1. RESPIRATORY MEDICINE
1. Topics
2. OSCE scenarios
A B C
Asthma Bronchiectasis PCP/HIV
COPD Interstitial lung disease
Lung Cancer Sarcoid
PE Sleep apnoea
Pleural effusion
Pneumonia
Pneumothorax
Resp. failure – ABG profiles
TB
URTIs
ASTHMA:
Definition: Common chronic inflammatory disease of the airways
characterised by variable and recurring symptoms, reversible airflow
obstruction, and bronchospasm.
Signs and Symptoms:
SYMPTOMS SIGNS
Intermittent dyspnoea Tachypnoea
Wheeze Audible wheeze
Cough (often nocturnal) Hyperinflated chest
Sputum Hyperresonant percussion
Precipitating factors
Emotion, cold, allergens etc
Diminished air entry
Diurnal variation
Investigations:
• FBC, U&E, CRP
• ABG: / Pa02 and PaCO2
• Monitor PEF: >20% diurnal variation on 3 or more days per week (chronic
asthma)
• Spirometry: Obstructive changes (FEV1/FVC;  RV)
• Bronchodilator reversibility (>15% improvement in FEV1)
• Allergen skin prick tests: identify triggers
• Aspergillus serology
• CXR – hyperinflation: CXR > 6 anterior ribs

2. Management:
ACUTE:
1. Assess severity:
– Severe Attack - Can’t finish sentences; HR >110 bpm; RR > PEF 33 -
50% predicted
– Life-threatening Attack - Silent chest; cyanosis; bradycardia;
exhaustion; PEF <33% predicted; confusion; feeble respiratory effort
2. Sit patient up
3. High-dose O2 in 100% via non-rebreathing bag
4. Salbutamol 5mg + ipatropium bromide 0.5mg nebulised with O2
5. Hydrocortisone 100mg IV or prednisolone 40-50mg PO or both
6. Consider Magnesium sulphate
7. CXR
Safe to discharge?
• Stable on discharge meds for 24hrs
• Inhaler technique checked
• Peak flow rate > 75% predicted
• Own PEF meter and management plan
• GP appointment within a 1/52
CHRONIC: BTS Guidelines (just know this)
• Step 1: Occasional short-acting inhaled ß2-agonist as required for symptom
relief. (Salbutamol)
• Step 2: Add standard-dose inhaled steroid. (Beclometasone)
• Step 3: Add long-acting ß2-agonist (Salmeterol). If benefit but still inadequate
control, increase steroid dose
• Step 4: consider trials of: beclometasone up to 1000 μg/12h; modified-release
oral theophylline; modified-release oral ß2-agonist.
• Step 5: Add regular oral prednisolone. Refer to asthma clinic
COPD:
Definition: Common progressive disorder characterised by airway obstruction (FEV1
< 80% predicted; FEV1/FVC < 0.7) with little or no reversibility.
“Umbrella term for emphysema and chronic bronchitis”
• Emphysema – defined histologically as enlarged airspaces distal to
terminal bronchioles with destruction of alveolar walls.
• Bronchitis defined clinically as cough, sputum production on most
days for 3/12 of 2 successive years.

3. Emphysema
Bronchitis
Signs and Symptoms:
SYMPTOMS SIGNS
Cough Resp. distress –
Tachypnoea
Use of accessory muscles
Nasal flaring
Sputum – white and frothy Hyperinflation
Dyspnoea Hyperresonant
Wheeze Quiet breath sounds
Wheeze
Cyanosis

