Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Respiratory examination DR AMY ROSS (FY2)OSCE EXAMINATION– hints and tips INSPECTION Finger clubbing – causes PALPATION PERCUSSION AUSCULTATION RevisionQexaminationgns specific to Respiratory Causes for finger clubbing, resp causes for raised JVP OSCE: hints and tips Technique for palpation and percussion Know what sounds to hear forOSCE CHECK LIST - https://geekymedics.com/wp-content/uploads/2020/09/OSCE-Checklist- Respiratory-Examination.pdfIntroduction 1. Wash hands 2. Introduce yourself to the patient 3. Confirm the patient’s name and date of birth. 4. Briefly explainwhat the examination will involve 5. Gain consent 6. Position the patient, usually patient sat up in bed 45 degree angle 7. Adequate exposure of patient’s chest. Important - ** ask patient if they are in any pain prior to examining END OF THE BED- INSPECTION -? Comfortable at rest -? Any inhalers at bedside -?Any oxygen?masks ?nasal specs ?venturi masks -?Sputum pot -?cigarette packet -? Use of accessory muscles ?pursed lips ?nasal flaring -?CPAP machine -?fluid balance sheet ?furosemide ?peripheral oedema ?sacral oedema -?cough ?wheeze ?stridor - ?cachexia -?able to speak full sentences ?age of patientINSPECTION- HANDS CO2 flap asterixis Fine tremor associated with salbutamol useWhat are causes of finger clubbing?Finger clubbing to back.patient to place the nails of their index fingers back Normally small diamond-shaped window (known as Schamroth’s window) visible à lost in clubbing uniform soft tissue swelling of the terminalphalanx of a digit loss of the normal angle between the nail and the nail bed Respiratory causes: lungcancer, interstitial lung disease, cystic fibrosis and bronchiectasis.Temperature – cool or warm peripheries Heart Rate – rate and rhythm ?bounding pulse Respiratory Rate ?Raised JVP/Hepatojugular reflex à raised JVP à venous hypertension Pulmonary hypertension (causes right-sided heart failure) occurring during COPD or interstitial lung disease (e.g. congestive heart failure, tricuspid regurgitation and constrictive pericarditis). Inspection– FACE Ptosis, miosis and enophthalmos:all features of Horner’s syndrome (anhydrosis is another important sign) Horner’s syndrome à sympathetic trunk is damaged by pathology e.g Pancoast tumour Inspection– CHEST Median sternotomyscar - midline of the thorax à valve replacement and coronary artery bypass grafts (CABG). Axillary thoracotomy scar - chest drains. Posterolateral thoracotomscar - lobectomy, pneumonectomy and oesophageal surgery. Asymmetry - associated with pneumonectomy (e.g. lung cancer) asthma + COPDn (barrel chest) - Associated withTracheal positionHow do you measure cricosternal distance? What doesitmean?PALPATION Palpate for apex b–at Right ventricular hypertrophy (e.g. pulmonary hypertension, COPD, interstitial lung disease) Large pleural effusion Tension pneumothorax Assess for chest expansionPERCUSSSION+ VOCALFREMITUS Increased volumesuggests increased tissue density (e.g. consolidation, tumour, lobar Resonantnormal finding collapse). Decreased volumesuggests the presence of fluid or air Dullness cardiac dullness, consolidation, tumour, lobar collapse outside of the lung (e.g. pleural effusion, pneumothorax). Stony dullness typically caused by an underlying pleural effusion. Hyper-resonance. the opposite of dullness, suggestive of decreased tissue density (e.g. pneumothorax). Wheeze: a continuous, Bronchial: harsh-sounding inspiration and expiration Quiet breath coarse, whistling sound sounds: suggest reduced air produced in the are equal and there is a entry into region of the respiratoryairways during pause between. This type of lung (e.g pleural effusion, breathing. Associated with breath sound is associated pneumothorax). asthma, COPD and with consolidation. bronchiectasis. AUSCULT ATION Coarse Stridor: high-pitched extra- crackles: discontinuous, thoracic breath soundresulting brief, popping lung sounds from turbulent airflow through Fine end-inspiratory narrowed upper airways. associated with