Station Title: Chest Pain and Breathlessness Post-Trauma
Duration: 10 Minutes (2 minutes reading time, 8 minutes performance)
Focus: Focused Physical Examination and Clinical Reasoning
Learning Objectives
- Perform a systematic respiratory physical examination under time pressure.
- Demonstrate correct technique for chest expansion, percussion, and auscultation.
- Adapt the respiratory exam to an acute trauma context (rib fracture/pneumothorax).
- Communicate findings and preliminary management using layman’s terms.
Patient Profile
- Name: Mr. David Miller
- Age: 45 years old
- Occupation: Construction worker
- Ethnicity: Caucasian
- Social History: Smoker (20 pack-years). Lives with wife and two children.
Presenting Complaint
Mr. Miller presents to the Emergency Department following a fall at a construction site 2 hours ago. He landed heavily on his right side against a metal scaffolding pole. He is now complaining of sharp right-sided chest pain and increasing shortness of breath.
Contextual Information
- History of Presenting Complaint (HPC): Sharp, “stabbing” pain on the right side of the chest, worse on deep inspiration or coughing. He feels “puffed” even while sitting.
- Past Medical History: Mild Asthma (infrequent use of inhaler). No previous surgeries.
- Medications: Salbutamol PRN.
- Allergies: Penicillin (Rash).
Exam Instructions
Candidate Instructions
You are the HMO in the Emergency Department. Mr. Miller has just arrived after a fall. Your colleague has stabilized him, but he requires a focused respiratory examination to determine the extent of his injury.
- Perform a focused respiratory physical examination.
- Explain your findings and the likely diagnosis to the patient.
- State your immediate management steps to the examiner.
Standardised Patient (SP) Instructions
- Demeanor: You are in pain. You find it difficult to take deep breaths. You speak in short, clipped sentences because you feel breathless.
- Pain: If the candidate touches your right lower ribs or asks you to take a deep breath, wince and say, “That really hurts right there.”
- Response to “99”: Say “99” clearly but softly.
- Questions for Candidate: “Is my lung collapsed? Do I need a tube in my chest?”
Examiner Checklist Items
- WIP: Washed hands, introduced self, positioned patient at 45-90 degrees, ensured adequate exposure.
- Distress Check: Identified if the patient can speak in full sentences.
- Peripheral Signs: Checked hands (clubbing/cyanosis), face (Horner’s/central cyanosis), and trachea (correct 2-finger technique).
- Chest Expansion: Fingers wrapped around the chest, thumbs lifted off the skin to observe movement.
- Percussion: Systematic side-to-side comparison on the front and axilla.
- Auscultation: Used Bell for apices, switched to Diaphragm; listened to a full breath at each point.
- Front vs. Back: Prioritized the front of the chest to assess all lobes.
Key Clinical Findings
- Vitals: HR 105 bpm, RR 24/min, SpO2 93% on room air, BP 130/85 mmHg.
- Inspection: Bruising over the right 5th-7th ribs. Shallows breaths.
- Palpation: Reduced chest expansion on the right side. Trachea is central.
- Percussion: Hyper-resonant note on the right lower/middle zones.
- Auscultation: Decreased breath sounds at the right base and right axilla.
Communication Triggers (Murtagh’s Approach)
- Open-ended Start: “Mr. Miller, I understand you had a nasty fall. Can you tell me exactly where you are feeling the discomfort right now?”
- Signposting: “I’m going to start by looking at your hands and face, and then I’ll move to tapping and listening to your chest.”
- Lay Language: Instead of “crepitus” or “pneumothorax,” use “crunching feeling under the skin” or “a small pocket of air leaking outside the lung.”
- Empathy: “I can see that taking deep breaths is quite painful for you. I will be as gentle as I can during the exam.”
Assessment & Marking Guide
| Domain | Key Performance Indicator | Score (1-5) |
| Technical Skill | Correct “thumbs-off” technique for expansion; auscultated apices with Bell. | |
| Systematic Flow | Followed IPPA sequence without skipping the front of the chest. | |
| Time Management | Completed the core exam within 6 minutes, leaving time for explanation. | |
| Clinical Reasoning | Correctly identified signs of a likely Pneumothorax/Rib Fracture. | |
| Communication | Explained the need for a Chest X-ray using clear, non-medical language. |
Global Rating: Fail / Borderline / Pass / Excellent
Sample Answers / Model Performance
Suggested Clinical Reasoning:
“Based on the hyper-resonance to percussion and decreased breath sounds on the right side following trauma, my primary differential is a Traumatic Pneumothorax, likely secondary to rib fractures. I must also rule out a Tension Pneumothorax, though the trachea is currently central.”
Model Explanation to Patient:
“Mr. Miller, thank you for your patience. From my examination, I can see you’re struggling to take a full breath because of the pain on your right side. I’ve noticed that the air isn’t moving as well on that side, and there’s a possibility that a bit of air has leaked out of your lung due to the impact. I’d like to get a Chest X-ray right away to see exactly what’s happening with the ribs and the lung. We will also give you some stronger pain relief to help you breathe more comfortably.”