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Year 3 Clinical OSCE Skills CODE-BLUE-OSCE Teaching Acute Breathlessness Sarah Martin Oct 05, 2023Disclaimer • Code Blue OSCE Crew is a platform created by Manchester medical students, independently of the University of Manchester and Manchester Students’ Union • This teaching should not replace any formal teaching provided by the university - Any changes to CCAs would be communicated by your university, follow their guidance • Content is generated by students with input from senior doctorsIn Partnership with Enrolled activity under the International Federation of Medical Students’ Association (IFMSA) T eaching Medical Skills programme. In Partnership with Comprehensive, accessible OSCE resources, notes, videos and OSCE stations for practice. Use CODEBLUE23 at checkout on GeekyMedics.com for 20% their paid resources **not an affiliate code** Session Structure 4 2 1 Common Group differentials 3 practice Acute SoB Hx Respiratory Breakout rooms exam for 1 hour of CCA practiceLearning Objectives ● Recall the steps of a respiratory-focused history and exam ● Recall common differentials for acute breathlessness and their common findings on examination ● Understand and apply how to present a history and exam to a CCA examinerVery Quick Quiz!Question 1Question 2 Question 3 What are some respiratory causes of finger clubbing?Acute Breathlessness History Tutor: Sarah MartinIntroduction Tutor: Sarah MartinIntroduction ● Remember non-verbal communication ● Will take up to 30 seconds – REHERSE! - CHECK DET AILS - “Hello, my name is _____ and I’m a 3rd year medical student at the University of Manchester, could I just confirm your full name and date of birth please?” “What do you like to be called?” **REMEMBER THEIR AGE FOR PRESENT ATION TO EXAMINER** CONSENT – “Would it be okay if I …” CHAPERONE – “ Are you happy for the examiner to act as a chaperone today?” Tutor: Sarah MartinPresenting Complaint ● OPEN QUESTION – “So [name], what brings you in today?” ● EXPLORE – “Could you tell me more about your breathlessness?” ● Patient will cover most of SOCRA TES here to save you time ● SOCRA TES usually for pain, can use for some aspects of any PC ● ICE – Does not have to be done now but must be done at some point ● Do you have any ideas as to what might be going on? ● Is there anything you’re particularly concerned about? ● Is there anything in particular you’re hoping to get from this appointment today? Tutor: Sarah MartinSOCRA TES ● CLASSIC PRESENT ATIONS ● ACS (MI/Angina) ● Crushing, central CP, 10/10 radiating down L arm, nausea, vomiting, sudden? (MI) ?exertional (stable angina), ?at rest (unstable angina) ● PE ● Sudden SOB, pleuritic CP , hemoptysis, swollen/painful leg ● Also know presentations for: ● AF, asthma, COPD, pneumothorax, anemia, CF , TB, viral URTI, pneumonia, anaphylaxis, CHF Tutor: Sarah MartinRespiratory Systems Review Further Qs Conditions How long? Any mucus? How much? What colour? Infective: Pneumonia, URTI (viral), bronchitis (acute Blood? or chronic), TB Cardiovascular: HF, PE Anyone else coughing? Fever? Inflammatory: GORD, asthma, COPD, bronchiectasis, Cough sarcoidosis New medications? New environmental triggers? Drugs: ACEi Malignancy When does it come on? Lying down? After eating? Sudden onset or all the time? Worse at night? Asthma, COPD, inducible laryngeal obstruction Expiratory or inspiratory? Wheeze Check what they mean by wheeze! People use it to describe all kinds of sounds. Recent travel? Surgery? Mobility? Unilateral? Pulmonary embolism (from DVT) Leg swelling/pain Tutor: Sarah MartinSYSTEMS REVIEW You don’t always have to review EVERY system, in an OSCE do the RELEVANT ones - e.g. cardiovascular , respiratory, psychosocial -Think about what can cause shortness of breath -Think about the patient in front of you -Always do constitutional/general systems review - headache, fever , unintentional weight loss, fatigue, loss of appetite -If they say YES to any other symptoms, EXPLORE that further in the same way - SOCRA TES Tutor: Sarah MartinRed Flag Symptoms Do NOT forget to ask these!! - they are key Sx that point towards a significant diagnosis / will help you rule them out ● Chest pain – MI? Angina? Pericarditis? ● Hemoptysis - lung cancer? PE? Tuberculosis? ● Weight loss, night sweats, fatigue - cancer? Always ask this!! ● Unilateral swollen leg – PE from DVT ● Signs of sepsis (unlikely in CCA) Tutor: Sarah MartinPast Medical History