pneumonia, crackles: sounds similar to bronchiectasis and the noise generated when pulmonary oedema. separating velcro. Associated Several causes e.g. foreign with pulmonary fibrosis. body inhalation (acute) and subglottic stenosis (chronic).Furtherinvestigations Observations Sputum Sample Peak Flow Meter CXR ABGGENERALPASTPAPEQ1. A 67-year-old man presents to his GP with an 8-week cough and 7kg of unintentional weight loss. He has a 35 pack-year smoking history. He has noticed some changes with his right eye, which the GP recognises as Horner's syndrome. He is referred on the suspected cancer pathway and is diagnosed with a Pancoast tumour. What sign is this man most likely to have? A. Anhidrosis B Exophthalmos C Hypopyon D Mydriasis E SynechiaeAnswer A 2. A 38-year-old man presents with a 1-week history of blurring of vision involving both eyes. He also complains of visual floaters and blind spots. He had tested positive for human immunodeficiency virus (HIV) a few years ago and his latest CD4 count is 20 cells/mm³. Fundoscopy revealed findings consistent with retinitis. Which of the following is the most likely causative organism? A Cryptosporidium B Cytomegalovirus C Aspergillius fumigatus D Epstein-Barr Virus E Pneumocystis jiroveciiAnswer B3. A 32-year-old woman presents with an episode of haemoptysis and is found to have metastatic tumour present within the parenchyma of the lungs. This is biopsied and subsequent histology shows clear cells. What is the most likely primary site? A Kidney B Breast C Liver D Adrenal E BoneAnswer A4. 86-years-old man with a past medical history of interstitial lung disease presents with fever, productive cough and dyspnoea. His inflammatory markers are raisedand a chest x-ray shows focal patchy consolidation in the right lung. His oxygen saturation level is 87% on room air and required oxygen supplementation. Which of the following causes a decrease in affinity to oxygen by haemoglobin? A Increase in temperature B Decrease in carbon dioxide C Increase in pH D Decrease in temperature E Decrease in 2,3-bisphosphoglycerateShifts to Left = Lower oxygen delivery Shifts to Right = Raised oxygendelivery HbF, methaemoglobin, carboxyhaemoglobin Raised [H+] (acidic) Low [H+] (alkali) Low pCO2 Raised pCO2 Low 2,3-DPG Raised 2,3-DPG* Low temperature Raised temperature Answer A. The oxygen dissociation curve à describes the relationship between the percentage of saturated haemoglobin and partial pressure of oxygen in the blood. It is not affected by haemoglobin concentration5. A 65-year-old woman attends her GP with a 4-month history of weight loss, fatigue and upper abdominal pain. On examination, a mass is felt in the epigastric region. The doctor suspects gastric cancer and refers the patient for an endoscopy during which a biopsy is taken from the stomach. The presence of which cell would confirm the suspected diagnosis? A. Chief B Megaloblast C Merkel D Mucous E Signet ringAnswer E Presenting with gastric adenocarcinoma. The presence of signet ring cells on biopsy is a concerning feature and suggestive of an aggressive type of adenocarcinoma. Chief cells are a normal part of the gastric epithelium and so would not be a sign of pathology It would not be expected megaloblast cells on a gastric biopsy, as these are abnormally large red blood cells that can occur for a variety of reasons, including leukaemia. Merkel cells are benign cells found in the skin and are responsible for communicating the sensation of touch to the rest of the nervous system. Mucous cells are part of the ordinary gastric lining and are responsible for secreting mucus.6. A 49-year-old man is involved in a road traffic accident and is subsequently placed on a neuro -rehabilitation ward to help with his recovery. His cranial nerve (CN) examination is as follows: CN I: demonstrates anosmia with the scents used for this test (orange and coffee). CN II: pupils are equal and reactive to light. Snellen chart examination is 6/6 bilaterally. No visual field deficits found o n direct confrontation. No colour blindness is