Knowledge · Clinical Examination

Respiratory Examination for MRCS Part B: Inspection to Auscultation

By Dr Richard Miller, MBChB FRCS with the MRCS Part B Questions Team · Reviewed 15 September 2026

In brief

The respiratory examination is inspection, palpation for expansion and trachea, percussion and auscultation, repeated front and back, with the percussion note and breath sounds interpreted together to name the pathology.

The respiratory examination is four steps repeated twice: inspect, palpate, percuss and auscultate, first on the front of the chest and then on the back. Percussion note and breath sounds interpreted together are what let you name consolidation, collapse, effusion or pneumothorax out loud. Compare side with side at every step.

Key takeaways

Sit the patient at 45 degrees, exposed to the waist, and count the respiratory rate while they are distracted.
The side that moves less is the side of the pathology.
Dullness means consolidation, collapse or fluid; stony dullness means a pleural effusion; hyper-resonance means air.
Bronchial breathing and increased vocal resonance point to consolidation; both are reduced over an effusion.
Always examine the back, and always offer lymph nodes and sacral oedema before you finish.

How is this station marked in MRCS Part B?

A physical examination station is marked out of 20 across four domains: clinical and technical skill carries 8 marks, and clinical knowledge and its application, communication, and professionalism carry 4 marks each. The examiner also gives the station a separate global rating of pass, borderline or fail.

Two things follow from that split. More than half the marks sit outside your knowledge of the condition, so a silent, technically correct examination scores poorly. And you are signalled at six minutes of the nine to present your findings, so the sequence has to finish inside six.

How do I start the respiratory examination?

Gel your hands where the examiners can see, introduce yourself, gain consent and ask about pain. Position the patient at 45 degrees and expose the chest, keeping a sheet available.

From the end of the bed: breathless at rest, using accessory muscles, pursed lip breathing, audible wheeze or stridor.
Around the bed: oxygen and its delivery device, inhalers, nebulisers, sputum pot, non-invasive ventilation.
Count the respiratory rate over 15 seconds while you appear to be testing for a flap.

What are the peripheral signs in the hands and face?

Hands: tar staining, finger clubbing, peripheral cyanosis, and wasting of the small muscles in a Pancoast tumour.
Wrists: tenderness of hypertrophic pulmonary osteoarthropathy, associated with bronchial carcinoma.
Asterixis: ask the patient to stretch the arms out and cock the wrists back, looking for the flap of carbon dioxide retention.
Face and mouth: central cyanosis under the tongue, Horner's syndrome, plethora and swelling of superior vena cava obstruction.

How do I assess chest expansion and the trachea?

Check the trachea is central by placing two fingers either side of it, warning the patient that it is uncomfortable. The trachea deviates away from a tension pneumothorax or large effusion and towards a collapse.

For expansion, place both hands on the chest with the thumbs lifted off and meeting in the midline, and ask the patient to take a deep breath. Reduced movement on one side means pathology on that side.

What do the percussion notes mean?

Percuss and compare the same point on each side before moving down, over the clavicle, the upper chest, the nipple line and the axilla.

Resonant is the normal note over aerated lung.
Hyper-resonant suggests a pneumothorax or emphysematous bullae.
Dull suggests consolidation or collapse.
Stony dull is the classic note of a pleural effusion.

Stanford Medicine 25 teaches the 5-7-9 rule for the normal lower border of resonance: the fifth intercostal space in the midclavicular line, the seventh in the midaxillary line and the ninth at the scapular line.

What am I listening for on auscultation?

Ask the patient to breathe in and out through an open mouth, and listen over the same areas you percussed, comparing side with side.

Vesicular breath sounds are normal.
Bronchial breathing over the lung fields indicates consolidation.
Reduced or absent breath sounds indicate an effusion, a pneumothorax or collapse.
Added sounds: coarse crackles in bronchiectasis, fine late crackles in fibrosis, wheeze in airflow obstruction, and a pleural rub.

Then test vocal resonance. Whispering pectoriloquy is the whispered voice heard clearly through the stethoscope, and it is increased over consolidation and reduced over an effusion.

How do I complete the examination on the back?

Sit the patient forward and repeat inspection, expansion, percussion, auscultation and vocal resonance, then palpate the cervical and supraclavicular nodes and press for sacral oedema. Offer observations including oxygen saturations, peak flow and a sputum pot.

What is the examiner marking, and what goes wrong?

The respiratory station sits in Clinical and Procedural Skills, one of the five such stations in the 17-station OSCE, and is marked out of 20 with a global rating.

Forgetting the back entirely, which is where an effusion is most often found.
Percussing both sides in turn rather than comparing the same level side to side.
Describing crackles without saying whether they are fine or coarse, early or late.
Failing to offer oxygen saturations, which the examiner will ask for anyway.
Presenting a list of negatives instead of a diagnosis with supporting signs.

MRCS Part B Questions has a respiratory examination station with a marked checklist at /Sample-Questions. Reviewed and updated 15 September 2026.

Key evidence

Candidate Instructions and Guidance Notes: MRCS Part B (OSCE), updated August 2021 — Intercollegiate Committee for Basic Surgical Examinations (2021)
Pulmonary Exam: Percussion and Inspection — Stanford Medicine 25

FAQ

Do I examine the front or the back first?

Either is acceptable provided you are systematic and complete. Most candidates work down the front from the clavicles to the axillae and then sit the patient forward for the back. Say which order you are using so the examiner can follow you.

What is the difference between dull and stony dull?

Dullness is the note over consolidated or collapsed lung, where the air has been replaced by tissue. Stony dullness is a flatter, harder note produced by fluid in the pleural space, and it is the classic percussion note of a pleural effusion.

Is whispering pectoriloquy still worth testing?

Yes, because it is quick and it changes your interpretation. Increased transmission of the whispered voice supports consolidation, while reduced transmission over a dull area supports an effusion. It takes about fifteen seconds and adds a positive finding to your presentation.

Should I offer to check the peak flow?

Offer it when airflow obstruction is the likely diagnosis, alongside oxygen saturations and a full set of observations. Framing it as something you would do to complete the assessment scores better than performing it and running out of time.

How do I tell collapse from an effusion at the bedside?

Both give reduced expansion, dullness and reduced breath sounds on the affected side. The tracheal position separates them: it is pulled towards a collapse and pushed away by a large effusion. Vocal resonance is reduced in both, so lead with the trachea.

The MRCS Part B Questions Team

Written and maintained by doctors who have sat and scored well at this interview, and reviewed against the current published guideline in each case. Guidance changes — check the source before you rely on a threshold.

Last reviewed 15 September 2026

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