- A six-minute period is allowed for the examination portion of the station and it is our advice

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to spend the first two minutes examining the patient from a general perspective (including
full inspection, hands and face) then the second two minutes on the posterior chest and
Introduction to the Respiratory Station the final two minutes on the anterior chest. As time is limited, palpate for features of
pulmonary hypertension or right-sided heart failure at the anterior chest, before moving to
The MRCP PACES respiratory station offers an opportunity to demonstrate a slick
the respiratory signs. The anterior chest signs are likely to be similar to those elicited on
examination technique that is performed on practically all patients. Respiratory diseases,
the posterior chest).
after cardiovascular and musculoskeletal complaints, are the third most common cause
for presentation to either the Emergency Department or the General Practitioner and
- Most cases at the respiratory station involve ‘chronic’ conditions – the majority of which
remains proof of the concept that “common things are common”.
can be identified well before auscultation. Never underestimate the power of observation
both of the patient and of the surrounding environment!
Respiratory disease can be generally divided into three major categories: airways,
parenchymal and pleural disease. We have aimed to structure the following chapter to
- The chest is physiologically symmetrical and therefore careful observation may
reflect this. Certain ‘high-yield’ or ‘favourites’ that recur in the PACES examination are
immediately suggest the side of pathology – unilateral pathology includes collapse,
covered in this section.
consolidation, pleural effusion and pneumonectomy. However, if chest symmetry is

During PACES, examiners assess your ability to both elicit and then correctly interpret preserved, consider airways disease, pulmonary fibrosis or bronchiectasis.

physical signs. A general sense exists that a decision to pass or fail a candidate rests on
an aura of competence (or incompetence!) during the clinical performance. In essence, - As with any other system’s examination, at the start and the end of the physical

the examiners are looking for you to demonstrate correct techniques whilst eliciting the examination wash your hands or use hand gel. Having introduced yourself and obtained

signs, and logical thinking when interpreting them. Therefore, eliciting the physical signs permission to examine your patient, ensure correct position, exposure and patient comfort

is only the first step; the interpretation and presentation are equally, if not more, before commencing. On completion, ask yourself whether you have checked for the

important. following: evidence of complications (pulmonary hypertension), treatment (at bedside) or

underlying cause and ensure to complete your presentation stating “To complete my
With this in mind, the following useful general points should be considered; examination, I would check the peak flow rate, sputum pot and temperature chart”
Remember to thank the patient and help them dress.
- The respiratory examination does not need to be a lengthy one. Start at the peripheries
with the hands and then move to the back (unless specifically advised otherwise by
Examination
your examiners). Traditionally the physical examination starts with the anterior chest
but it is perfectly acceptable to do the back first then return to the front (most signs and The key to the examination is practice. Try to collate your examination findings and ensure
clues to the diagnosis, for example scars, will be detected by examining the posterior the signs you elicit fit together.
chest).

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Inspection - Inhalers or a nebuliser. Ensure that you are familiar with the commonly used inhalers so
that you can be specific during your presentation.
Ensure the patient is comfortably positioned at 45 degrees and is exposed from the waist
- Sputum pot
up. Take time to inspect the patient for important clues from the end of the bed. Stand
- Walking aids which may suggest the patient has a reduced exercise tolerance
directly opposite the patient in order to correctly assess any differences in each
hemithorax. Remember to cover the patient up after completing each element of the
Look for complications of disease or treatment e.g. evidence of steroid use (rounded face,
examination in order to maintain dignity.
central obesity, intrascapular fat pad, thin skin, bruising, hirsuitism, proximal muscle
weakness).
General appearance
Consider the patients age.
Hands
Note the body habitus. Short stature is suggestive of a disease in childhood e.g. cystic
fibrosis. Also note their BMI Inspect the hands for:

Is the patient short of breath at rest? - palmar erythema (CO2 retention)

Look for use of accessory muscles (tracheal tug, in-drawing of intercostal muscles, use - wasting of the small muscles of the hand (Pancoast tumour)

of abdominal muscles). - changes of rheumatological conditions associated with respiratory disease eg.

Is there pursed lip breathing (patient providing own positive end-expiratory pressure). rheumatoid arthritis, scleroderma

Are any audible noises from the end of the bed, for example wheeze, stridor, a hoarse Inspect the nails for:

voice, or cough (note whether this is productive or dry) - clubbing with the patients fingers directly in line with your vision so that the nail is

Note any deformities of the chest wall. observed at 90 degrees. Schamroth’s sign (directly opposing distal phalanges of

- pectus excavatum - depression of the sternum corresponding fingers and looking for the obliteration of the usual diamond shaped

- pectus carinatum - outward bowing of the sternum due to chronic respiratory window between the nailbeds) can be performed to assess clubbing.

infection or rickets - peripheral cyanosis

- kyphoscoliosis - tar staining and yellow nails (yellow nail syndrome).

- barrel shaped chest indicating increased anteroposterior diameter and

hyperexpansion. Ask the patient to straighten out their arms and hold out their hands looking for:

Is the chest expansion equal? - a fine tremor associated with beta 2 agonist use.

Carefully observe for any visible scars on the patient’s chest. These are useful to locate - a course flapping tremor of CO2 retention by asking the patient to cock their wrists back

at the beginning of the examination as if they were about to stop traffic. Asterixis is more likely to be present in an acutely

Look for radiotherapy tattoos and radiation induced skin changes. unwell patient rather than a patient selected for the PACES exam

Bedside clues including: Feel the patients’ radial pulse. A bounding pulse is a characteristic sign of CO2 retention.