4. Investigations:
FBC
ABG – PaO2  +/- hypercapnia
Spirometry – obstructive (FEV1<80%, FEV1/FVC<0.7)  TLC,  RV.
CXR – hyperventilation, flat diaphragms, Large central pulmonary vasculature
ECG – RAH + RVH (right axis deviation)
Blood cults.
Sputum cults.
Management:
ACUTE: Look for cause – infection, pneummthorax
1. Controlled oxygen thx – start at 24 – 28% (aim for PaO2>8.0kPa + rise in
PaCO2<1.5kPa
2. Nebulized bronchodilators – Salbutamol + Ipatropium
3. Steriods – IV hydrocortisone + PO prednisolone
4. Broad spectrum Abx to cover S. pneumonia, H. influenza and M. catarrhalis.
E.g. amoxicillin & trimethoprim, doxycycline or cefuroxime
NO RESPONSE
Repeat nebs and consider aminophylline
STILL NO RESPONSE
Consider nasal intermittent positive pressure NIPPV if RR>30 or pH<7.35
Or consider intubation + ventilation if pH<7.26 and rising PaCO2
CHRONIC/STABLE:
Life style advice – smoking cessation, exercise, dietary advice, vaccines etc
MILD = FEV1 50-80% of predicted
Antimuscarinic – Ipratropium bromide or B2 agonist Salbutamol
PRN
MODERATE = 30-49% of precicted
Regular anticholinergic – Ipratropium bromide/tiotropium (long
acting)
+/- long acting B2 agonist Salmeterol + inhaled corticosteroids –
beclomethasone (NB// Seretide – combines corticosteroid + LABA)
SEVERE = FEV1<30% of predicted
LABA + inhaled corticosteroid + anticholingeric
Consider PO prednisolone trial
EXTRA:
Consider long term oxygen therapy (LTOT) if:

5. Clinically stable non-smokers
PaO2 <7.3kPA satble on two separate occasions
Or if PaO2 7.3-8.0 kPa + pulmonary hypertension + cor pulmonale
TUBERCULOSIS:
Definition:
 Common infectious disease caused by a variety of strains of Mycobacterium,
most commonly Mycobacterium tuberculosis and Mycobacterium Bovis,
spread by airborne transmission
 Worldwide epidemic - 1/3 of the world’s population is thought to be infected
with M. tuberculosis
 Accounted for 1.8 millions deaths worldwide in 2007, with 13 millions
chronic/active cases in existence
Pathogenesis & Progression:
TB = granulomatous inflammatory condition
TB  pulmonary alveoli and invade and replicate in alveolar macrophages
They are then taken up by dendritic cells and can spread to lymph node  GHON
COMPLEX
T and B lymphocytes, macrophage and fibroblasts all aggregate and surround the
infected macrophages to form a granuloma (granuloma is formed to prevent
spread)
Abnormal cell death at the centre  caseous necrosis.
Can remain dormant or be reactivated and spread
10
TB (pulmonary)  20
TB (post 10
) – result of reactivation  Progressive TB
75% cases active cases termed pulmonary TB
25% active cases can move from lungs to other sites e.g. upper airways and
gut
Disseminated TB = mammillary TB
Primary TB (10
)
First contact with Bacillus
Initial lesion in the parenchyma and subpleural space
Involvement of draining hilar lymph nodes
Leads to formation of the GHON COMPLEX
Usually asymptomatic and most cases heal by scar formation

6. Secondary TB (20
)
Result of activation of latent 10
TB.
GHON COMPLEX  ASSMAN FOCUS
Signs and Symptoms:
Investigations:
Latent TB – Mantoux test if +ve consider interferon gamma testing
Active TB – CXR = Consolidation, cavitation, fibrosis + calcification esp. in the
apices. If CXR suggestive take sputum samples. At least 3 sputum samples (one in
morning) and send for acid fast bacilli (consider bronchoscopy and lavage – obtain
samples)
Active non-pulmonary TB – find relevant clinical sample and send for cultures +
CXR to exclude co-existing pulmonary TB
Management: START WITHOUT CULTURE RESULTS!
Test colour vision – ishihara plates and stress COMPLIANCE – consider direct
observed thx.
Initial phase - 8 weeks
Continuation phase – further 16 weeks (24/52 on R & I in total)

7. R - Rifampicin
I - Isoniazid
P -Pyrazinamide
E - Ethambutol
SIDE EFFECTS: MUST KNOW
R
I
P
EXTRA –
 ETHAMBUTOL - (EYE) Optic neuritis – 1st
sign = colour vision damage
 RIFAMPICIN - Red/orange discolouration of tears and urine + inactivation of
the OCP + flu-like syndrome
 ISONIAZID - Neuropathy, agranulocytosis ( WCC – mainly neutrophils)
 PYRAZINAMIDE – Arthalgia (CI = Acute gout or porphyria)
PE:
Definition:
• Thrombus usually formed in systemic veins embolized into the pulmonary
arterial system.
• 90% of cases arise from DVT. DVT present in 70% of patients with proven
PE.
• Silent PE present in 50% of patients with proximal DVT
Signs and Symptoms:
• Small PE:
SYMPTOMS SIGNS
Unexplained dyspnoea Tachypnoea
Pleuritic chest pain Pleural rub
Haemoptysis Crackles
• Massive PE:
SYMPTOMS SIGNS
Sudden collapse Tachycardia
Severe central chest pain Hypotension
Peripheral shutdown
ALL = HEPATITS (small  AST OK, if  bilirubin STOP thx)

