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OSCE SERIES THE RESPIRATORY STATION PART 1 Srinjay Mukhopadhyay PROUDLY IN COLLABORATION WITH COUGH 1 Contents 2 SHORTNESS OF BTHA 3 SAMPLE CASEINSTRUCTIONS History of Presenting Complaint: • When did the cough start? • Has it been there constantly for the past X days/weeks? • Has it gotten worse over time? • Is it worse at any time of the day? • Are you coughing anything up? If yes: What colour is it? How much are you coughing up? Does it smell? • Have you coughed up blood? If yes: what colour was it? How much blood? • Have you noticed anything else associated with the cough (REMEMBER open to closed questions!) Systems Review: • Have you noticed any chest pain? • Any SOB? • Any Fever, Night Sweats or weight loss? • Any Nausea or Vomiting? • Any Leg Swelling? Past Medical History: • Any Respiratory diagnosis? If yes: When were you diagnosed, and is it well managed? • Any previous surgeries? Drug History: • What medications do you take currently? • Any Herbal remedies? • Any over-the-counter medications? • Do you have any drug allergies? Family History: • Any Family history of respiratory conditions? Social History: • Do you smoke? Or Have you ever smoked? If so how many cigarettes per day and for how long? • Do you drink? • Where do you work? • Who is with you at home? • Any pets? • Any Long-haul flights recently? ICEE COUGH HISTORY PRODUCTIVE COUGH? DRY COUGH Differentials: Differentials: Pneumonia Viral Infection TB Haemoptysis: Pulmonary fibrosis COPD • Lung Cancer Medication Related • TB (ACEi) Bronchiectasis • Pulmonary Embolism Heart failure GORD Summarising the history Patient details, occupation I took a history from Rhory Adams, a 75 year old man who came in with a cough & key presenting complaint The cough started about 3 days ago and has progressively worsened. He is coughing up 1 egg cup History of presenting complaint per day of yellow-green coloured phlegm, however he says there is no blood in his sputum. He describes having rigors and has recorded a temperature of up 39.9 degrees C. There is no weight loss or night sweats, chest pain or SOB Relevant negatives PMH is significant for hypertension and diabetes, both of which are well controlled. He takes Rampril and Relevant PMH/PSH/SH/DH Metformin as prescribed by the GP, and occasional paracetamol for headaches OTC. NKDA! He is a smoker with a 20 pack year history. He is an ex-marine and currently lives with his wife and is well supported at home. Ideas, concerns & expectations He is worried he might have lung cancer Top differential & why My top differential is Pneumonia Other differentials that I would like to rule out include COPD, lung cancer. Other differentials COUGH INVESTIGATIONS TEST JUSTIFICATION A-E For any acutely unwell patient always start with the A-E approach! Senior Support! Basic observations Assess for haemodynamic instability, hypoxia and fever BEDSIDE Respiratory examination Look for signs of infection, COPD, Bronchiectasis. Auscultation is key!!! Peak Flow If you are suspecting Asthma Attack 12-lead ECG PE, pneumonia may cause ECG changes Full blood count (FBC) Assess for anaemia and signs of infection Liver function test (LFT) Assess for liver function (especially if amiodarone is given) Urea and Electrolytes (U&Es) Assess for electrolyte abnormalities & Acute kidney Injury BLOODS ABG If patient is respiratory distress ABG is useful! D dimer If you consider PE (Well’s Score 4 or below) C-reactive protein (CRP) Assess for infection Chest X-ray Assess for consolidation indicating pneumonia or cancer.? CT Thorax High Resolution CT for Bronchiectasis, Pulmonary Fibrosis, Staging for Lung Cancer IMAGING CTPA If you consider PE (Wells Score>4) Spirometry Useful to diagnose asthma, COPD SPECIAL Sputum MC+S Useful for severe bacterial infections, 3 early morning samples if you suspect TB TESTS Pneumonia: If very unwell: A-E Approach and Sepsis 6 Conservative Medical CXR • Admit to Hospital of CURB 65 • Counsel patient on diagnosis • Provide information leaflets score 2 