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11-minute physical-examination master page

Complete respiratory examination

Perform a safe, focused respiratory examination, localize abnormal findings, present a prioritized differential, choose targeted investigations and state immediate management and escalation criteria.

Candidate instructions

Unilateral dyspnea respiratory examination station

Your task

Perform a focused respiratory examination on a 58-year-old patient with progressive shortness of breath and right-sided chest heaviness. At the end, present your findings, leading diagnosis, prioritized differential, targeted investigations, immediate management and safety-netting. You have 11 minutes.

Information available at entry
HR 104/minBP 126/74 mm HgRR 24/minSpO₂ 91% room airTemp 37.8°C
Safety priority: Assess airway, breathing, circulation and oxygenation before beginning. Stop the routine sequence and escalate for severe respiratory distress, exhaustion, cyanosis, hypotension, altered mentation, rapidly falling oxygen saturation or suspected tension pneumothorax.

What examiners expect

  • Introduction, two identifiers, explanation, consent and hand hygiene.
  • Immediate assessment of work of breathing and stability.
  • Appropriate exposure of the chest with dignity preserved.
  • Systematic inspection, palpation, percussion and auscultation comparing both sides.
  • Recognition and localization of a pleural-effusion pattern.
  • Concise synthesis, prioritized differential, investigations, management and clear escalation criteria.
Timed rehearsal

Run the complete station in 11 minutes

Aim to complete patient contact by 9:15 and reserve the final 105 seconds for findings, differential, investigations, management and safety-netting.

Open Station 30Review procedure
Station time
11:00

Ready for an 11-minute attempt.

Complete procedure

Exact 11-minute respiratory examination sequence

Use this as a rehearsal structure, not a rigid ritual. Modify or stop when the patient’s stability, pain or breathlessness requires it.

0:00–0:35

1. Safety glance and immediate breathing assessment

Say: “Before I begin, are you severely short of breath, having chest pain, feeling faint or unable to speak comfortably?”
  • Observe airway patency, respiratory rate, work of breathing, colour, posture, speech and mental status.
  • Review oxygen saturation, heart rate, blood pressure and temperature.
  • Escalate before examination if unstable.
0:35–1:15

2. Introduce, identify, explain and consent

Say: “Hello, my name is ____, one of the clinical candidates. Could I confirm your full name and date of birth? I have been asked to examine your breathing. I will look, feel, tap and listen over the front and back of your chest. Is that okay?”
  • Confirm two identifiers.
  • Explain the examination in plain language.
  • Obtain consent and offer a chaperone according to patient preference and local policy.
1:15–1:45

3. Hand hygiene, pain, position and exposure

Say: “I will clean my hands. Do you have pain anywhere before I begin? I will sit you upright and expose only the chest areas I need while keeping you covered.”
  • Sanitize hands.
  • Ask about pain, dizziness and positional intolerance.
  • Position upright, usually at 45–90 degrees.
  • Expose front, sides and back sequentially while preserving warmth and dignity.
1:45–2:25

4. General inspection from the end of the bed

Say: “I am looking for signs of breathing difficulty and clues to the cause.”
  • Inspect respiratory pattern, accessory-muscle use, pursed-lip breathing, cough, sputum container, oxygen, inhalers, drains, scars and body habitus.
  • Note asymmetry of movement or a patient leaning to one side.
2:25–3:05

5. Hands, pulse and face

Say: “May I examine your hands and check your pulse?”
  • Check temperature, capillary refill, peripheral cyanosis, clubbing, nicotine staining and tremor.
  • Assess pulse rate and rhythm.
  • Inspect conjunctivae for pallor and lips/tongue for central cyanosis.
3:05–3:40

6. Neck and upper airway

Say: “I am checking the position of your windpipe and the neck structures that can affect breathing.”
  • Assess tracheal position gently.
  • Look for cervical or supraclavicular lymphadenopathy when relevant.
  • Assess JVP if heart failure is a plausible cause.
3:40–4:30

7. Inspect the chest

Say: “I am comparing the shape and movement of both sides of your chest.”
  • Inspect chest shape, scars, deformity, intercostal recession and symmetry.
  • Count respiratory rate if not already supplied.
  • Observe anterior, lateral and posterior expansion.
4:30–5:30

8. Palpate expansion and tactile vocal fremitus

Say: “I will place my hands on your chest to compare movement. Please take a deep breath when asked.”
  • Compare anterior and posterior chest expansion.
  • Assess tactile vocal fremitus selectively when consolidation or pleural disease is suspected.
  • Stop if the patient becomes distressed.
5:30–6:40

9. Percuss systematically

Say: “I am going to tap on your chest and compare the sound on both sides.”
  • Percuss side-to-side at matching levels over the anterior, lateral and posterior chest.
  • Identify stony dullness over the right lower zone in this station.
  • Estimate the upper level of dullness without repeatedly percussing an exhausted patient.
6:40–8:15

10. Auscultate breath sounds and voice transmission

Say: “Please breathe in and out through your mouth each time I move the stethoscope. Tell me if you feel dizzy.”
  • Use the diaphragm and compare matching sites from apices to bases.
  • Listen anteriorly, laterally and posteriorly.
  • Identify markedly reduced breath sounds at the right base.
  • Assess vocal resonance or egophony selectively above the fluid level.
  • Listen for crackles, wheeze, bronchial breathing and pleural rub.
8:15–9:00