Always ask with intention, not just to tick a box - WHY are you asking? What are you trying to rule out/in? Risk factors? PMH - any other medical conditions? Asthma/COPD? HTN? Diabetes? Cancer? Exacerbation, ACS, PE, pneumothorax If yes - how many admissions a year? What Mx was involved? Chest drain? Previous ITU admissions? Previous need for NIV/CPAP? Recent/past surgery? PE, infection DH - Currently on any medication, inhalers? Nebulisers? Oxygen? Oral contraceptive pill? PE If yes - check compliance, inhaler technique etc. Any allergies? Anaphylaxis FH - Any conditions that run in the family? Heart disease? Atopy? lung cancer? Specifically ask these. Tutor: Sarah MartinSocial History SH can be VERY important in a respiratory focused-history. ● Do you smoke? Have you EVER smoked? For how long/how long ago? ○ Pack years = [(#cigarettes per day)/20] x years smoking ○ COPD / asthma / lung cancer / coronary heart disease • General SH - alcohol? What was/is your job? (this is more relevant with CHRONIC breathlessness) ○ Any asbestos exposure? Mesothelioma ○ Exposure to allergens? Respiratory irritants? Work with clay? ● Do you have pets? Birds? Allergic pneumonitis ● Are you independent at home? Can you climb the stairs? Exertional dyspnoea? Heart failure, COPD ● Recent travel? PE, tuberculosis Tutor: Sarah MartinClosing Thank you so much for sharing that with me. T o SUMMARISE, you said … Rapport is important here! You could also do ICE here. Any questions for me?” The examiner will ask you questions - probably “What are your differential diagnoses?” - Try to give at least 3, say why more/less likely - Organise by system You could be shown some data to interpret after - e.g. CXR, ABG, lung function tests (join next week for these!!), Bloods - and then asked your differentials Tutor: Sarah MartinCommon Differentials Associated Sx Hints in Hx (ask about it) New job as a baker, hairdresser - occupational asthma Asthma Wheezing, nocturnal cough Triggered by cold air, exercise, allergy, dust, pollen exacerbation Younger patient - Hx of atopy (eczema, hay fever, allergic rhinitis) Pulmonary Haemoptysis, tachypnoea and tachycardia, PMH cancer, recent surgery, long travel, immobility, pregnancy, embolism leg swelling, pleuritic chest pain clotting disorders Sudden, severe and crushing central chest pain / Sympathetic responses (nausea, Heavy smoker, no exercise, poor diet, sedentary lifestyle or job Acute coronary vomiting, sweating) Family history of heart disease / ACS syndrome Diabetes, hypertension, peripheral arterial disease Also could be acute pulmonary oedema Diabetic/elderly - could be silent!!! I.e. atypical presentation linked to this - frothy pink sputum Tension Sudden pleuritic pain PMH lung disease, Marfan’s syndrome, recent chest trauma, young pneumothorax tall/slim males SOB on exertion/lying down (orthopnea), PMH: HTN, coronary artery dsiease/valvular heart disease Medications that worsen: calcium antagonists, anti arrhythmics, Heart Failure pedal oedma, nocturnal cough (+/- cytotoxic meds, beta-blocks (in acute phase) hemoptysis - “pink frothy sputum”), Fhx close relatives w cardiomyopathy/coronary artery disease arrhythmia, pre-syncope,syncope Social: smoking, alcohol, recreational drugs Tutor: Sarah MartinPresenting in a CCA ‘In summary, [NAME] is a [AGE and SEX} with [BACKGROUND PMH] who presented with [Acute breathlessness + any other key symptoms]. They are currently [stable] but did have [findings] on examination. My impression is that this is [your main differential] because [give reasons why], but another differential is [----] because [------]. ‘ -When presenting on the wards, you would give more detail, running through PC, HPC, PMH, including important negative and positive findings on systems review , PMH, DH, FH, SH - and also examination findings if you did an exam. Tutor: Sarah Martin Other tips ● The common things are common!! ○ ‘If you hear hoofbeats, think horses not zebras’ ○ Do NOT miss out the common causes of symptoms in your DDx ○ MSK pain, anxiety, viral infections • Think about the overall picture - is it likely a 20 year old non-smoker with hemoptysis has lung cancer? Think about differentials outside station ● Aim to cover ALL aspects of history, but focus on where is most relevant ● Confidence is key - Don’t hesitate in giving your DDx and explanations Tutor: Sarah MartinRespiratory Exam Tutor: Sarah MartinGeneral Structure The actual bulky bit Introduction - WIPER QQ Nails