Station Title & Timing
Title: Respiratory Physical Examination – The Chronic Smoker
Total Duration: 10 minutes
- Reading Time: 2 minutes
- Examination Time: 6 minutes
- Discussion/Viva Time: 2 minutes
Learning Objective(s)
- Primary: Demonstrate a systematic, time-efficient respiratory physical examination (IPPAV).
- Secondary: Integrate clinical reasoning via “running commentary” focusing on COPD and Lung Cancer.
- Tertiary: Communicate a management plan to a patient with a “normal” physical exam but high-risk history.
Patient Profile
- Name: Mr. Robert Miller
- Age: 45 years old
- Ethnicity: Caucasian
- Occupation: Construction Foreman
- Social History: Current smoker (25 pack-years); drinks 2–3 beers on weekends.
Presenting Complaint
Robert presents with a 6-month history of a persistent “smoker’s cough” and increasing shortness of breath when climbing stairs at work.
Contextual Information
- HPC: Cough is productive of scant white sputum, worse in the mornings. No hemoptysis. SOB is gradual; no sudden chest pain.
- PMHx: No history of asthma or childhood respiratory illness. No hypertension or diabetes.
- Medications: Nil.
- Allergies: No known drug allergies.
- Family History: Father died of “emphysema”; Mother has hypertension.
Exam Instructions
Candidate Instructions
Mr. Robert Miller, 45, is a chronic smoker complaining of shortness of breath and cough. You have already taken a history.
- Perform a focused respiratory physical examination.
- Provide a running commentary to the examiner regarding your findings and clinical reasoning.
- Discuss your preliminary findings and differential diagnosis with the patient.
Standardised Patient (SP) Instructions
- Demeanor: You are slightly anxious about your health but cooperative.
- Physical Findings: You will act as a “Normal” patient. You do not have a barrel chest, your breath sounds are clear, and there is no clubbing.
- Key Trigger: If the candidate asks how you are feeling, say: “I’m just worried this is more than just a smoker’s cough.”
- Reaction: If the candidate mentions “Cancer,” look concerned but appreciative of the honesty.
Examiner Checklist Items
- Washes hands and introduces self.
- Assesses peripheral signs (Clubbing, Cyanosis, Horner’s, Tracheal position).
- Correctly executes IPPAV (Inspection, Palpation, Percussion, Auscultation, Vocal Resonance).
- Completes the core exam within the 6-minute window.
- Maintains patient dignity (appropriate draping).
Key Clinical Findings
- Vitals: HR 82 bpm, BP 130/80 mmHg, SpO2 96% on room air, RR 18 bpm.
- General: No acute distress, no cachexia, no accessory muscle use.
- Hands/Face: No clubbing, no nicotine staining (for the sake of this OSCE), no ptosis or miosis.
- Trachea: Central; no tracheal tug.
- Chest: Symmetrical expansion, resonant percussion throughout, vesicular breath sounds, no added sounds (wheeze/crackles).
Communication Triggers (Murtagh’s Approach)
- Open-ended start: “Mr. Miller, before I begin the physical exam, is there anything specific you are worried about today?”
- Signposting: “I am going to start by looking at your hands and face, then move to your chest.”
- The “Normal” Explanation: “Robert, the good news is that my examination today didn’t show any immediate red flags, but because of your smoking history, we still need to run some tests.”
- Empathy: “I understand it’s worrying to feel short of breath at work.”
Assessment & Marking Guide
| Domain | Critical Actions | Score (1-5) |
| Technical Proficiency | Smooth execution of IPPAV; correct use of bell/diaphragm. | |
| Clinical Reasoning | Mentioned Pancoast tumor (Horner’s) and COPD (Barrel chest/Hoover’s). | |
| Time Management | Finished all 5 core steps of the chest exam. | |
| Communication | Used lay language; explained the need for further tests (Spirometry/CXR). | |
| Global Rating | Fail / Borderline / Pass / Clear Pass |
Sample Answers / Model Performance
Suggested “Running Commentary”:
“I am checking the hands for clubbing which might suggest malignancy, and wasting of the small muscles which could indicate a Pancoast tumor. Looking at the eyes for Horner’s syndrome (ptosis/miosis). I am checking the trachea for deviation. On inspection of the chest, I am looking for a barrel chest or scars. I will now palpate for symmetrical expansion and percuss 8 zones to rule out dullness or hyper-resonance…”
Explanation of Diagnosis (The Discussion Phase):
“Robert, your physical exam today was actually quite normal—your lungs sound clear and your heart sounds healthy. However, given your history of smoking and your new shortness of breath, we cannot ignore the possibility of early COPD (emphysema) or other growths in the lung. To be 105% sure, I would like to organize a Chest X-ray and a breathing test called Spirometry. Does that sound like a reasonable plan to you?”