8. Raised JVP (prominent A wave)
Investigations:
• Well’s Score to assess probability:
o <2 = low probability
o 2-6 = moderate probability
o >6 = high probability
• CTPA
• V/Q scan
• Duplex US with compression (for DVT)
• Pulmonary angiography
• ECG: S1Q3T3
• CXR
• ABG: Decreased pO2 and pCO2
• D-dimer
Management:
• Admit
• Non-massive:
o IV LMW heparin (until INR = 2-3 for 2 consecutive days),
o Warfarin continued for 6 months
• Massive:
o Thrombolysis
o Unfractionated heparin

9. o Warfarin min. 6 months
PLEURAL EFFUSION – EXUDATES VS TRANSUDATES:
Definition:
• Excessive accumulation of fluid in the pleural space.
• Divided into two types depending on their protein concentration:
o Transudate effusion < 30g/L
o Exudate effusion > 30g/L
• Pleural fluid: Serous fluid produced by normal pleura, contained within the
cavity to aid lung function.
Signs and Symptoms:
• Asymptomatic
OR:

10. SYMPTOMS SIGNS
Dyspnoea Signs of associated disease
Pleuritic chest pain – sharp &
localised
Investigations:
• CXR:
Management:
• Drainage < 2L/24h
• Pleurodesis - if recurrent
• Thorascopic talc pleurodesis
• Surgery
PNEUMONIA:
Definition:
• Defined as the inflammation of lung parenchyma, usually as a result of
infection.
• It is a clinically acute illness typically presenting with cough, purulent sputum
and fever.
• Both physical signs and radiological changes are consistent with
consolidation of the lungs.
• Classification:
o CAP vs. HAP
o Lobar vs. Interstitial
o Typical vs. Atypical

11. • CAP: Pneumonia presenting in the community or within 48 hours of attending
hospital. Mainly caused by bacteria, although can also be caused by viruses.
• HAP: Acute pneumonia presenting 48hrs or more after admission to hospital.
Occurs in up to 5% of all admissions. Ventilator Associated pneumonia is a
subset of HAP and has a mortality of between 50-60%.
• CAP organisms:
o TYPICAL
 Streptococcus pneumonia, Haemophilus influenzae, Moraxella
influenzae, Staphylococcus aureus
o ATYPICALS
 Mycoplasma pneumonia, Legionella pneumophilia
(Legionnaires), Chlamydia species, Pneumocystis jiroveci
o VIRAL
 RSV (especially in 2<yrs and elderly, risk of secondary
bacterial infection)
• HAP organisms:
o 20% - Staphlococcus aureus
o 60%- Pseudomonas aeruginosa, Acinetobacter spp, E. coli.
o 20%- Other plus respiratory viruses in the immunosuppressed
Signs and Symptoms:
SYMPTOMS SIGNS
Fever Temp. up to 39.5 °C
Pleuritic chest pain Rigors, Malaise, Anorexia
Dry cough progressing to a rusty-
sputum producing cough
Purulent sputum
Rapid shallow breathing Reduced O2 Sats
CVS: Tachycardia, hypotensive,
cyanosis
Resp: Dyspnoea, tachypnoea, signs of
consolidation (reduced expansion,
dull percussion note, increased
resonance, bronchial breathing,
pleural rub)
Investigations:
• CXR: Chest X-ray will show consolidation. Imaging can lag behind clinical
presentations. Similarly, consolidation can remain despite resolution of
symptoms