11. Complete targeted peripheral examination

Say: “I need to check briefly for fluid retention, clot signs and other clues.”
  • Check ankle edema and calves only when clinically indicated and with consent.
  • Look for cachexia, lymph nodes or signs of chronic liver disease when relevant.
  • State that you would review sputum and peak flow only if appropriate to the presentation.
9:00–9:20

12. Restore comfort and close

Say: “Thank you. I will help you get comfortable, cover you and clean my hands. Are you feeling more short of breath or unwell after the examination?”
  • Cover and reposition the patient.
  • Repeat hand hygiene.
  • Reassess symptoms and oxygenation if needed.
9:20–11:00

13. Present, investigate, manage and safety-net

Say: “The patient is mildly hypoxemic and tachypneic. There is reduced right lower-zone expansion, stony dull percussion, reduced breath sounds and reduced vocal resonance at the right base, consistent with a right pleural effusion. I would investigate the cause and treat respiratory compromise urgently.”
  • Give a one-sentence stability statement.
  • Localize the findings and state the leading diagnosis.
  • Give prioritized alternatives, investigations, immediate management and escalation criteria.
Interpretation

Pleural-effusion examination pattern

FindingInterpretationHow to present it
Reduced right basal expansionLocalized restriction of movement.“Chest expansion is reduced at the right base.”
Stony dull percussionStrongly supports pleural fluid at that level.“Percussion is stony dull over the right lower zone.”
Reduced breath sounds and vocal resonanceSound transmission is reduced through pleural fluid.“Breath sounds and vocal resonance are reduced at the right base.”
Bronchial breathing or egophony just above the levelCompressed lung may transmit higher-frequency sounds above the effusion.State only if actually found.
Tracheal deviation awayMay occur with a very large effusion; absence does not exclude it.“The trachea is central” or specify direction.
“This patient is tachypneic and mildly hypoxemic but currently alert and hemodynamically stable. There is reduced expansion, stony dull percussion, markedly reduced breath sounds and reduced vocal resonance at the right base, with no tension features. These findings localize to the right pleural space and are most consistent with a moderate-to-large right pleural effusion.”
Prioritized reasoning

Differential diagnosis

Malignant effusion

Consider with weight loss, smoking history, unilateral recurrent fluid or lymphadenopathy.

Parapneumonic effusion or empyema

Prioritize with fever, pleuritic pain, productive cough, sepsis or loculation.

Heart failure

Often bilateral but may be asymmetric; integrate JVP, edema, crackles and cardiac findings.

Pulmonary embolism

Consider with sudden pleuritic pain, tachycardia, hypoxemia and thromboembolic risk.

Tuberculous pleuritis

Consider exposure, subacute fever, night sweats, weight loss and epidemiology.

Other causes

Include hepatic hydrothorax, renal disease, autoimmune disease, pancreatitis, trauma or hemothorax according to context.

Targeted work-up

Investigations and purpose

InvestigationPurposePriority
Repeat vital signs, continuous oximetry and monitoringDefine severity and detect deterioration.Immediate
Bedside lung ultrasoundConfirm fluid, estimate size, identify loculation and guide safe drainage.Early
Chest radiographConfirm effusion, assess size, mediastinal shift and alternative lung pathology.Early
CBC, electrolytes, renal/liver tests, CRP and blood cultures when septicAssess infection, organ function and procedural safety.Early
Diagnostic thoracentesis when new and unexplainedDetermine transudative/exudative pattern and evaluate cell count, protein, LDH, glucose, pH, Gram stain/culture and cytology as indicated.Early when appropriate
CT chestAssess malignancy, loculation, pulmonary embolism or complex pleural disease when indicated.Targeted
Immediate management

Treat severity before the final diagnosis

  1. Sit the patient upright and call for help if respiratory distress is significant.
  2. Give supplemental oxygen for hypoxemia and monitor the response.
  3. Establish IV access and obtain urgent tests when the patient is unwell.
  4. Use ultrasound guidance for pleural procedures.
  5. Drain urgently when there is major respiratory compromise, suspected empyema/complicated infection or another time-critical indication.
  6. Treat the underlying cause and arrange appropriate respiratory, medical, oncology or surgical consultation.

Safety-net and escalation

  • Increasing work of breathing or exhaustion
  • Falling oxygen saturation
  • Hypotension or poor perfusion
  • Confusion or reduced consciousness
  • Sepsis or suspected empyema
  • Rapidly enlarging effusion, hemothorax or tension physiology
Examiner checklist

Respiratory examination self-score

Patient contact

  • Assesses immediate stability
  • Introduces self and confirms two identifiers
  • Explains, consents and performs hand hygiene
  • Checks pain and positions appropriately
  • Preserves exposure and dignity
  • Compares both sides systematically
  • Restores comfort and thanks the patient

Clinical reasoning

  • Localizes the abnormality to the pleural space
  • Identifies pleural effusion as the leading diagnosis
  • Prioritizes dangerous causes
  • Selects imaging and pleural-fluid investigations appropriately
  • States oxygen/monitoring for hypoxemia
  • Recognizes urgent drainage indications
  • Gives explicit deterioration criteria
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