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RESPIRATORY EXAMINATION STATION OSCEazy Coco LiOverview Steps to a respiratory examination Small Cases Common CXR SPOT DIAGNOSIS On examination, the patient has finger clubbing, reduced chest Pulmonary fibrosis expansion and bilateral fine inspiratory crackles at the lung bases. Swan neck deformity and swollen PIP joints are noted as well. An RTC patient was admitted to the ED. On examination, the patient Tension pneumothorax is tachypnoeic and cyanotic, with tracheal deviated to the left side. The left hemithorax is hyperreesonant to percussion with absent breath sounds and reduced chest expansion. Patient is haemodynamically unstable. On examination, a patient has coarse crackles in both lung bases that Bronchiectasis alter when coughing. There is a sputum pot and a LAMA at the bedside. There is evidence of finger clubbing. On examination, a patient has reduced breath sounds over the right Pneumonectomy side of his back. There is a scar seen under his axilla. There is tracheal deviation to the right side and reduced chest expansion. GENERAL INSPECTION BEDSIDE Metered dose inhalers Peak flowmeter Numbers of pillow Sputum pots MART RegimeS BBrown: Steroidl Spacer device Cannula Haemoptysis Cigarettes Soft mist inhaler Dry powder Nebuliser inhaler INSPECTION PALPATION PERCUSSION AUSCULTATION GENERAL INSPECTION BEDSIDE – OXYGEN DELIVERY DEVICES NEWS Chart Oxygen Prescription Chart Oxygen Flowmeter Nasal Cannula Simple Face Mask Non-rebreather Venturi Mask Humidified Non Invasive Intubation + mask Oxygen Ventilation Ventilation 4L/ min 5-10L/ min 15L/ min 2-4L/min Moisturise the 24-30% O2 30-40% O2 70% O2 24% O2 airway Mild hypoxia Mild – mod hypoxia Acute hypoxia COPD (Blue venturi) INSPECTION PALPATION PERCUSSION AUSCULTATION GENERAL INSPECTION OBSERVE PATIENT FROM END OF BED PursedLipBreathing -anoverview| ScienceDirectTopics Pursed lip breathing Subcostal recession Nasal flaring Tripod position Ask patient to cough Tracheal tug & accessory muscle use INSPECTION PALPATION PERCUSSION AUSCULTATION GENERAL INSPECTION HANDS + OFFER BP MEASUREMENT A ABCESS BRONCHIECTASIS B Cystic fibrosis Tar stain Fine tremor Finger clubbing C CANCER (LUNG) (Beta blocker) (Schramroth sign) D RHEUMATOID DISEASE DON’T say COPD/ Asthma E EMPYEMA F PULMONARY FIBROSIS Peripheral Thenar muscle CO2 retention Palmar erythema cyanosis atrophy Asterixis INSPECTION PALPATION PERCUSSION AUSCULTATION GENERAL INSPECTION HEAD & NECK Central cyanosis Lupus pernio Oral candidiasis 1. 1. Position the patient at 45˚, turn head to the left 1. 2. Apply direct pressure to the liver 1. 3. In health individuals, the JVP should rise then fall 1. 4. Positive if the rise in JVP is Horner’s Syndrome Tracheal position Cervical sustained and ≥4cm tall Miosis + ptosis +anhidrosis lymphadenopathy INSPECTION PALPATION PERCUSSION AUSCULTATION GENERAL INSPECTION BACK & CHEST Pectus Pectus Scoliosis Barrel chest Chest drain site excavatum carinatum INSPECTION PALPATION PERCUSSION AUSCULTATION GENERAL INSPECTION CARDIOTHORACIC SCARS Midline sternotomy scar Anterolateral Bilateral thoracotomy Left subclavicular thoracotomy scar scar/ clamshell incision Posterolateral scar thoracotomy scar Open heart surgery Pacemaker insertion Lobectomy Lung transplantation Lobectomy, (CABG, ICD Pneumonectomy pneumonectomy, valve replacement) ILR Bullectomy Emergency bullectomy, Single lung transplant decompression for mitral valvuloplasty cardiac tamponade (less invasive than anterolateral) INSPECTION PALPATION PERCUSSION AUSCULTATION PALPATION CHEST EXPANSION Flattened chest → Hyperinflation in COPD Unilateral reduced movement → Pneumothorax, pleural effusion Comment on which side has a reduced chest expansion “Breathe all the way out and take a deep breath in” INSPECTION PALPATION PERCUSSION