12. Lobar Pneumonia:
Focal area of consolidation. This can be difficult to differentiate from pulmonary
oedema and fluid accumulation
Try to spot air bronchiograms.
These can be hard to spot but they
are essentially round black areas
surrounded by white consolidation
(representing consolidation
surrounding bronchioles).
• Oxygen saturation (ABGs)
• ECG?
• Blood tests (FBC, U+Es, LFTs, CRP, blood cultures, tailor to presentation)
• Sputum (microscopy and culture)
• Check urine antigen for legionella in severe cases
Management:
• Oxygen (prevent respiratory failure O2< kpa)
• IV fluids (hypotensive, dehydrated, hypovolemic shock)
• Analgesia (eg. Paracetamol)
• Antibiotics (empirical then adjust to results of cultures)

13. • Check for progression/ complications
• F/U at 6 weeks (repeat CXR)
• CURB65 to assess severity:
o Confusion (abbreviated mental test <8)
o Urea (> 7mmol/L)
o Respiratory Rate (>30/min)
o Blood pressure (systolic< 90, diastolic< 60)
o 65 yrs and above
• 0-1 = Mild
• 2 = Moderate
• 3-5 = Severe
• 0-1 treat as an outpatient, 2 consider a short stay in hospital or watch very
closely as an outpatient 3-5 requires hospitalization possibly ITU
• MILD/MODERATE
o Amoxicillin or Clarithromycin
• SEVERE
o Cefuroxime plus clarithromycin
o Benzylpencillin plus clarithromycin
o Clarithromycin plus rifampicin for Legionnaires
• This treatment is empirical until organism sensitivities can be elicited
• Prevention:
o Vaccination and pencillin prophylaxis in those at high risk (HIV, Cystic
fibrosis, lymphomas, leukaemias, cytotoxic drugs and corticosteroids)
o Hand washing and VAP precautions
o Hyperchlorination of water and heating (prevent legionaires)
o Stop smoking (mucocillary paralysis etc…)
PNEUMOTHORAX:
Definition:
• A collection of air in the pleural cavity between the lung and the chest wall.
• Tension pneumothorax: A breach in the lung surface acts as a valve, allowing
air into the cavity but not out.
• Causes:
o Spontaneous - thin young men
o Trauma
o Iatrogenic

14. o Secondary to e.g. Asthma; COPD; pneumonia; lung abcess; carcinoma;
cystic fibrosis
Signs and Symptoms:
SYMPTOMS SIGNS
None Reduced chest expansion
Sudden onset dyspnoea Hyper-resonant percussion
Pleuritic chest pain Reduced Breath sounds
If 2˚ to asthma/COPD – sudden
deterioration
Tension Pneumothorax:
SIGNS
Deviated trachea and apex away
from pneumothorax
Hypotension
Distended neck veins
Respiratory distress
Tachycardia
Investigation:
• If a tension pneumothorax is suspected, no tests as immediate treatment
required
• Otherwise, expiratory CXR to confirm
• Dark area devoid of lung markings, peripheral to edge of collapsed lung
• ABG if patient is dyspnoeic or has chronic lung disease.

15. Management:
BRONCHIECTASIS:
Definition:
• “Abnormal and permanently dilated airways”
• Classification: OBSTRUCTIVE*
LOWER respiratory tract
• Aetiology: the airways become dilated secondary to a chronic, destructive
(hence irreversible), inflammatory process.
• Causes:
o Congenital: Cystic fibrosis, Primary ciliary dyskinesia
o Acquired: Post-infective bronchial damage. Major organisms: H.
influenza; Strep. Pneumoniae; Staph. Aureus; Pseudomonas
aeruginosa; Klebsiella
o Mechanical bronchial obstruction. Extrinsic ( tumour, lymph nodes) or
Intrinsic (foreign body)
Signs and Symptoms:

16. SYMPTOMS SIGNS
Persistent cough Copious purulent sputum
Frequent production of green sputum SOB
Intermittent haemoptysis Clubbing
Coarse inspiratory crepitations
Wheeze
Investigations:
• CXR: Cystic shadows, thickened bronchial walls. Can be normal
• CT: Dilated cygnet-ring appearance airways. Use to assess extent and severity.
• Sputum culture essential for treatment
• Spirometry: obstructive pattern. Assess reversibility
Management:
• Postural drainage: BD
• Abx: ciprofloxacin 500mg 2x;
o Flucloxacillin 500mg per 6 hours in cases of Staph. Aureus.
• (Bronchodilators)
• (Anti-inflammatory agents e.g steroids)
INTERSTITIAL LUNG DISEASE:
Definition:
• A group of lung diseases affecting the interstitium (the tissue and space around
the air sacs of the lungs). i.e alveolar epithelium, pulmonary capillary
endothelium, basement membrane, perivascular and perilymphatic tissues.
• Are classified as a restrictive lung disease
• Prolonged ILD may result in pulmonary fibrosis, but this is not always the
case.