or more for IV Abx. • Ensure if patient was hospitalized with • Inform them that fatigue and • If CURB 65= 1 or 0: pneumonia, that they cough may persist • PO Amoxicillin 5 days • If the patient develops feve, • Paracetamol for fevers can are booked for a CXR 6 weeks post discharge severe SOB they should seek be taken every 4-6 hours as medical assistance needed. immediately! Lung Cancer: Conservative Medical Surgical • Counsel patient on diagnosis • You will not be the one deciding management: • If MDT deems surgery • Provide information leaflets • It will be a MDT approach to to be possible the • Offer psychosocial support care • Smoking Cessation patient may require • Patient may require lobectomy or complete • Ensure Family is well chemotherapy pneumonectomy . supported • Radiotherapy • Respiratory Physio and Rehabilitation Bronchiectasis Conservative Medical • Counsel patient on diagnosis • Annual Flu Vaccine • Provide information leaflets • Pneumococcal Vaccine • Smoking Cessation • Inhalers may help • Annual follow up • Respiratory Physio and RehabilitationChest X-Rays: • Airway: • Trachea A • Aortic Knob • DO NOT MISS TRACHEAL DEVIATION • Breathing Fields: • Look at the B lungs and the pleura • Cardiac: • Heart Size on C PA film • Diaphragm: • Look at the levels of the D hemidiaphragm • Costophrenic angles • Everything Else: • Equipment? E • BonesLet’s look at some common CXRsPleural EffusionRight Upper Lobe ConsolidationLeft Mid Zone ConsolidationTension PneumothoraxINSTRUCTIONS History of Presenting Complaint: • When did the SOB start? • Has it been there constantly for the past X days/weeks? • Has it gotten worse over time? • Does anything make it worse? • How much can you walk before you get SOB? • How much could you walk before? • How many pillows do you sleep on? • Have you ever woken up at night gasping for breath? • Have you noticed anything else associated with the cough (REMEMBER open to closed questions!) Systems Review: • Do you have a cough with the SOB? • Any chest pain? • Do you feel more fatigued than usual? • Have you fainted recently? • Any blood in your bowel movements or urine? • Any Nausea or Vomiting? • Any fever, night sweats or weight loss? • Any swelling in your legs? Past Medical History: • Any Respiratory diagnosis? If yes: When were you diagnosed, and is it well managed? • Any Previous Hospitalisation (looking for previous heart attack which may indicate Heart failure) • Any previous surgeries? Drug History: • What medications do you take currently? • Any Herbal remedies? • Any over-the-counter medications? • Do you have any drug allergies? Family History: • Any Family history of respiratory conditions? Social History: • Do you smoke? Or Have you ever smoked? If so how many cigarettes per day and for how long? • Do you drink? • Where do you work? • Who is with you at home? • Any pets? • Any long Haul Flights SOB Differentials: Chronic: Non-Resp: Pulmonary Fibrosis COPD Anaemia Lung Cancer Heart Failure Mesothelioma Aortic Stenosis Pleural Effusions Angina (atypical) Asthma Acute: Pulmonary Embolism Pneumothorax Pneumonia Summarising the history Patient details, occupation I took a history from Jan Williams, a 35 year old man who came in with a Shortness of breath & key presenting complaint The Shortness of breath started about 3 weeks ago, and has progressively worsened, such that History of presenting complaint she is SOB on walking 100 yards now. She does complain of a cough with a pink frothy sputum but denies any blood present. She has noticed her ankles are more swollen than usual, her joints in her hands are also swollen, red and painful. She denies any fevers, weightloss, or nigh sweats. She has no chestpain, and is not pregnant. Relevant negatives No significant PMH, takes no medication and has NKDA. FH is significant for rheumatiological conditions Relevant PMH/PSH/SH/DH however she can’t remember the name. Does not smoke, works as a lawyer is affected by SOB, husband has to help with household chores.. Ideas, concerns & expectations She will loose her