OSCE: Respiratory History and Examination

RESPIRATORY MEDICINERespiratory History History of Presenting Complaint  Associated Symptoms (6): o Shortness of breath o Wheeze o Chest Pain o Cough, sputum or blood? o Fevers or Night Sweats, shivers or rigors o Snoring or sleep issues during the day Past Medical History    COPD, Pneumonia, TB, bronchitis, CF Asthma, eczema, allergic rhinitis (hayfever) Recent respiratory investigations o Chest x-ray, spirometry etc Occupational History    Dusts, metal ores, asbestos Animal exposures → birds and cats Paints, plastics, soldering Travel History       Have you travelled overseas recently? Where did you travel to? How long did you stay? (each destination) Where you able to maintain your normal hygiene? o Unbottled water? o Local foods? o Adequate sewage systems Did you receive any immunisations before travelling or have you immune status checked? Were you sexually active overseas? → sexual history may be relevant o Did you engage in safe sex? Family History   1 CF, lung cancer, emphysema TB, asthma, eczema, hayfever Richard Shaw palpitations. dysphonia. wheeze  Bronchiectasis  ASx .g. productive cough. sinus headache  Anaphylaxis (laryngeal oedema)*  Hx of allergy  Epiglottitis  Children  Foreign body obstruction  Children.wheeze)  Asthma  Highly variable symptoms often worse at night  ASx . Guillain-Barre syndrome o Polymyositis. dyspnoea.sore throat. anorexia. MND . obesity. productive sputum. PE Hx.night sweats. MR) o Pulmonary oedema o Dilated Cardiomyopathy  Strong alcohol hx o Cardiac tamponade* o Constrictive pericarditis Respiratory o Upper Airway (+/. travel  ASx . PND NYHA Dyspnoea Classification Class I On heavy exertion Class II On moderate exertion Class III On minimal exertion Class IV At rest Cardiovascular o Acute MI* o CHF/LV failure  Exertional dyspnoea.wheeze.Pleuritic pain. fever +/. dyspnoea less common o Pulmonary Embolism*  Hx of immobilisaton. malaise. haemoptysis.stridor)  URTI  ASx . syncope (massive PE). idiopathic pulmonary fibrosis)  Progressing over weeks to years  ASx . pregnancy o Kyphoscoliosis o C-spine injury o Myasthenia gravis.fever. weight loss. change in sputum production/colour. joint ache  ILD (e. rhinorrhoea. orthopaedic procedures. AR. haemoptysis.RESPIRATORY MEDICINE Differential Diagnosis of Common Presentations Chest Pain  See Cardiovascular History and Examination Notes Wheeze     Asthma COPD Infections o Bronchiolitis Airway obstruction o Foreign body o Tumour Dyspnoea     2 How far can you walk on flat ground/up stairs before you become breathless? What was normal for you before? How many pillows do you sleep on? Orthopnoea. MS. pleuritic chest pain. nasal blockage. cyanosis. dysphagia. post-nasal drip. chronic cough  CF o Parenchymal  ARDS*  Pneumonia  Rapid onset  ASx .significant sputum production. pleuritic chest pain  Tension pneumothorax*  Pleural effusion  Secondary to infection or malignancy Chest Wall o Deconditioning. cough.fever.cough  Pulmonary tumours*  ASx . fever.  Chest pain. hx of choking  Laryngeal/pharyngeal tumour* o Lower Airway (+/.cough. orthopnoea +/PND o Valvular heart disease (AS. cough  Tuberculosis  Travel hx to TB endemic areas  Immunosuppressed status (HIV/AIDS)  ASx -cough. tachypnoea  COPD    Richard Shaw Gradual worsening over yrs Hx of smoking ASx. COCP. tachycardia  Pulmonary HTN  Pulmonary vasculitis o Pleural  Pneumothorax  Instantaneous. liver failure BNP o ↑ in CCF D-dimer o PE  . lactic acidosis. URTI Relevant negatives o Wheeze o Cough +/. asthma. asthma. smoke.RESPIRATORY MEDICINE  Other o o o o Acidosis (DKA.sputum o Fever/night sweats o Chest pain/discomfort o PND/orthopnoea o Leg swelling By time course of onset:  Seconds to Minutes o Asthma o PE o Pneumothorax o Pulmonary Oedema o Anaphylaxis o Foreign body airway obstruction  Hours to Days o COPD exacerbation o Cardiac failure o Asthma o Respiratory infection o Pleural effusion o Metabolic acidosis  Weeks or Longer o Pulmonary fibrosis o COPD o Pleural effusion o Anaemia