17. Causes:
• Inhaled substances – inorganic (e.g. asbestosis) or organic (e.g.
Hypersensitivity pneumonitis)
• Drug induced e.g. statins, methotrexate, amiodarone
• Connective tissue disease
• Infection e.g. Atypical pneumonia or TB
• Idiopathic – Sarcoid or IPF
• Malignancy - Lymphangitic carcinomatosis
Signs and Symptoms:
• Pneumoconiosis:
SYMPTOMS SIGNS
SOB End inspiratory crackles
Cough Wheeze
Fever
Occur hours after antigen exposure.
• Pulmonary fibrosis:
SYMPTOMS SIGNS
Progressive breathlessness as
disease becomes more severe
Progressive cyanosis
Resp. failure
Pulmonary hypotension
Cor pulmonale
Gross finger clubbing (2/3
patients)
Fine bilateral end-inspiratory
crackles
Investgations:
• Restrictive pulmonary spirometry with decreased DLCO.
• Decreased VC and TLC
• FVC and FEV1 decreased to similar degree therefore FEV1/FVC normal or
even raised.
• CXR:
o Pneumoconiosis: upper zone fibrosis and/or honeycomb lung.
o Pulmonary fibrosis: shows irregular reticulonodular shadowing

18. • CT:
o Pulmonary fibrosis: Typically ground glass opacification – best seen at
the bases. Honeycomb lung in severe cases – represents cystic air
spaces which are dilated and thickened terminal bronchioles.
Management:
• Depends on type.
• Pneumoconioses/Hypersensitivity pneumonites: Remove source of allergen.
Damage present is irreversible.
SARCOIDOSIS:
Definition:
• A multisystem non-caseating granulomatous disorder
• Granuloma: An organised collection of macrophages
• Unknown aetiology
• Can affect almost any organ. 90% cases lung
Signs and Symptoms:
SYMPTOMS SIGNS
None Erythema nodosum
Cough & exertional
breathlessness
Superficial lymphadenopathy
Respiratory & constitutional
symptoms
Restrictive pattern of spirometry
due to decreased lung compliance
and gas exchange
Arthralgia Clear chest auscultation
Ocular symptoms
Investigations:
• Lymphopenia
• LFTs
• Hypercalcaemia (increased formation of calcitriol by macrophages)
• Hypercalciuria
• Raised serum ACE
• CXR: symmetrical BHL, paratracheal nodes
• FEV1/FVC
• Biopsy (non caseating granuloma)
• Bronchoscopy: cobblestone

19. Management:
• If acute illness, NSAIDS
• If severe, steroids
• Most have spontaneous remission
• If hypercalcaemia, pulmonary impairment, renal impairment, uveitis then
PREDNISOLONE
• Strong sunlight avoidance
• Poor prognosis: afrocaribbean, >40, symptoms more than 6 months, more than
3 organs, lupus pernio. Use methotrexate, azathioprine. Single lung transplant
• Overall mortality is low and reflects cardiac involvement or pulmonary
fibrosis.

20. 2. OSCE
a) Respiratory history
b) Respiratory exam
c) Presenting a chest x-ray
d) Inhaler technique/PEAK flow
e) Explaining a procedure such as a chest drain
a) Respiratory History: Key things to remember
SOCRATES if pain = Pleuritic or cardiac
Associated symptoms =
Wheeze
SOB
Cough – character + productive
Phlegm – colour and volume or blood?
Night sweats
Weight loss
PND – wake up gasping
Systemic symptoms
Travel history
If female – COCP?
b) Respiratory exam
Notes The Set-up
Washes hands
Introduces themselves to the patient
Asks what the patient prefers to be called by
Explains the examination and gets permission
Assesses pain status of the patient
Exposes patient from the waist up
Repositions patient to 45
End of the bed
Checks for signs of breathlessness/wheeze/stridor/distress
Checks whether the patient can speak in full sentences without
breathing in between
Checks surroundings for CPAP, oxygen tubing, peak flow meter,
sputum pots, nebulisers, inhalers, cigarettes
Hands
Checks for temperature (warm in CO2 retention, cold with