- Oxygen therapy Calculate their respiratory rate by counting the number of respirations over 15 seconds
whilst feeling the pulse

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Face - JVP waveform: is the a wave prominent (right atrial hypertrophy) or are there large v

Look closely at the patients face for: waves (tricuspid regurgitation).

- A Cushingoid appearance suggesting steroid therapy

- Stigmata of underlying pathology for example Thorax
- connective tissue disease eg telangiectasia and microstomia in scleroderma Trachea Warn the patient that you are going to feel their windpipe and that this may feel
patients; butterfly rash in patients with SLE; heliotrope rash of dermatomyositis. slightly uncomfortable. Place your middle finger in the centre of the trachea with your
- lupus pernio (sarcoidosis) and lupus vulgaris (tuberculosis) which are most index and ring finger on either side. Look for evidence of deviation or tracheal tug. Check
commonly visible on the nose the crico-sternal distance (the distance between the suprasternal notch to the cricoid
- Facial plethora consistent with secondary polycythaemia cartilage). This is normally 3 finger breaths and is reduced in hyperinflation.
- Evidence of SVC obstruction (facial and upper body swelling)

Apex beat Feel for the patients’ apex beat, which may be displaced due to mediastinal shift
Eyes or poorly palpable due to hyperexpansion of the chest

- Suffused conjunctivae present in secondary polycythaemia

- Horner’s syndrome (meiosis, partial ptosis, enophthalmous, anhydrosis) Pulmonary hypertension Palpate for a right ventricular heave by placing the palm of your

- Ask the patient to look up and warn them that you are going to pull down gently on hand over the left sternal border and for a palpable pulmonary second heart sound.

their lower eyelid. Look for:

- anaemia present in chronic disease eg cystic fibrosis Lymphadenopathy Ask the patient to sit forward and cross their arms over their chest.

- jaundice which may indicate malignancy Palpate for cervical and supraclavicular lymphadenopathy - ensure you feel all areas
(submandibular, pre and post auricular, anterior and posterior cervical triangle, occipital
and supraclavicular regions). If you find lymphadenopathy offer to examine the axillae.
Mouth
- Look for central cyanosis in the patient’s lips and the undersurface of the tongue.
Expansion
- Evidence of oral candidiasis - consistent with steroid use
Expansion is a high yield sign but is often performed incorrectly. Place the palm of your
hands with fingers in the intercostal spaces on either side of the patients’ chest and pull in
Neck
the subcutaneous tissues slightly. Lift your thumbs off the chest wall so that they meet
- Look at the patients’ neck size (larger collar size increases risk of obstructive sleep
opposite each other in the middle of the chest. Ask the patient to take a deep breath in
apnoea).
and out of their mouth and observe for any asymmetry or reduction in expansion of the
- Assess the patients JVP at 45 degrees
chest wall movement. This manoeuvre should be performed in the upper and lower zones
- A raised JVP may suggest cor pulmonale
of the chest.
- Fixed in superior vena cava obstruction

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 transmits higher frequencies, giving the speech a “bleating” quality. If aegophony is present,
Tactile vocal fremitus
the patient saying “a” will sound like “e” through the stethoscope.
Place the ulnar border of your hands obliquely in the intercostal spaces on either side of
the patient’s chest and ask them to say “99”. Observe for any difference as the sound
Having examined the posterior of the thorax move onto the anterior of the chest, by which
resonates through the lungs and chest wall. Repeat this in the upper, middle and lower
point you a good idea of the possible diagnosis should already have been made. Use the
zones of the chest.
rest of the examination to confirm or dispute your findings.
Percussion
You should percuss with your middle finger in a firm connection with the patients’ skin. Prior to completing the examination look at the patients ankles for any evidence of
Move the percussing hand from the wrist in order to generate a good sound. Compare peripheral oedema (cor pulmonale).
each side of the chest in turn and moving down from the apex to the lung bases, not
forgetting the axillae. Is the percussion note resonant, dull or stony dull? Absence of Ensure your patient is covered up, thank them and wash your hands.
hepatic and cardiac dullness may signify hyperexpansion.

Auscultation To complete the examination offer to look at the patient’s observation chart and sputum pot

Ask the patient to take deep breaths in and out of their mouth and ensure your (if one is available), to perform a peak flow/bedside spirometry and look at the patients

stethoscope is in contact with their chest wall throughout inspiration and expiration. chest radiograph.

Consider the following in each area of the chest:

Is the air entry normal or reduced?
Remember
Are the breath sounds vesicular or is there bronchial breathing?
- If you are confident of the diagnosis it is better to give the diagnosis first
Is the inspiratory: expiratory ratio of respiration normal (usually 1:2) or is there a
(otherwise present the case in a systematic manor mentioning the
prolonged expiratory phase (airflow obstruction)?
pertinent positive and negative findings).
Are there any added sounds such as wheeze, crepitations or a pleural rub?
- Make sure you do not miss out descriptors e.g. specific features of
Ensure you describe these sounds detailing where they occur in the respiratory cycle as
crepitations.
well as their quality, for example, are they fine late inspiratory crepitations or early and
- Attempt to give a possible cause for the patients underlying respiratory
course.
condition e.g. pulmonary fibrosis most likely secondary to rheumatoid
Vocal Resonance
arthritis.
Ask the patient to say “99” each time you place your stethoscope on their chest and - Comment on any complications of the disease or of the treatment, for
compare each hemithorax. example cor pulmonale or Cushing’s syndrome secondary to steroid use.
If the vocal resonance is increased, examine for whispering pectriloquy by asking the - Make an assessment of severity of disease.
patient to whisper “99” and determine if this sound is increased (for example over areas
of fibrosis). Assess for aegophony (Greek for “goat voice”), which occurs when the lung

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