Investigations            3 Pulse oximetry o Hypoxaemia Peak Expiratory Flow o ↓ in COPD. pneumonia.Chronic fatigue Richard Shaw   TSH levels Sputum Culture  Exacerbating/Alleviating Factors o Allergens. exertion. PE) (<70mmHg) ECG Spirometry o Pre and post-bronchodilator FBC o ↓ Hb in anaemia o ↑ WCC in infection o Cardiac enzymes if chest pain Electrolytes o Hyponatraemia in CCF. pulmonary oedema. CKD. CF CXR o Pneumothorax o Pneumonia o Pulmonary oedema ABG o ↑ PaCO2 in COPD (>45mmHg) o ↓PaCO2 in anxiety. PE (<45mmHg) o ↓PaO2 in ARDS. V/Q mismatch (COPD. salicylates) Anxiety/psychosomatic Thyroid disease Severe anaemia  ASx . weather. wheeze. scratchy and persistent o Psychogenic    Investigations    Chest X-Ray o Lung cancer. TB. bronchiectasis. pneumonia. dyspnoea o Non-asthmatic eosinophilic bronchitis o External compression by node of mass lesion*  Loud and brassy cough (tracheal compression) Parenchymal Disease o Pneumonia  ASx . painful cough  Acute or persistent o Bronchiolitis  Age < 1 yr. weight loss. distended veins) o Lung abscesses*  ASx . sore throat o Laryngitis  Barking. chest tightness. dysphagia. hx of prematurity  Underlying cardiopulmonary disease or immunodeficiency  ASx .haemoptysis. dyspnoea o Tracheitis  Acute.fever. painful. chest pain o Lung Cancer*  Change in character of chronic cough  Smoking hx  ASx .anorexia. fever +/. aspiration If asthma suspected o Spirometry (pre and post-bronchodilator) o Bronchoprovocation challenges CT Chest/Bronchoscopy .g. rhinitis) Richard Shaw ASx . atopy (eczema. ACEI  Dry. frothy sputum Other o CHF  Wakening from sleep. headaches o Aspiration  Gastric contents (GORD)  Heart burn. throat clearing.productive cough.night sweats. wheeze. chest pain. fumes o Upper airway cough syndrome (UACS)  ASx . dark-coloured sputum o Interstitial lung disease  Irritating. malaise.nasal discharge/obstruction. sneezing. weight loss.sub-acute dyspnoea o Tuberculosis  Travel hx to TB endemic areas  Productive with haemoptysis  Immunosuppressed status (HIV/AIDS)  ASx . acid regurgitation (taste?)  Reflux coughing awakening from sleep  Immediately after eating/drinking  Positional. dry and persistent cough  Sub-acute onset  ASx . postnasal drip and sinusitis)  Post infectious cough (3-8 weeks after acute viral illness)  ASx .dyspnoea. productive sputum. acute or persistent o Pertussis  Paroxysms of barking. haemoptysis o Pulmonary oedema  Worse lying down  ASx . nonpurulent nasal discharge. sinus congestion. painful cough  Post-tussive vomiting.Nasal/sinus congestion.Foul. productive sputum (usually). haemoptysis o COPD (Chronic Bronchitis/Emphysema)  CB . dark coloured sputum  Diurnal variation (worse in morning)  ASx . malaise. dusts. dusts.cough. acute onset Airway disease o URTI (incl. highly productive  Foul-smelling.pink. worse at night o Drugs e. hoarseness. SVC syndrome (face/upper oedema.cold. pulmonary fibrosis. supine/slouching  Foreign body  Children.RESPIRATORY MEDICINE Cough   4 Airway irritants o Inhaled smoke. worse at night  Triggers . dyspnoea (often exertional)  Strong smoking hx  Worse in morning o Asthma  Intermittent. painful o Acute/chronic bronchitis o Bronchiectasis  Chronic. inspiratory whooping sound  Local area of increased prevalence? o Croup  Barking. URTI  FHx .asthma. exercise.wheezing. RESPIRATORY MEDICINE 5 Richard Shaw . chest pain. dyslipidaemia.fever. SVC syndrome (face/upper oedema.high fever/night sweats.cough dyspnoea. distended veins) o Bronchiectasis  Large amounts of sputum with blood  Chronic. epistaxis. dyspnoea.cough. orthopnoea. anorexia. weight loss. liver disease. orthopaedic procedures. tobacco use  ASx .chest pressure/pain  Acute triggers . wheeze o Foreign Body  Hx of inhalation  ASx . weight loss o Drugs/Toxins  Anticoagulant drugs etc  Toxins (smoke. cannabis. oedema. endobronchial carcinoid tumour. nausea.tobacco smoke. age 20-30 or 60-70  White.dyspnoea. blood loss. fever. malaise. PND. palpitations. PE Hx.RESPIRATORY MEDICINE Haemoptysis       6 Coughing up of blood. ↓ urine