21. peripheral vasoconstriction or heart failure)
Checks for tar staining (nicotine does no stain)
Checks for peripheral cyanosis (poor perfusion to peripheries due to
peripheral vascular disease, Reynaud’s phenomenon or
vasoconstriction eg. in the cold)
Checks for clubbing (respiratory causes are most commonly lung
cancer, interstitial lung disease (importantly asbestositis) and
suppurative lung diseases such as abscess, empyema,
bronchiectasis. NOT COPD/asthma)
Checks for fine tremor (caused by beta-agonists such as
salbutamol)
Checks for CO2 retention flap (late sign of CO2 retention)
Arms
Measurer radial pulse (Rate, rhythm and character. Bounding pulse
present in CO2 retention)
Measures respiratory rate subtly while taking pulse
Face
Checks eyes for anemia (pale conjunctiva)
Checks eyes for Horner’s syndrome (compression of the sympathetic
chain in the chest cavity interrupts sympathetic supply causing
ptosis [relaxed superior tarsal muscle], anhydrosis and meiosis)
Checks face for lupus pernio (purple swelling of sarcoid granuloma)
Checks lips and tongue for central cyanosis (seen in severe
pneumonia, COPD and pulmonary embolism)
Neck
Checks the JVP (raised in states of pulmonary hypertension and/or
right-sided heart failure such as cor pulmonale, superior vena cava
obstruction, cardiac tamponade, constrictive pericarditis and
restrictive cardiomyopathy)
Palpates the submental, submandibular, pre-auricular, post-auricular,
cervical chain, supraclavicular, occipital and axillary lymph nodes
Inspecting the Chest
Checks for scars (such as a sternotomy or thoracotomy)
Check for assymmetrical expansion (indicates lung disease on that
side)
Checks for visible veins (sign of superior vena cava obstruction)
Checks for pectus excavatum (normal variant whereby sternum is
depressed into the chest)
Checks for pectus carinatum (abnormal deformity with chest wall
protruding outwards caused by increased respiratory effort in
childhood when bones are still malleable, eg. asthma)
Checks for barrel chest (rounded thorax caused by hyperinflation, a

22. marker of smoking related lung disease)
Checks for spinal deformities such as scoliosis or kyphosis
Checks for the use of accessory muscles
Palpating the Chest
Palpates for tracheal deviation (deviated towards collapsed lung or
localised fibrosis, deviated away from pneumothorax and large
pleural effusion)
Assesses chest expansion (unilateral reduction in expansion caused
by pneumothorax, pleural effusion, pneumonia and collapsed lung)
Assesses the tactile vocal fremitus by asking the patient to say “99”
while feeling at 3 places each side of the chest using the ulnar edge
of the hand (Increased over areas of consolidation eg. pulmonary
edema, inflammatory exudate, blood or pus. Increased over areas of
pleural effusion or pneumothorax as the filled pleaural space acts
as a barrier to sound)
Percussing the Chest
Percusses the clavicle (without the flat hand)
Percusses 3 areas of the lung on each side (Resonant=normal lung.
Dullness=areas of increased density such as consolidation (eg.
pneumonia), collapse, alveolar fluid, pleural thickening, fibrosis,
peripheral abscess or neoplasm. Stony dullness=the unique extreme
dullness heard over a pleural effusion. Hyper-resonant=areas of
reduced density emphysema, pneumothorax, COPD)
Auscultation of the Chest
Asks patient to take deep breaths in through the mouth when
stethoscope is placed on the chest
Auscultates both sides of the chest (Normal “vesicular” sounds are
produced by the large airways and then changed as they come
through the normal small airways. Reduced sound is caused by an
effusion, tumor, pneumothorax. Bronchial breathing occurs when
consolidation, lung absesses and dense fibrosis cause the sound
from the bronchi and larynx to be better transmitted to the chest
wall and therefore sounds like breath sounds at the trachea. Added
sounds include: 1) Wheeze is a whistling caused by a narrowed
airways heard best in expiration. A polyphonic wheeze occurs in
asthma as many airways are constricted. A monophonic wheeze
occurs when a single airway is narrowed eg. foreign body or
carcinoma. 2) Crackles (also called crepitations or rales) are
caused by “popping open” of collapsed alveoli as air enters them.
Fine crackles occur in small airways late in inspiration and are
caused by fluid, infection or fibrosis usually at the lung bases.
Coarse crackles sound like rice krispies and are in the larger
airways caused by infection or fluid. 3) Pleural rub occurs in both
expiration and inspiration due to inflamed surfaces of the pleura

