiratory or cardiovacular disease. Inspect the praecordium for scars (remember to look in the axilla ‘triangle of safety’ for trauma chest drains) and for implantable devices and colour. Look for surface vessels, muscular deformity and breathing symmetry. Question 8 What will you do next? Answer Palpation, percussion and auscultation of the anterior chest Palpate the trachea, looking for signs of deviation or tracheal tug. Chest expansion should be performed with both hands at the same time on the anterior chest and then posteriorly for lateral movement. Perform auscultation and percussion side-to-side for comparison and over the entirety of the lung fields. Palpate Chest expansion (place both hands over pec major, thumbs meeting in the midline below nipples – reduced expansion implies pathology on that side) Percussion Percuss over the clavicles, pectorals, nipple and axilla areas to cover all lung fields, comparing sides. • Supraclavicular (lung apices) • Infraclavicular • Chest wall (3-4 locations bilaterally) • Axilla Sounds and vibrations travel differently through different tissue densities. High (hyper-)resonance = air in lungs e.g. pneumothorax, emphysema. Low (hypo-)resonance = increased tissue density - consolidation, collapse or fluid. (‘Stony dull’ percussion note is heard in pleural effusion) Auscultation Ask the patient to take deep breaths in and out through their mouth. Listen with the diaphragm over the same areas percussed Check for whispering petriloquy by asking the patient to ‘Whisper 99’ and listening with the bell of the stethoscope (increased in consolidation) Breath sounds: Normally vesicular. Bronchial breathing indicates consolidation. Reduced or absent breath sounds indicate pleural effusion, pneumothorax or lobar collapse. Wheeze: asthma or COPD Coarse crackles: pneumonia or bronchiectasis or fluid overload Fine crackles: pulmonary fibrosis Question 9 After palpating, percussing and auscultating the anterior chest what would you do next? Answer Ask the patient to sit the patient up and repeat inspection, palpation, percussion and auscultation from behind. Basal crepitations and sacral oedema will be most evident posteriorly due to the surface markings of the lungs. With the patient sat forward examine their lymph nodes from behind, palpating in a logical sequence. Sit the patient forward Inspect As you sit them forward inspect the back for deformity and scars. Palpate Feel for lymph nodes in the neck from behind o Anterior and posterior triangles o Supraclavicular region o Axillary region Lymphadenopathy may indicate infective or malignant pathology e.g. lung cancer, tuberculosis or sarcoidosis Feel the spine for any scoliosis (can affect breathing if significant) Press for sacral oedema Percuss Tap again over the lung fields comparing each side Auscultate Over the lung fields Ask the patient to take deep breaths in and out through their mouth. Check for whispering petriloquy by asking the patient to ‘Whisper 99’ and listening with the bell of the stethoscope (increased in consolidation) Question 10 On inspection, the patient has a large body habitus and pursed lips when breathing. He has a barrel-shaped, hyper-expanded chest and his breathing has a prolonged expiratory phase with mild end-expiratory wheeze. There are no further findings. Is there anything else you would like to do?
9. What features might you look for when inspecting the chest?
10. What will you do next?
11. After palpating, percussing and auscultating the anterior chest what would you do next?
12. On inspection, the patient has a large body habitus and pursed lips when breathing. He has a barrel-shaped, hyper-expanded chest and his breathing has a prolonged expiratory phase with mild end-expiratory wheeze. There are no further findings. Is there anything else you would like to do?

And 3 more at this station.

How is the physical examination station marked in MRCS Part B?

A physical examination station is marked out of 20: 8 marks for clinical and technical skill, and 4 each for clinical knowledge and its application, communication and professionalism. More than half the marks therefore sit outside your knowledge of the condition, so a silent but technically correct examination scores poorly. You are signalled at six minutes of the nine to present your findings.