output Vascular Disease o Pulmonary Embolism  Hx of immobilisaton. chest discomfort.echocardiogram → cardiovascular causes Imaging o Chest X-Ray → Cancer. mixed with sputum and immediately after couhing Differentiated from haematemesis which follows nausea and is mixed with vomitus or after dry wretching. joint ache o Pulmonary Infarction  ASx . syncope (massive PE). DM. worse in morning  ASx . hoarseness. tachycardia o ↑Pulmonary Venous Pressure  Acute LVF  Hx of HTN. dyspnoea. trace metals. COCP. dyspnoea. solvents) o Rupture of mucosal blood vessel after vigorous coughing Massive Haemoptysis  Carcinoma  Cystic Fibrosis  Bronchiectasis  Tuberculosis  Chronic Lung Abscess o Investigations       FBC o Infection. weight loss.  Coagulopathy  liver disease.hoarseness. dark coloured sputum  Diurnal variation (worse in morning)  ASx . purulent sputum o Goodpasture's Syndrome  Males. travel  ASx . hx of smoking    Richard Shaw ASx .pleuritic chest pain. TB. dyspnoea o Cystic Fibrosis  Hx of recurrent infections o Lung Abscess*  ASx . palpitations. Mild haemoptysis → 15-30 mL in 24 hrs Massive haemoptysis → >250mL in 24hrs Airway Disease o Acute/Chronic Bronchitis  Small amounts of blood with sputum  CB . saddle-nose deformity  ASx . productive sputum. rhinorrhoea. fever. haematological disease Coagulation studies → coagulopathies ABGs U/A → pulmonary-renal syndrome ECG +/.Pleuritic pain. lung metastases)  Frank blood in sputum  Smoking hx  ASx .dyspnoea. productive sputum (usually). fatigue  Severe mitral stenosis  Hx of recurrent respiratory infection during childhood (rheumatic heart disease)  ASx . ammonia.productive cough. productive cough. air pollutants. dyspnoea (often exertional)  Strong smoking hx. anorexia.cough. fever +/. malaise. renal failure hx  Disseminated Intravascular Coagulation Wegener's granulomatosis  Hx of sinusitis. palpitations Other o Haematological Disease  Thrombocytopoenia  Hx of HIV. fatigue.cough. various infectious agents o Carcinoma* (primary ca.night sweats. weight loss. chest pain. bronchiectasis etc o Chest CT with contrast → ↑ sensitivity o Bronchoscopy . stridor Parenchymal Disease o Pneumonia  Recent onset of symptoms  ASx . cyanosis. haemoptysis. pleuritic chest pain o Tuberculosis  Travel hx to TB endemic areas  Immunosuppressed status (HIV/AIDS)  ASx -cough. highly productive cough  Foul-smelling. PE. IE Pulse (normal → 60-100) (rate. Pancoast  Upper lobe atelectasis infiltration of T1 lower trunk nerve  Upper lobe fibrosis root) Test abduction power if suspected  Pneumonectomy  Wrists  Away from side of lesion (uncommon) o Asterixis (hold for ~30s)  Massive pleural effusion  Hypercapnia (e. orientated Respiratory Distress/↑Work of Breathing/Dyspnoea o Obvious tachypnoea o Accessory muscle use  SCM. Miosis. from COPD)  Tension pneumothorax Palpation o Tracheal tug (thyroid cartilage ↓ movement) 7 . pneumonia) o Engorged turbinates → allergic conditions  Cyanotic heart disease and cold temp. pneumothorax. o Septum deviation → nasal obstruction o Clubbing  Mouth  Lung carcinoma o Central cyanosis (tongue)  Chronic pulmonary suppuration  V/Q imbalance (COPD. nebulisers. Anhydrosis. pneumonia o Palmar erythema Neck  Hypercapnia Inspection o Palmar crease pallor  Trachea  Anaemia o Displaced trachea o Muscle wasting  Towards side of lesion  Peripheral lung tumour (e. drugs (asthma corticosteroids). CHF Surrounding features o O2 masks. inhalers o Sputum cup → look inside/describe contents Stridor o Sudden: anaphylaxis.pus (white)  Empyema  URTI  HPOA.  