Summary of Common Conditions Seen in OSCEs
Hints and Tips for the Exam
Inspection
Inspection can often provide the diagnosis at the respiratory station. There are some key stereotypical features of a few conditions that can give the case away.
| Findings | Condition |
| Young, thin, short patient with a PEG site near the umbilicus and a tunnelled catheter at the axilla or on the chest | Bronchiectasis secondary to cystic fibrosis |
| Middle-aged patient with full sputum pot | Bronchiectasis |
| Cushingoid features (high BMI, bruising, striae) and bruising (from steroid use) | Pulmonary fibrosis |
| Features of rheumatological disease, e.g. rheumatoid hands (ulnar deviation, swollen metacarpophalangeal joints, swan neck deformity) or scleroderma (beak-shaped nose, small mouth, tight skin, telangiectasia) | Pulmonary fibrosis |
| Elderly patient with tar-stained fingernails and an oxygen cylinder at the bedside | COPD |
| Characteristic scars (with pictures) | Lobectomy/pneumonectomy |
Timing
A common problem at the respiratory station is timing as students find it difficult to listen to carefully all the breath sounds in enough places during the 5–10 minutes they have.
Once you have completed your inspection, start examining from the back. Most physicians will agree that it is easier to percuss and auscultate at the back as you have more surface area available. In addition, the position of the heart often makes it difficult to establish findings in the left lower zone of the lung anteriorly.
One of the ways you can minimise collateral time losses is by reducing the time spent in changing the patient’s position. When the patient is lying down, palpate, percuss and auscultate the anterior aspect of the chest. When he or she is sitting forwards, palpate, percuss and auscultate the posterior aspect, and examine for lymphadenopathy at the same time.
Lobectomies and Pneumonectomies
These are very common in OSCEs as patients are usually stable and ambulant, and the examination findings are obvious. Students are often surprised when they do not hear decreased breath sounds at the site of lobectomy scars, which they may have done during their ward attachments. This is because, after a few months or years, patients with lobectomies develop compensatory hyperinflation, and lung tissue fills up areas it was removed from. This will not be the case immediately after lobectomy surgery as sufficient time has not surpassed for compensatory hyperinflation to occur.
The scar from a pneumonectomy can be very similar to the scar from a lobectomy (Figure 2.1), although they can immediately be distinguished by the fact that chest expansion and breaths sounds are usually completely absent on the side of a chest that has undergone a pneumonectomy.
Figure 2.1 Lobectomy scar: side view (a) and back view (b)
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