🫁 MOCK OSCE · FCPS, MCPS, MD PAEDIATRICS ⏱ 10 min · RESPIRATORY · PNEUMOTHORAX (RIGHT)

Right‑sided Pneumothorax · Short Case

Candidate task: perform focused respiratory examination on a child with right‑sided pneumothorax.
Then discuss differential diagnosis, investigations, management & follow‑up.
Pre‑exam Protocol
⏤ · Wash, Warm, Introduce, Position, Expose, Approach ▾

Standard pre‑examination protocol – must be demonstrated:

🖐 Wash hands with sterilizing solution.
🔥 Warm hands and stethoscope.
👋 Introduce yourself to child & parent.
🧍 Position child: supine, sitting, then left lateral.
👕 Exposure — chest fully exposed, warm environment.
➡️ Approach from the right side.
✔ CPSP marker: Pre‑exam Protocol is observed and scored.
1. Clinical Examination (≈6 min)
02 General Look (Inspection from end of bed) ▾

Key observations – “Right‑sided pneumothorax” clues:

  • Posture: may be orthopnoeic, prefers sitting up.
  • Respiratory effort: tachypnoea, use of accessory muscles, tracheal tug.
  • Chest shape: asymmetrical; fullness of right intercostal spaces (tension).
  • Colour: cyanosis (if tension / massive).
  • Nutritional status: usually normal (acute).
  • Clubbing: not a feature (unless chronic underlying lung disease).
👁 Red flags: respiratory distress + hyperresonance + absent breath sounds → pneumothorax.
03 Inspection (Respiratory Examination) ▾

Inspection findings in right‑sided pneumothorax:

Trachea Shifted to the left (opposite side).
Chest wall Fullness / bulging of right intercostal spaces (tension).
Respiratory movements Decreased / absent on the right side.
Apex beat Shifted to the left (if tension).
Accessory muscles May be used if respiratory distress.
Scars / sinuses May indicate previous surgery / TB.
🔍 Key: tracheal shift to opposite side + bulging chest → tension pneumothorax.
04 Palpation (Respiratory Examination) ▾

Palpation findings in right‑sided pneumothorax:

Tracheal position Shifted to the left (opposite side).
Chest expansion Decreased on the right side.
Vocal fremitus Decreased / Absent on the right.
Tactile fremitus Decreased / Absent.
Apex beat Shifted to the left (tension).
Tenderness Usually absent (may be present if traumatic).
🖐 Key: absent vocal fremitus on affected side is a hallmark.
05 Percussion (Respiratory Examination) ▾

Percussion findings in right‑sided pneumothorax:

Percussion note Hyperresonant over the right hemithorax.
Upper border Not applicable (air replaces lung).
Traube's space Tympanic (unless associated effusion).
Skodiac resonance Not a feature.
Grocco's triangle Not a feature.
Garland's triangle Not a feature.
👂 Key: hyperresonant percussion note is characteristic.
06 Auscultation (Respiratory Examination) ▾

Auscultation findings in right‑sided pneumothorax:

Breath sounds Decreased / Absent on the right.
Vocal resonance Decreased / Absent.
Coin test Positive (high‑pitched metallic sound).
Aegophony Not a feature.
Added sounds Usually absent.
Pleural rub May be heard if associated pleurisy.
🩺 Key: absent breath sounds + hyperresonance = pneumothorax.
07 General Physical Exam (Hands → Face → Chest → Abdomen → Limbs) ▾

Systematic GPE – identify aetiology & complications:

  • Hands: clubbing (chronic lung disease), cyanosis, pallor.
  • Face: cyanosis, malar rash (SLE).
  • Chest: respiratory rate, accessory muscles, JVP (raised in tension).
  • Abdomen: hepatomegaly (cardiac / TB), ascites.
  • Limbs: oedema (cardiac), joint swelling (rheumatoid / SLE).
  • Back: spine tenderness (TB spine), kyphoscoliosis.
  • Skin: BCG scar, surgical scars, rash (SLE), subcutaneous emphysema.
📏 Anthropometry: weight, height, head circumference – plot growth.
08 Developmental Assessment & Associated Signs ▾

Assess developmental regression and associated features:

  • Motor milestones: delay / regression (chronic illness).
  • Speech: dysarthria, nasal speech (bulbar if neuromuscular).
  • Feeding: poor suck, dysphagia, aspiration.
  • Behaviour: irritability, pain (pleuritic).
  • Growth: failure to thrive (chronic TB, malignancy, CF).
  • Respiratory: recurrent infections, clubbing, cyanosis.
🧠 Red flags: rapid progression, respiratory failure, dysautonomia → ICU admission.