23. rubbing together in pneumonia and pulmonary embolism with
infarction.)
Assesses vocal resonance
Assesses vocal pectoriloquy (whispering sound instead of “99”. If
still loud, then consolidation is likely)
Back
Inspects the patient’s back
Palpates the patient’s back
Percusses the patient’s back
Auscultates the patient’s back
Finishing off (SOAP)
Sends off a Sputum pot
Checks Oxygen saturation
Checks for Ankle edema
Measures Peak flow
Asks if patient would like help getting dressed
c) Presenting a chest x-ray
DO NOT TOUCH THE FILM!!!!!!
Identify film
NAME
DOB
DATE OF FILM
TYPE (AP/PA)
Quality of film:
R – rotation = position of clavicle heads
I – inspiration > 6 anterior ribs = hyperinflation
P – penetration = see thoracic spine through heart
E – exposure
F – framing
L – lines or anything else
Then state the most striking abnormality.
Now Begin by looking at:
• Trachea – central or displaced?
• Towards lesion = Collapse
• Away from lesion = Tension

24. • Mediastinum – widened?
• Aneurysm
• Unfolded aorta
• LN enlargement – TB/ Sarcoidosis/ Lymphoma
• Hila = L usually higher than R & compare shape and density
• Enlarged – Pulmonary artery HTN
• Calcified – Post TB/ Silicosis
• Heart = CTR – 50% (hard to assess in AP film) – can you see the R and L
heart borders
• Diaphragm = Costophrenic angles – blunt or defined?
• Look for stomach bubble/ raised hemi-diaphragm
IF NOTHING SEEN – KEY AREAS:
1. Behind the heart
2. Pleura
3. Apices
4. Below diaphragms
5. Bones
Finally summarise your findings, mentioning the important negatives and the stating
the most consistent diagnosis.
d) Inhaler technique
WIPER
Introduce and explain purpose of interview
Check understanding of Asthma and rationale behind inhaler therapy
1. Stand up sit up straight before using inhaler
2. Remove cap and shake inhaler
3. Hold canister vertical for delivery of drug
4. Hold canister with middle finger and thumb
5. Put mouthpiece in mouth at start of inspiration
6. Inhalation should be slow and deep
7. Press canister down with index finger
8. Hold breath for 10 seconds

25. 9. Wait about 30 seconds before administering the next dose
10. Close cap
Offer Spacer if still difficult. Same rules just breath normally through spacer
Spacer not dishwasher safe, just simply rinse and leave to dry.
If steroid inhaler advise to do just before teeth – good mouth hygiene indicated
Offer leaflet and a follow up to answer questions they might have later on.
Rotahaler Capsule administration of drug
Twist to release drug – inhale simultaneously
Hold breath for 10 s
Other inhalers Easi-breath (teeth bite mouthpiece inhaler), Accuhaler (metered
dosing)
e) Explaining a procedure such as a chest drain
Key to all explaining stations is to have a proforma that can be applied to all of them
and avoid jargon. They are checking your communication not your knowledge.
WIPER
Emphasis on explaining why here – that want to discuss proposed action and
answer any of their questions. Say that this is a chance for them to ask you
anything so feel free to interrupt me.
Then establish their knowledge base and what they want to know?
Background – reasons for doing procedure etc
Before – if there is any prep needed ie fasting etc
During – on the day what to expect
After – Can they leave straight after/ drive/operate machinery etc also will
they need a friend or family member to pick them up
Risks and benefits
Results – when will they receive them and how
Any questions?
Ask them to repeat back what you have said and then offer leaflet and another
chance to chat if they would like
NB// if this is a consent station bare in mind you must also offer alternatives
and risks if patient choses not to have procedure.