Hands ● Wash hands Arms ● Introduce ● Tremor ● Permission ● Pulse and respiratory rate Face + Eyes + Mouth ● Exposure Neck ● Reposition - how many degrees? ● 4 things ● Q: Are you in any pain? Chest (IPPA) ● Front of chest ● Q: Are you comfortable? ● Back of chest Sacrum + Legs End of the bed general inspection Lymph nodes Tutor: Sarah MartinGeneral Structure Time is not in your favour!!! :( Do INSPECTION and PALPATION of Introduction The the FRONT of the chest, then jump to NailsPPA for BACK of chest - if you have - WIPER QQ Handsime at the end, go back to the front ● Wash hands Arms ● Introduce ● Tremor ● Pulse and respiratory rate ● Permission ● Exposure Face + Eyes + Mouth Neck ● Reposition - how many degrees? ● 4 things ● Q: Are you in any pain? Chest (IPPA) ● Q: Are you comfortable? ● Front of chest ● Back of chest Sacrum + Legs End of the bed general inspection Lymph nodes Tutor: Sarah MartinTips before we start Examiners won’t know what you’re doing or thinking unless you say it out loud! ★ Say everything you’re doing out loud ★ Say what you see and what you don’t see (not “I’m looking for…”) ★ Say the reason you’re looking for a sign ★ Say your findings as you go (eg. ‘I can hear normal breath sounds throughout all the lung fields’) ★ During FOCUSED examination - say what you would see if the patient had that condition Tutor: Sarah Martin Introduction “Hello my name is […] and I’m a 3rd year medical student at the University of Manchester. Could I confirm your full name and DOB? Today I’d like to examine your lungs. Introduction (WIPER QQ) ● Wash hands If it’s okay with you, I’ll start by having a look at you generally. Then, would ask ● Introduce ● Permission you to undress from the waist up so that I can have closer look, feel and listen ● Exposure to your chest. I’ll talk you through it all as we go. And I’ll also be talking to the ● Reposition - how many examiner throughout. degrees? ● Q: Are you in any pain? ● Q: Are you I’ll just reposition the bed so that you’re lying at 45 degrees. comfortable? Are you in any pain? Are you comfortable to begin? Tutor: Sarah MartinGeneral Inspection Patient - Well/unwell Surrounding area - Normal/Increased/decreased body habitus -Drips - Not breathless/Breathless -Oxygen - Pursed lip breathing -Medication - Cyanosis - Cough -Sputum pot -Inhalers - Wheeze -Nebuliser box - Stridor -Cigarettes - Pallor - Oedema - Cachexia Tutor: Sarah MartinNails and Hands Don’t get caught up systemic signs! Important to get to the chest in a resp exam! Important things to mention: Temperature - Feel with back of hand - ”Warm and well perfused” Capillary Refill Time - Perfusion - Press for 5 seconds, return should be <2 seconds - “Capillary refill time is normal and under 2 seconds” Tutor: Sarah MartinIf present, mention it. - can suggest a cause of it now or in summary If not, “no nail changes such as…” (2 examples) Tutor: Sarah MartinKoilonychia Peripheral Cyanosis Clubbing Tar staining - Hypoxia - DO MANOEUVER - smoker - Spooning of nails - Iron def anemia - Hypoperfusion - ILD, Ca, bronchiectasis - NOT COPD!!!! Tutor: Sarah MartinArms and pulse/resp rate Tremor ● Flapping tremor (severe CO2 retention) ○ Arms straight out, wrists cocked back ○ Mention you would have them hold for 15 seconds ○Fine tremor (excessive use of beta 2 agonists) ○ Arms straight out, palms down ~ 10 seconds Radial pulse ● Feel and comment on rate/rhythm ● Offer to take for full 60 seconds Respiratory rate ● Comment, say you would count for full 60 seconds Tutor: Sarah MartinNeck 4 things 1. JVP ○ ‘Please turn your head to your left, I’m looking for a vein in your neck called the JVP’ ○ RHF , overload, massive PE, tension pneumothorax, cardiac tamponade, SVC obstruction ○ Indirect measure of central venous pressure - IJV connects to right atrium without valves Tutor: Sarah Martin Neck 1. JVP 2. Tracheal deviation - index and 4 finger on heads of clavicle, middle finger to palpate - WARN this will be uncomfortable 3. Tracheal tug -trachea pulled down on inspiration Towards side of lesion - Collapse (atelectasis) - Fibrosis 4. Cricosternal distance - Pneumonectomy - normal: about 3 of THEIR fingers Away from side of lesion - reduced with hyperinflation - Massive pleural effusion - Tension pneumothorax - Upper mediastinal mass Tutor: Sarah MartinFace, eyes, mouth Face ● Cushingoid features ● -long-term steroid use Eyes ● Conjunctival pallor -anemia ● Ptosis, miosis, enophthalmos (Horner’s syndrome) - Ca affected