📋 Case Presentation – (fill in during exam)

I have examined _____, _____ years old who is conscious and cooperative, having _____ built and a cannula in his _____ arm. He is _____ (pink / cyanosed) in room air with _____ (no / signs of) respiratory distress or dysmorphism.

His respiration is _____ (abdominothoracic / thoracic) with a rate of _____ per minute.

Inspection: Chest is _____ (normal in shape / bulging on the right). There are no scars, prominent veins or Harrison sulcus. He has _____ (mediastinal shifting / no mediastinal shifting) as evident by _____ (tracheal shift to the left / central trachea). Apex beat is in _____ ICS about _____ cms lateral to midclavicular line.

Palpation: Superficial palpation reveals no tenderness. My findings are confined to _____ (right / left) hemithorax in the form of decreased chest expansion and absent vocal fremitus.

Percussion: Hyperresonant percussion note over the right hemithorax.

Auscultation: Breath sounds are decreased / absent with no added sounds and decreased vocal resonance. He has vesicular breathing in the left lung.

Back: Back is normal in shape with no visible deformity and similar findings are found in the right infrascapular area.

He is _____ (afebrile / febrile), Pulse is _____ beats/min, regular in rhythm and normal in volume and character, BCG scar mark is _____ (present / absent), throat is normal.

There is no evidence of cyanosis, clubbing, lymphadenopathy, rash and oral ulcers.

I would like to know his height and weight.
I want to see his chest X-ray.

2. Viva Discussion (≈4 min)
09 Viva · Differential, Investigations, Management, Follow‑up ▾
🔹 Differential Diagnosis

• Pneumothorax – spontaneous / traumatic / tension
• Pleural effusion – fluid in pleural space
• Empyema thoracis – pus in pleural space
• Consolidation – pneumonia (bacterial / viral / TB)
• Collapse (atelectasis) – with obstructed main bronchus
• Hydropneumothorax – air and fluid
• Pulmonary embolism – infarction
• Bullous lung disease – congenital / acquired
• Congenital lobar emphysema – hyperinflation

🔹 Investigations – Diagnosis

• Chest X-ray (PA & lateral) – air in pleural space, lung collapse
• Expiratory film – accentuates pneumothorax
• CT chest – differentiate from bullae / cysts
• Ultrasound – lung point sign
• Arterial blood gas – hypoxia / hypercapnia
• Complete blood count, CRP, ESR – infection

🔹 Investigations – Aetiology

• Sputum / blood culture – if infection
• Mantoux test / gastric aspirate – TB
• Autoantibodies (ANA, RF) – collagen vascular
• Sweat chloride test – cystic fibrosis
• Alpha‑1 antitrypsin levels – emphysema
• Genetic testing – Marfan / Ehlers‑Danlos

🔹 Investigations – Exclude / Complications

• Pulmonary function tests (VC, MIP) – respiratory failure
• Autonomic function – BP/HR monitoring
• Swallow study – aspiration risk
• DVT prophylaxis – Doppler if immobile
• ECG / echocardiography – cardiac complications

🔹 Management – Across Organ Systems

Respiratory

Oxygen, intercostal tube drainage (tension / large). Monitor VC, early intubation if respiratory failure.

Medical

Analgesics, bronchodilators, antibiotics (if infection).

Surgical

Chest tube insertion, pleurodesis (recurrent), VATS, bullectomy.

Antimicrobial

Antibiotics if empyema / infection.

Nutrition

High‑calorie feeds (chronic illness), NG if bulbar.

Multidisciplinary

Respiratory therapy, dietitian, physiotherapy, social work.

📈 Prognosis

  • Small spontaneous: good; resolves spontaneously.
  • Tension pneumothorax: good if treated promptly; emergency.
  • Recurrent: may need pleurodesis.
  • Traumatic: depends on associated injuries.
  • Underlying lung disease: prognosis variable.

📋 Follow‑up Schedule

  • Acute: daily clinical & X‑ray monitoring.
  • Post‑drainage: X‑ray until resolved.
  • Long‑term: 3‑6 monthly if recurrent / underlying disease.
  • Avoid flying / diving: if recurrent.
💡 Examiner expectation: logical differential (pneumothorax vs effusion vs bullae), systematic investigation (CXR, CT), and management plan with respiratory support, drainage, and follow‑up. Know coin test and hyperresonance for pneumothorax.
📚 Visit paeds.online for more CPSP resources
Mock OSCE · Right‑sided Pneumothorax · Based on Wyne‑Harris, Nelson & CPSP curriculum