AUSCULTATION PERCUSSION FRONT OF CHEST HYPER-RESONANT RESONANT DULLNESS Compare Pneumothorax Normal Consolidation like for like COPD Pleural effusion Asthma Specific points: Axilla & supraclavicular areas: Lung apices (?Pancoast tumours) Below the scapulae: Fibrosis, effusions INSPECTION PALPATION PERCUSSION AUSCULTATION AUSCULTATION Breath though an open mouth Describe: Early inspiratory? Late inspiratory? Wheezes? INSPECTION PALPATION PERCUSSION AUSCULTATION AUSCULTATION VOCAL RESONANCE INCREASED DECREASED 99 Consolidation Pleural effusion Pneumothorax Tactile vocal fremitus → more reliable than percussion for detecting consolidation Voice Transmission Test → Whispering pectoriloquy – whispers are amplified in consolidations INSPECTION PALPATION PERCUSSION AUSCULTATION REPEAT FOR THE BACK INSPECTION CHEST EXPANSION PERCUSSION AUSCULTATION VOCAL RESONANCE CHEST EXPANSION PERCUSSION AUSCULTATION VOCAL RESONANCE PERIPHERAL LEGS No Cause (idiopathic) D Drugs Sulfonamides, amoxicillin Pitting oedema Varicose veins O Oral contraceptives S Sarcoidosis U Ulcerative colitis & Crohn’s Disease Erythema nodosum M Microbes Streptococcal pharyngitis, Cellulitis DVT histoplasmosis CHEST EXPANSION PERCUSSION AUSCULTATION VOCAL RESONANCE TRACHEAL VOCAL POSITION PERCUSSION RESONANCE BREATH SOUNDS NORMAL CENTRAL RESONANT NORMAL VESICULAR PLEURAL DEVIATES AWAY STONY-DULL DECREASED REDUCED EFFUSION IF SIGNIFICANT on affected sidon affected side over effusion PNEUMONIA DULL INCREASED COARSE (CONSOLIDATION) CENTRAL over consolidatover consolidationCRACKLES TENSION AWAY FROM HYPER RESONANT DECREASED REDUCED/ PNEUMOTHORAX LUNG LESION on affected sidon affected side ABSENT POLYPHONIC COPD CENTRAL HYPER RESONANT DECREASED WHEEZE PULMONARY TOWARDS IF REDUCED/ DULL VARIABLE FIBROSIS SIGNIFICANT FINE CRACKLES LOBECTOMY/ TOWARDS DULL DECREASED REDUCED LUNG COLLAPSE LUNG LESION over lobectomy over lobectomy over lobectomy WIPE GENERAL INSPECTION OXYGEN DELIVERY DEVICES (SURROUNDING) W Wash your hands + PPE Nasal cannulae 24-30% O2, 4L/min I Introduce your name + role Mobility aids Hudson mask 30-40% O2, 5-10L/min NEWS chart P Patient details ECG Non-rebreather Critically unwell Pt. Drug chart mask 70% O2, 15L.min E Explain the process Fluid balance Fill bag by closing valve first Exposed from waist up Inhalers Venturi mask Flow rate: 24%/ 28%/ Spacer device Nebuliser 35%/ 40%/ 60% Offer chaperone Pillows COPD/ Type 2 resp Ask if they are in any pain Gastrostomy + Creon -> ?CF failure: 24% FiO2 HEAD & NECK HANDS GENERAL INSPECTION JVP (PATIENT) Plethoric complexion (Polycythaemia) Tar staining Conjunctival pallor Finger clubbing 1. Stance – Tripod position, cachexia Horner’s syndrome Peripheral cyanosis 2. Breathing: Distress, hoarse voice, Oral candidiasis Palmar erythema Cervical lymphadenopathy Thenar muscle atrophy wheeze, stridor, pursed lips 3. Ask them to cough: Dysphonia, Cricosternal distance Asterixis “bovine cough”, airway Tracheal position Fine tremor (Beta agonist use) obstruction, dry/ wet cough Joint deformity (RA associated with 4. Respiratory rate pulmonary fibrosis) 5. Cyanosis (peripheral and central) Measure HR, RR, CRT Blue bloater – Chronic bronchitis Offer to measure BP on both arms Pink puffer - Emphysema CHEST INSPECTION CHEST PALPATION CHEST PERCUSSION Asymmetry th Barrel chest Apex beat (5 IC space midclavicular) ”Like for like” Tactile Vocal Cardiothoracic surgery scars Chest expansion Fremitus “99” Deformity (Pectus excavatum/ carinatum • Midline sternotomy: CABG, valve replacement • Left subclavicular: Pacemaker, ICD • Anterolateral/ posterolateral thoracotomy: Lobectomy, pneumonectomy, bullectomy, lung transplant • Clamshell incision: Lung transplant LEGS BACK CHEST AUSCULTATION Pitting oedema Deep Vein Thrombosis Repeat the steps: Inspection > Palpation > Note on: Varicose veins