apex of lung - Pancoast tumour Mouth ● Central cyanosis ● Oral candidiasis – inhaled steroids Tutor: Sarah MartinIPP A – Front of Chest Inspection - Deformity - Barrel chest (hyperinflation) - pectus excavatum (developmental) - Scars - chest drain, thoracotomy - Intercostal drawing Palpation - Chest expansion th - Apex beat – MCL, 5 IC space - Parasternal heave – R vent. hypertrophy Tutor: Sarah MartinIPP A – Back of Chest “In the interest of time, I will move on to the back of the chest for percussion and auscultation. But will finish the front of the chest if there is time left at the end.” Get patient to wrap arms around themselves to move scapula out of the way. Percussion – practice! -Intercostal space - 4 x each side - 2 x each axilla - Compare side to side - If abnormality noted, map out Resonant = normal Hyper-resonant = air - pneumothorax/emphysema Dull = fluid Stony dull = pleural effusion (duller than dull! Similar to over thigh) Tutor: Sarah MartinIPP A – Back of Chest Auscultation “Please take deep breaths in and out through your mouth. Let me know if you get dizzy or want to stop.” - Same places as percussion - Normal – vesicular - Diminished – effusion, pneumothorax, pneumonia, poor resp effort - Bronchial (Darth Vader) – consolidation - Wheeze – polyphonic – asthma/COPD - Rub (footsteps in fresh snow) – pneumonia PE with infarction - Coarse crackles – pneumonia, bronchiectasis, oedema - Fine crackles – pulmonary fibrosis - Offer vocal resonance Tutor: Sarah Martin T o Finish… Sacrum + legs - Oedema OFFER: - Lymph node exam THANK patient PRESENT (PRACTICE THIS!!) Tutor: Sarah MartinClosing PRACTICE, PRACTICE, PRACTICE - ‘Today I performed a respiratory examination on Rachel who is a 44 year old female patient with acute breathlessness. There were no peripheral stigmata of respiratory disease. [OR present any findings]… Observations of pulse, perfusion and respiratory rate were [normal/abnormal]. Palpation, percussion, and auscultation were all normal [or summarise findings]. - In summary, this is a normal respiratory exam - OR… in summary, findings are in keeping with a diagnosis of ______________ - To complete my examination… - Full history, CV exam, any relevant other examinations - BEDSIDE: Set of observations including SATS, temp, BP , peak flow, ECG - LABS: bloods (FBC, U+E, CRP , BNP), ABG, sputum sample - IMAGING: CXR, CT , MRI - OTHER: spirometry (COPD/asthma) - Choose as appropriate, don’t need to mention everything! Tutor: Sarah MartinExamples of focused examinations Condition What you might see Pneumonia Temperature COPD Tachypnoea Respiratory rate Wheeze on auscultation Tachycardia Cyanosis Pursed lip breathing Dull percussion Barrel chest Auscultation: diminished, rub Peripheral cyanosis or coarse crackles, increased Cor pulmonale (oedema, heave) CO2 retention flap vocal resonance Tar staining Pneumothorax Unequal breath sounds Hyperresonance with Asthma Inhaler, spacer, PEFR meter percussion Cyanosis Decreased chest wall Cough, wheeze movement SOB Fine tremor Cyanosis Tachycardia Oral candidiasis (steroid inhaler) Tachycardia Expiratory wheeze **Infective endocarditis, not a resp condition but lots of signs including ones that would be elicited in resp exam including: SOB on exertion, cough Tutor: Sarah MartinExaminer Tips: Do NOT forget ICE No problem if you use a blank paper to write down you SOCRA TES or whatever mnemonic to keep organised and make sure you don’t miss anything Remain kind to the patient, smile and build rapport Make sure you cover the patient back after examination Memorise presentation lines Tutor: Sarah MartinResources ●Uni examinations booklet!! ●The easy guide to focused history taking for OSCEs ●https://mmsonemedlearn.s3.eu-west-1.amazonaws.com/wp-content/uploads /sites/9/2016/08/Clinical-History-taking-framework.pdf ●https://drive.google.com/file/d/1j5ffmlN8AcXs5dn68kaPBeNe0Bc_DGap/view ?fbclid=IwAR1Ao1nurXRvihQDPL-ihOrtgiHN3KGk7SbiTY_O7EigRqRG-ZqNO8oc LNU ●https://geekymedics.com/respiratory-history-taking/ ●https://geekymedics.com/respiratory-examination-2/ ●https://mmsonemedlearn.s3.eu-west-1.amazonaws.com/wp-content/uploads /sites/9/2016/08/Y3_Exam_V3.2.pdf ●https://oscestop.education/clinical-examination/respiratory-examination/ ●https://oscestop.education/history-taking/presenting-histories/Give us feedback to get the slides linktr.ee/codeblueteaching cbosceteaching@gmail.com IG: @codeblueteaching facebook.com/cbosceteaching Now for OSCE practice!