Bronchiectasis pneumonia). congenital heart disease.g. character) o Tachycardia  Asthma (B-agonist SE)  + pulsus parodoxus → severe asthma  Accompanies dyspnoea or hypoxia o Bounding Pulse → CO2 retention o Pulse characters → see cardiovascular notes Respiratory Rate (normal → 12-20) (measure for 30s) Arm Blood Pressure  Pulsus parodoxus (↓BP by > 10mmHg on inspiration) o Severe asthma Face Inspection  Eyes o Partial Ptosis. foreign body o Gradual: laryngeal. strap neck muscles o Tripod positioning o Pursing of the lips o Tracheal tug o COPD. cyanotic heart disease  Lung Abscess o Pharyngeal/tonsillar erythema +/. soft palate pleural mesothelioma/fibroma  Sleep apnea o Tar staining o Dental hygiene/tooth decay  Palms  Lung abscess. idiopathic pulmonary fibrosis o Velopharyngeal lumen obstruction  CF. alert. rhythm. tongue. vocal cord palsy Hoarseness o Laryngitis. epiglottitis. pleural effusion. pharyngeal. pulmonary embolism. Platysma. TB. PE. asbestosis.g. asthma.RESPIRATORY MEDICINE Richard Shaw Examination   Patient undressed to waist (women can have gown or other to cover anterior chest when not being examined) Patient sitting on the edge of the bed or in a chair is ideal General Observation     Well at rest. Enopthalmos  Horner's syndrome → Pancoast tumor o Conjunctival pallor   Anaemia Fundoscopy for hypertensive changes (Keith-Wegerer)  Sinuses o Palpate frontal and maxillary sinuses Hands  Tenderness → sinusitis (consider transillumination) Inspection  Nose (patient head tilted back and use torch)  Fingers o Polyps → associated with asthma o Peripheral cyanosis  V/Q imbalance (COPD. lung carcinoma (recurrent laryngeal nerve palsy)    Wrist swelling and tenderness o HPOA → lung carcinoma. laryngeal carcinoma. tracheal tumours.  Tonsils. pneumonia. fibrosing alveolitis. severe coughing  Axillary Lymph Nodes o Tumour metastases. middle lobe otherwise missed). use (if dyspnoea evident). emphysema o Pectus carinatum  Chronic childhood respiratory illness. infection Percussion  The patient’s arms should be folded in front when examining the posterior chest (anterior scapula rotation)  Don't forget supraclavicular fossae (lung apices). move in an S  Percuss to just below nipple anteriorly o o o REVIEW LUNG SURFACE ANATOMY Dull (solid) o Consolidation (pneumonia) o Atelectasis o Solid structures (e. infection Palpation  Chest Expansion (grip firmly. chest drains o Surgery → pneumonectomy. lobectomy. palpate for scalenus m. thumbs off chest) 8 Richard Shaw Upper and lower on the back and once on front Normal chest expansion >5cm Hoover's sign (thumbs at xiphisternum)  +ve → thumbs (ribs) move inwards  COPD  Ribs (should be done during chest expansion) o Compress chest anteroposteriorly and laterally o Localised pain → rib fracture  Trauma. skin thickening  Small tattoo markings  Subcutaneous emphysema o Pneumothorax. interstitial lung disease o Unilateral ↓ movements  Pleuritic chest pain. superiorly) o Less movements on affected side o Bilateral ↓ movements  COPD. rib fracture o Costal in-drawing  ↑ WOB o Parodoxical inspiratory abdominal in-drawing  Diaphragmatic paralysis Move posteriorly to finish inspection (WARN THE PATIENT)  Cervical Lymph Nodes o Ideally palpate all 8 groups → supraclavicular nodes most important o Lung /chest carcinoma spread. posteriorly. liver)  Stony Dull (fluid) o Pleural effusion  Hyperresonant o Pneumothorax o Emphysema o Bowel  Liver and Cardiac Dullness o Chest resonance below 5th rib in R.9)  Severe asthma. in supraclavicular fossae Forced Expiratory Time  Time taken for patient to completely exhale forcefully (x3)  Time by auscultating over trachea o Normal <3s → ↑time in obstruction → COPD Cough Test  Assess character of cough o Bovine  Vocal cord paralysis o Muffled.RESPIRATORY MEDICINE  Respiratory distress/COPD Confirm accessory m. 'ports' o Radiotherapy marks →  Erythema. pneumomediastinum  Prominent veins (determine direction of flow) o SVC obstruction  Chest wall movements (anteriorly. tumour deposition. MCL o ↓ area of cardiac dullness on left side of chest  Hyperinflation  Emphysema or asthma Auscultation (diaphragm + bell in supraclavicular fossae)  Patient breathing comfortably through the mouth  Listen through full cycle of inspiration/expiration  . clavicle and sides (R. bone disease. oesophageal rupture. rickets o Pectus excavatum  Causing ↓ lung capacity o Kyphoscoliosis  Causing ↓ lung capacity and ↑WOB  Scars (look under axilla too) o Trauma. wheezy. ineffective  COPD o Loose Productive  Chronic