job if he doesn’t reciver Top differential & why My top differential is Pleural Effusion due to Nephrotic Syndrome secondary to SLE Other differentials that I would like to rule out include Heart Failure, Liver Fallure. Other differentials SOB INVESTIGATIONS TEST JUSTIFICATION A-E For any acutely unwell patient always start with the A-E approach! Senior Support! Basic observations Assess for haemodynamic instability, hypoxia and fever BEDSIDE Respiratory examination Look for signs of infection, COPD, Bronchiectasis. Auscultation is key!!! Peak Flow If you are suspecting Asthma Attack 12-lead ECG PE, pneumonia may cause ECG changes Full blood count (FBC) Assess for anaemia and signs of infection Liver function test (LFT) Assess for liver function D Dimer If Wells Score 4 or below- Rule put PE BLOODS Urea and Electrolytes (U&Es) Assess for electrolyte abnormalities & Acute kidney Injury ABG If patient is respiratory distress ABG is useful! BNP To rule out Heart Failure C-reactive protein (CRP) Assess for infection Chest X-ray Assess for consolidation indicating pneumonia, or look for asbcence of lung markings in pneumothorax CT Thorax High Resolution CT for Bronchiectasis, Pulmonary Fibrosis, Staging for Lung Cancer IMAGING CTPA If Wells Score more than 4 Echocardiogram Rule out Heart Failure Spirometry Useful to diagnose asthma, COPD SPECIAL TESTS Sputum MC+S Useful for severe bacterial infections, 3 early morning samples if you suspect TB Acute Asthma Attack Oxygen! NEB Salbutamol ANY ACUTE NEB Ipatropium SCENARIO: A-E approach Call Seniors Consider putting out a IV hydrocortisione/ PO Prednisolone med emergency call on 2222 IV MgSO4 IV Aminophylline Intubate and Ventilate Chronic Asthma Management Conservative Medical • Counsel patient on diagnosis • SABA • Provide information leaflets • SABA + ICS • Quit Smoking/Parents to stop • SABA + ICS + LTRA • SABA + ICS + LABA smoking • Inhaler echnique • Remember to double check that • If Severe SOB, not subsiding there are no medications which on the use of inhalers call for exacerbate symptoms assistance!!Acute Exacerbation of COPD Oxygen! NEB Salbutamol ANY ACUTE NEB Ipatropium SCENARIO: A-E approach Call Seniors Consider putting out a IV hydrocortisione/ PO Prednisolone med emergency call on 2222 IV Aminophylline Non-Invasive Ventilation (BiPAP) Chronic COPD Management Conservative Medical Surgical • Counsel patient on diagnosis • SABA/SAMA • SABA + LABA + LAMA • Lung Volume • Provide information leaflets • OR if eosinophilic features: Reduction surgery • Smoking Cessation • SABA + LABA + ICS • Respiratory Physio and (Specialist input). • LTOT: if PO2<7.3KPa Rehabilitation • Or if 7.3Kpa – 8KPa • Flu Vaccine (Annual) • If polycythemia • One off Pneumococcal • Signs of Right Ventricular Vaccine failure BASED ON BTS 2010 GUIDELINES SPONTANEOUS PNEUMOTHORAX BILATERAL ABCDE ASSESSMENT CHEST DRAIN AGE > 50 & SMOKING HISTORY OR EVIDENCE OF LUNG DISEASE SECONDARY PRIMARY SIZE >2cm AND/OR SIZE >2cm AND/OR BREATHLESS BREATHLESS CONSIDER DISCHARGE & REVIEW IN ASPIRATE ASPIRATE SIZE 1-2cm OUTPATIENTS ADMIT GIVE HIGH FLOW SUCCESS? CHEST DRAIN SUCCESS? O breathing improved) (SIZE < 1cm) 2 Credit: Nish OBSERVE PE: If very unwell: A-E Approach and Thrombolysis! Conservative Medical Surgical • Counsel patient on diagnosis • DOAC (Apixaban or Rivoroxaban) For 3 months if provoked or 6 • IVC filter for recurrent • Provide information leaflets • Smoking Cessation months if unprovoked. PEs • Ensure the patient has adequate pain relief. Interpreting ABGs ABG Interpretation Steps What to Look For >7.45- Alkalosis Look at the pH <7.35- Acidosis >6KPa- Respiratory Acidosis Look at PCO2 <4.7KPa- Respiratory Alkalosis Look at P02 <10 KPa- Respiratory Failure HCO3 <22- Metabolic Acidosis >26- Metabolic Alkalosis <-2- METABOLIC Acidosis Base Excess >2- METABOLIC AlkalosisInterpreting ABGs Name James Sloane Age 60 Date of study 14/03/2023, 15:00 pm PH 7.22 (7.35-7.45) PO2 7.2 Kpa (>10KPa) PCO2 8.7KPa. (4.7-6KPa) HCO3 29mmol/l (22-26mmol/l) Base Excess -2Interpreting ABGs Name James