Wheeze, stridor Cellulitis Percussion > Auscultation Crackles (Fine + Erythema nodosum coarse) Areas of dullness Check for sacral oedema Deep breaths in and out Thank the pt. + Get dressed + PPE Listen with diaphragm SMALL CASES COMMON PRESENTATIONS SHORTNESS OF BREATH CHEST PAIN COUGH HAEMOPTYSIS Note: We have covered asthma, COPD, PE and lung cancer at the respiratory history sessionCANDIDATE INSTRUCTION EXAMINATION FINDINGS Role FY1 Setting Emergency department Inspection: Mild respiratory distress, nil cyanosis Patient Simon Banks is a 21 y/o male presenting to the ED with acute Palpation: Slightly reduced left sided chest shortness of breath expansion. Reduced tactile vocal fremitus on the Student Perform a focused respiratory left side task examination on this patient. At 7 minutes, the examiner will Percussion: Hyperresonance on the left side stop you, ask you to summarise your findings and present a Auscultation: Markedly reduced breath sounds on differential diagnosis. the left side with no added lung sounds No tracheal deviation, signs of infection, peripheral oedema or signs of DVT Top differential diagnosis? .TENSION PNEUMOTHORAX Tracheal deviation AWAY from tension pneumothorax Lack of lung markings seen on the right lung field “Increased lucency of right lung field” Heart shifted to the CONTRAlateral side Spinal column appears more obvious as the heart is pushed to the side NO Symptomatic? (SoB, pleuritic chest pain) PNEUMOTHORAX YE S YE BTS 2023 Guideline High risk characteristics? S Safe to intervene? NO NO NO Safe to intervene? CT imaging and reassess YE YE HIGH RISK CHARACTERISTICS S Tension pneumothorax S Haemodynamically unstable What does the patient want? Significant hypoxia Bilateral pneumothorax Underlying lung disease 50+ age with significant Smoking history Haemopneumothorax Preference: Avoid procedure Preference: Rapid Preference: Rapid Chest drain in Symptom relief symptom relief safe triangle Axilla + Ambulatory TRIANGLE Conservative care device available Needle aspiration Daily review as in Anterior PSP: OPD r/v every in safe triangle patient border 2-4 days Ambulatory device of the OPD r/v every 2-3 Resolved: D/C + Remove drain Lateral latissimus SSP: R/V in patient days R/V in 2-4 weeks border of dorsi when resolved pectoralis Once stable – major If stable – follow up remove device + Not resolved: D/C + R/V in OPD In A line superior to the in OPD in 2-4 Chest drain 2-4 weeks horizontal level weeks OPD in 2-4 weeks of the nippleCANDIDATE INSTRUCTION EXAMINATION FINDINGS Role FY1 Setting General practice Inspection: Mild respiratory distress, finger Patient Ellen Parks, 74 y/o female, presents clubbing present, swan neck deformity and ulnar to the GP with persistent dry deviation noted. coughs and progressive shortness of breath Palpation: Reduced chest expansion bilaterally Student Perform a focused respiratory task examination on this patient. Percussion: Normal At 7 minutes, the examiner will stop you, ask you to summarise Auscultation: Bilateral fine inspiratory crackles your findings and present a differential diagnosis. (“Velcro-like”) at the lung bases. No wheeze No hyperresonance, signs of infection, raised JVP Top differential diagnosis? .PULMONARY FIBROSIS Common Presentation: Dry cough, SoB, fatigue Causes: Idiopathic, hypersensitivity pneumonitis, sarcoidosis, asbestosis, lung damage due to pneumonia/ TB, connective tissue disease (RA, SLE, Sjogren’s), medications (amiodarone, nitrofurantoin, bleomycin), radiation exposure Honeycombing, ground glass changes + Investigations: Bloods (FBC, U&E, LFT, CRP, RF, ANA, ANCA, Scl-70, serum traction bronchiectasis precipitin, serum ACE), Imaging (CXR, high resolution CT), Special tests (spirometry, bronchoscopy, lung biopsy) Management: Smoking cessation, long term O2 therapy, antifibrotic drugs (pirfenidone and nintedanib), referral for lung transplant Complications: Type 2 respiratory failure, increased risk of lung cancer, cor pulmonale, 50% mortality in 5 yearsCANDIDATE INSTRUCTION EXAMINATION FINDINGS Role FY1 Setting General practice Inspection: Appears unwell and flushed. Tachypnoeic Patient John Doe, 83 y/o male, presents to (RR 24), pyrexial (39˚c), Sats 93%, normotensive. Rusty the GP with fever and productive colour sputum noted on bedside cough Student Perform a focused respiratory Palpation: Reduced chest expansion on the left side task examination on this patient. At 7 minutes, the examiner will Percussion: Dull percussion over left lower zone stop you, ask you to summarise your findings and present a Auscultation: Increased vocal resonance and coarse differential diagnosis. crackles heard over the left lower zone No widespread wheeze or calf tenderness/ swelling Top differential diagnosis? .PNEUMONIA Presentation: Fever, malaise, productive cough, pleuritic chest pain Investigation: Bedside → Sputum MC&S, urinary legionella and pneumococcal antigens, ECG Bloods → Blood culture, ABG, FBC, CRP, U&E, LFTs, mycoplasma serology, HIV testing if recurrent pneumonia Imaging → CXR, CT chest if ?malignancy Management: Escalate for respiratory support if patient is severely unwell “Consolidation” is usually only used to Conservative → O2 if low sats, IV fluids if dehydrated, analgesia with fluid/ pus/ blood/ cells (pneumonia, Medical → Antibiotics (local microguide) pulmonary oedema, haemorrhage) PO Amoxicillin 500mg TDS for 5 days if CURB-65 <2 IV co-amoxiclav if severe pneumonia (CURB-65 >3) “Opacincreased density in the lungarea of Patients should be followed up with repeat CXR after 6-8 weeks to screen for underlying lung cancer Use right/ left andupper/middle/lower zone to describe the location ofconsolidationPNEUMOTHORAX PULMONARY EMBOLISM Tachypnoea Reduced vocal fremitus Tachycardia Clear chest Tachycardia Reduced tactile vocal fremitus Raised JVP Pleuritic chest pain Hypotension Absent breath sounds RV heave Haemoptysis Tracheal deviation Reduced chest expansion Loud P2 Severe → Pulselessness, Respiratory distress Split S2 persistent bradycardia Tahypnoea SHORTNESS OF BREATH PULMONARY FIBROSIS OTHER Oxygen therapy Cyanosis Bronchiectasis Sarcoidosis Dry cough Reduced expansion Pleural effusion TB Tachypnoea Fine end expiratory Lobar collapse Extrinsic allergic alveolitis Fatigue crepitations (Velcro like sound) Neuromuscular causesPNEUMONIA ASTHMA Pyrexial Low O2 sats Increased work of Oral candidiasis Malaise Reduced breath sounds breathing Polyphonic expiratory wheeze Rust colour sputum Bronchial breathing Cyanosis Reduced air entry Tachycardia Crepitations/ crackles Cough Reduced peak flow Hypotension Dullness on percussion (fluid) Audible wheeze Hyperinflated chest Confusion Increased vocal fremitus Fine tremor Hyper-resonance Tachypnoea Tachycardia SHORTNESS OF BREATH COPD Pink Puffer → Emphysema Accessory muscle use Tracheal tug (CO2 responsive causing Tar-stained fingers Subcostal recession compensatory hyperventilation) Tachypnoea Hyper-resonance Lip pursing Quiet breath sounds Blue Bloater → Chronic bronchitis Reduced cricosternal Prolonged expiratory phase (CO2 retention) distance (<3 fingers)PULMONARY EMBOLISM OTHER Tachycardia Clear chest Pleurisy Raised JVP Pleuritic chest pain Costochondritis RV heave Haemoptysis Pneumonia Loud P2 Severe → Pulselessness, Cardiac causes Split S2 persistent bradycardia Tahypnoea CHEST PAIN PNEUMOTHORAX Tachypnoea Reduced vocal fremitus Tachycardia Reduced tactile vocal fremitus Hypotension Absent breath sounds Tracheal deviation Reduced chest expansion Respiratory distressPNEUMONIA ASTHMA Pyrexial Low O2 sats Increased work of Oral candidiasis Malaise Reduced breath sounds breathing Polyphonic expiratory wheeze