detected. CN III, IV and VI: no diplopia, nystagmus or gaze palsy detected. CN V: facial sensation is intact. Muscles of mastication are functioning and a jaw jerk reflex is present. CN VII: facial movement is intact. CN IX and X: no deviation of uvula detected.ing loss detected. CN XI: neck rotation and shrugging movements are intact. CN XII: no tongue muscle wastingor reduced power detected. When asking questions during this he understands and responds appropriately, however responds with poor grammar and long pauses between words. Which brain region is most likely to be damaged? A Cerebellum B Frontal lobe C Occipital lobe D Parietal lobe E Temporal lobeFrontal lobe is the correct answer, due to the characteristic anosmia and Broca’s (expressive) dysphasia described in this case. Other symptoms of frontal lobe damage include changes in personality and motor deficits on one or both sides of the body. Temporal lobe is incorrect as damage to this region may cause the following: a change in behavior and emotions, forgetfulness, disruption in the sense of smell, taste, and hearing, language and speech disorders, including Wernicke’s (receptive) dysphasia or homonymous superior quadrantanopia. Answer B7. You are asked to review an 81-year-old woman who was admitted to the surgical ward with diverticulitis. The nurses have called you as she is pyrexial, tachypnoeicand tachycardic. She is now on day three of intravenous antibiotics. As part of the work-up you order a chest x-ray: Wh at does the x-ray show? What does the x-ray show? A Pneumoperitoneum B Iatrogenic fluid overload C Lung cancer D Hospital acquired pneumonia E Septic arthritis of right humeral head © Image used on license from RadiopaediaAnswer A8. A 20 year old female presents to the Emergency Department after being hit in the back of the head with a squash racket. She is complaining of a headache and has a laceration to her occiput. Her eyes are open spontaneously, she is able to obey commands and is able to give you an accurate account of what happened. What is her Glasgow coma scale (GCS)? A 10 B 11 C 12 D 14 E 159. A 25-year-old lady, who was diagnosed with eczema and asthma in childhood, attends her annual asthma review. Over the past 3 months, she has frequently required her salbutamol reliever. She is worried that the deterioration in asthma control coincides with the adoption of a kitten. In the pathophysiology of allergic asthma which cell is found in inappropriately increased numbers? A Mast cells B Eosinophils C Dendritic cells D Macrophages E Neutrophils Answer B Increased numbers of circulating eosinophils have been demonstrated in the airways of allergic asthma sufferers. Eosinophil numbers correlate with the severity of asthma and they form a key part of the long-term airway inflammation process by promoting injury, obstruction, and hyperresponsiveness. Mast cell degranulation is responsible for the immediate asthma symptoms following provocation.8. A 76-year-old man presented to his GP complaining of a 6-week history of worsening shortness of breath, dry cough, and fatigue. Upon further questioning, the patient reveals he now has to stop multiple times on his daily walk to the shops to catch his breath and has been sleeping with another pillow at night to help with his is currently prescribed ramipril, amlodipine and atorvastatin.ion and has a 30 pack-year smoking history. He On examination the GP notes end-inspiratory crackles at both lung bases. Oxygen saturation is measured at 94% on room air, his pulse is 110 /min and regular and his respiratory rate is 24 /min. What is the most likely underlying diagnosis? A. COPD B Chronic heart failure C Pulmonary embolism D Pulmonary fibrosis E anginaAnswer BThank you! Please complete feedback.. ?organisation=osce-prep-3rd-ing/feedback/anonymous year&keyword=4a7854ad6ced2946fa83956eReferences https://geekymedics.com/respiratoryexamination-2/ The OSCE REVISION GUIDE for Medical Students, Christopher Mansbridge https://slidetodoc.com/rspt-1085-module-f-lesson-4-a-initial/ PassMedicine.com