Phys · general-medicine
Respiratory System Examination — DCE Short-Case Routine
Also known as respiratory examination · chest examination · lung examination · respiratory short case · DCE respiratory · PACES respiratory examination · IPAA examination · inspection palpation percussion auscultation · chest signs · respiratory system assessment
Consultant-physician guide to the systematic respiratory system examination for the DCE short case: the eleven-step routine (end of bed, hands, face, neck, anterior chest, posterior chest, legs, additional tests), the key physical signs and their physiological basis, the differential diagnosis from individual signs, the model presentation template, the examiner discussion questions, and the classic exam traps — the routine that every FRACP, MRCP PACES, and ABIM candidate must perform flawlessly.
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Red flags
- A patient with respiratory distress using accessory muscles, unable to speak in full sentences, with a respiratory rate above 30 and SpO2 below 90 per cent on room air requires immediate assessment for a life-threatening cause — tension pneumothorax, massive pulmonary embolism, acute severe asthma, decompensated heart failure, or pneumonia with sepsis
- A deviated trachea with hyperresonance and absent breath sounds on one side is a tension pneumothorax until proven otherwise — this is a clinical diagnosis requiring immediate needle decomression before imaging
- A patient with COPD who develops a fine tremor, drowsiness, or asterixis is retaining carbon dioxide — check an arterial blood gas immediately, because CO2 narcosis can progress rapidly to respiratory arrest
- Clubbing in a patient with COPD or asthma does NOT occur from the underlying disease — it signals a complication (lung cancer, bronchiectasis, pulmonary fibrosis) and warrants urgent imaging
Respiratory System Examination — DCE Short-Case Routine
Meet the patient
A 62-year-old smoker is your DCE short case. From the foot of the bed you see a cachectic man with a barrel chest, pursed-lip breathing, and oxygen tubing. The instruction is examine this patient's respiratory system. The examiner is watching from the moment you walk in.[1]
The five seconds at the end of the bed reveal the diagnosis in a significant proportion of cases — breathlessness, accessory-muscle use, barrel chest, cachexia, cyanosis, the oxygen tubing, the inhaler on the bedside table. The candidate who walks straight to the chest has lost the first-impression marks and demonstrated a failure of the systematic approach.[1]
References7ShowHide
- [1]Bohadana A, Izbicki G, Kraman SS Fundamentals of lung auscultation N Engl J Med, 2014.PMID 24552321
- [2]MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010 Thorax, 2010.PMID 20696690
- [3]Hooper C, Lee YCG, Maskell N; BTS Pleural Guideline Group Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010 Thorax, 2010.PMID 20696692
- [4]Sarkar M, Mahesh DM, Madabhavi I Digital clubbing Lung India, 2012.PMID 23243350
- [5]Burcovschii S, Aboeed A. Nail Clubbing 2026.PMID 30969535
- [6]Raghu G, Remy-Jardin M, Myers JL, et al. Diagnosis of Idiopathic Pulmonary Fibrosis. An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline Am J Respir Crit Care Med, 2018.PMID 30168753
- [7]Fatima SA, Sharma S Lung Pancoast Tumor 2026.PMID 32310569