Rust colour sputum Bronchial breathing Cyanosis Reduced air entry Tachycardia Crepitations/ crackles Cough Reduced peak flow Hypotension Dullness on percussion (fluid) Audible wheeze Hyperinflated chest Confusion Increased vocal fremitus Fine tremor Hyper-resonance Tachypnoea Tachycardia COUGH COPD OTHER Accessory muscle use Tracheal tug Post nasal drip Tar-stained fingers Subcostal recession Smoking Tachypnoea Hyper-resonance Bronchiectasis Lip pursing Quiet breath sounds Interstitial lung disease Sarcoidosis Reduced cricosternal Prolonged expiratory phase distance (<3 fingers) TB Cystic fibrosisPNEUMONIA PULMONARY EMBOLISM Pyrexial Low O2 sats Tachycardia Clear chest Malaise Reduced breath sounds Raised JVP Pleuritic chest pain Rust colour sputum Bronchial breathing RV heave Haemoptysis Tachycardia Crepitations/ crackles Loud P2 Severe → Pulselessness, Hypotension Dullness on percussion (fluid) Split S2 persistent bradycardia Confusion Increased vocal fremitus Tahypnoea Tachypnoea HAEMOPTYSIS LUNG CANCER BRONCHIECTASIS Cachexia Clubbing Productive cough Tar-stained fingers Inspiratory clicks Clubbing Hard irregular lymphadenopathy Coarse, late expiratory crepitations Radiation burns BG of cystic fibrosis Pain and swelling of wrists (hypertrophic pulmonary arthropathy) Lymphadenopathy Horner’s syndrome Kartagener’s syndrome - dextrocardial BASIC DETAILS Patient details Date and time taken Imaging modality → CXR Views → AP/ PA/ supine/ mobile view MOST OBVIOUS ABNORMALITIES ABCDE Airway – trachea position CXR Interpretation Breathing – lung fields, lung apices, hilar region (Opacity? Consolidation? Heterogenous/ homogenous changes? Density – soft tissue? Bone? Air?) Cardiac – check the ratio between the heart and lungs Diaphragm – hemidiaphragm levels, costophrenic angle, cardiophrenic angle, pneumoperitoneum Extra – Bones, organs, bowels, soft tissues SUMMARISE WITH IMPRESSION Pneumonia Lobar Collapse Consolidation usually appear heterogenous Lobarcollapse usually appear homogenous Fluid collection in the alveoli Both hemidiaphragm are on the same level (abnormal!) Do not typically cause tracheal deviation Tracheal deviated ipsilateral to collapseTRACHEAL DEVIATION TRACHEAL DEVIATION TRACHEAL DEVIATION AWAY FROM TENSION AWAY FROM TOWARDS PNEUMOTHORAX PLERUAL EFFUSION RIGHT LUNG COLLAPSE REACTIVATION TB: Cavities Bilateral upper lobe consolidation Fibrosis CAVITATING LUNG LESION Pleural thickening Causes: Tuberculosis Hilar lymphadenopathy Lung abscess Lung cancer - SCC TUBERCULOSIS GPA – multi nodular Squamous cell carcinoma is most Pancoast Tumour likely to cavitate Associated with “Lobulated, well Horner’s Syndrome defined 6-7cm (Miosis + Ptosis + Anhidrosis) and ipsilateral arm weakness wide mass located if it compresses in the left peri- the brachial plexus Primary Lung Cancer hilar region” Cannonball Pulmonary Metastasis Opacification Secondary to seen across the renal cell carcinoma right pleura “Multiple well circumscribed heterogenous lesions noted." Mesothelioma ALWAYS LOOK OUT FOR METS AND COMPLICATIONS AFTER IDENTIFYING THE TUMOUR FINAL TIPS 01 CONFIDENCE 03 CHEST EXPANSION 05 AUSCULTATION Speak clearly, smile (when Quantify the reduction open mouth foraccurate with appropriate), establish rapport. ”Reduced chest expansion on sound assessment Respect patient privacy. the right compared to the left” Crackles: Early or late inspiratory? TACTILE VOCAL OBSERVE SUBTLE SIGNS FREMITUS CONSOLIDATIONS 02 04 06 Voice transmission tests can be Respiratory patterns More reliable than percussion performed to check for Chest wall asymmetry for detecting consolidation! consolidation Nails & hand clues Whispers are amplified in Face & neck signs consolidation! PLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK osceazyofficial osceazy@gmail.com OSCEazy OSCEazy osceazyofficial