bronchitis  Pneumonia  Bronchiectasis o Chest Inspection  Chest wall deformity and asymmetry o Barrel-chest (↑AP:Lat → thoracic ratio is > 0.g. spontaneous pneumothorax. Pneumothorax o Pleural effusion. o Vocal resonance was symmetrical across all sleep apnoea. can use torch for tangent light o Chest expansion was normal at X cm o JVP vs Carotid Pulse (TnO p58) . Y. severe kyphoscoliosis lung fields. my provisional diagnosis o Ipsilateral displacement is X with differentials including X.6 reasons o Lung fields were resonant and symmetrical to o Elevated JVP (>3cm) percussion  RHF. cancer o Pleural Friction Rub  Pulmonary infarction. high-pitch = crepitations)  Fine Crackles  Pulmonary fibrosis (ILD)  Medium Crackles  LVF/pulmonary oedema (late inspiratory)  COPD (early inspiratory)  Coarse  Bronchiectasis  Others → infection. determine extent of involvement (what lobe and segments?) o ↑ resonance → consolidation o ↓ resonance → pleural effusion o Richard Shaw  Localised interstitial lung disease Contralateral displacement  Pleural effusion  Tension pneumothorax  Heave o RV heave at left sternal edge → RHF Abdomen  Palpate Liver o Ptosis → emphysema o Hepatomegaly → lung carcinoma metastases Back  Palpate for sacral oedema Legs  Inspect for peripheral cyanosis. tumour Added (Adventitious) Sounds o Wheeze (low pitch wheeze = rhonchi)  Asthma  COPD  Lung carcinoma (obstructing airway)  Foreign body o Crackles (low-pitch = rales.  Major findings were: o Most significant finding → second most  significant or findings related to most significant finding (positive and negative)  My other findings were: o No peripheral signs of X. swelling. pulmonary hypertension o Breath sounds were vesicular and of normal  Auscultation → loud P2 of pulmonary hypertension intensity in all lung fields with no adventitious  Cor pulmonale (pulmonary hypertensive heart disease) sounds o COPD. BP = Z and JVP was nonelevated at X cm. cervical or  Jugular Venous Pressure (vertical height to sternal angle) supraclavicular lymph nodes were palpable. X who is a X old male/female who presented with X. ILD. often gap between expiration/inspiration  Consolidation (lobar pneumonia) (above consolidation)  Pleural effusion (above the fluid)  Atelectasis  Tension pneumothorax Decreased Intensity o COPD (especially emphysema).  Lower lobe atelectasis 9 . Z. stridor and non-pulsatile JVP elevation o SVC obstruction Effusion Consolidation Percussion Note ↓ ↓ Vocal Resonance ↓ ↑ + harsher Atelectasis ↓ ↑ in pneumonia ↓ with tumour/mucus Pneumothorax ↑ ↓ Breath Sounds ↓ ↑ + harsher + higher pitch ↑ with pneumonia ↓ with tumour/mucus ↓ Respiratory Examination Summary  I performed a respiratory examination on Mr/Mrs. obesity. atelectasis. Y or any other respiratory disease on the hands. Cardiac (lie the patient down to 45°) o Trachea was midline and no axillary. Pneumonia o Neoplasm. pneumonia  Rare: pleural malignancy. Atelectasis o Unilateral/focal → foreign body. pulmonary thromboembolis. face or chest walls Other o RR = X and HR = Y. erythema  Palpate for peripheral oedema (15s)  Palpate for calf-tenderness and inspect other DVT signs Pemberton's sign  Arms up over head for 1 minute  +ve → development of facial plethora. o Patient looks left. pleurodynia Vocal Resonance o If localised abnormality is found. cyanosis.  Apex Beat (patient lying down)  Based on my current findings.RESPIRATORY MEDICINE     Don't forget axilla as well Quality o Normal breath sounds = vesicular o Bronchial breath sounds  Audible throughout expiration. Y. The investigations I would like to perform are X. Richard Shaw . Z (specifically looking for x.RESPIRATORY MEDICINE   10 Ideally I would also like to: o Anything up to vocal resonance that was not performed o Perform peak flow and forced expiratory time tests o Conduct a full cardiovascular examination specifically looking for evidence of pulmonary hypertension and cardiac failure o Conduct a full abdominal examination specifically looking for hepatomegaly and hepatic ptosis. y. z).