Sloane Age 60 Date of study 14/03/2023, 15:00 pm PH 7.56 (7.35-7.45) PO2 10.1 Kpa (>10KPa) PCO2 3.3 KPa. (4.7-6KPa) HCO3 24mmol/l (22-26mmol/l) Base Excess -2Interpreting ABGs Name James Sloane Age 60 Date of study 14/03/2023, 15:00 pm PH 7.22 (7.35-7.45) PO2 11.3 Kpa (>10KPa) PCO2 3.6 KPa. (4.7-6KPa) HCO3 15 mmol/l (22-26mmol/l) Base Excess -8Let’s Walk Through A Case Role Medical student Setting Acute Medical Unit Patient John Snow a 55 year-old man is complaining of Shortness of breath. STUDENT Student task Take a focused form this patient. INSTRUCTIONS At 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis. How can I help you today? I have been feeling more and more short of breath recently, such that I can only walk about 100m until I have to stop. This is a big change as I used to walk a mile or so everyday before. I can’t quite remember when it started, but it has been getting worse over the last two months or so. Have you noticed anything else with this shortness of breath? Not really, I do not have a cough or any pain anywhere. But I have been feeling more tired than usual. My wife checked my temperature, and it Question What do you think the most likely cause of the A Pneumonia patients symptoms is at this point? B COPD C Pneumothorax D Pulmonary Embolism E Pleural Effusion Question What do you think the most likely cause of the A Pneumonia patients symptoms is at this point? B COPD C Pneumothorax D Pulmonary Embolism E Pleural Effusion Systems Review No Palpitations, No Lightheadedness, No Malaena, No orthopnea, No Paroxysmal Nocturnal Dyspnea, Significant weight loss without trying, no night sweats, no haemoptysis. PMH/DH/FH High blood pressure and Type 2 Diabetes. Takes Ramipril, Linagliptin and Metformin. Occasional Gaviscon for ‘Acidity.’ NKDA. FH not significant for any respiratory illness. Question What if this patient mentioned that he was A Chromic Lymphocytic Leukemia having night sweats, what would your top differential be then? B HIV C TB D Acute Myeloid Leukaemia E Acute Lymphoblastic Leukaemia Question What if this patient mentioned that he was A Chromic Lymphocytic Leukemia having night sweats, what would your top differential be then? B HIV C TB D Acute Myeloid Leukaemia E Acute Lymphoblastic Leukaemia Social History 40 Pack year smoking history, drinks a glass of wine with dinner every day. He is retired now but used to work in a shipyard before. Lives alone in his house in the countryside. ICEE Has had to quit walking with friends, which has made him isolated. He is worried he will be unable to do his daily chores soon. Question Given this history, apart from examining the A CT Thorax patient, what is the first line imaging you would order? B VQ scan C Chest X ray D Echocardiogram E MRI Thorax Question Given this history, apart from examining the A CT Thorax patient, what is the first line imaging you would order? B VQ scan C Chest X ray D Echocardiogram E MRI ThoraxThis is his CXR: Question Given this patients occupational history and A Previous Lobectomy CXR findings. What do you think the most likely diagnosis is? B Pulmonary Embolism C Severe Pneumonia D Mesothelioma E Pneumothorax Question Given this patients occupational history and A Previous Lobectomy CXR findings. What do you think the most likely diagnosis is? B Pulmonary Embolism C Severe Pneumonia D Mesothelioma E Pneumothorax Mesothelioma Conservative Medical Surgical • Counsel patient on diagnosis • MDT management • Pleurectomy • Provide information leaflets • May require chemotherapy • Offer psychosocial support • Smoking Cessation • Ensure Family is well supported • Industrial Compensation References https://radiopaedia.org/articles/mesothelioma?lang=gb https://radiopaedia.org/cases/pleural-effusion-7 https://radiopaedia.org/cases/right-upper-lobe-pneumonia-8 https://radiopaedia.org/cases/lung-cancer-10?lang=gb https://radiopaedia.org/articles/tension-pneumothorax?lang=gb https://radiopaedia.org/cases/normal-chest-x-rayPLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO THE REST OF OUR OSCE SERIES