This document provides an overview of conducting a respiratory OSCE station, including examining common signs, conditions, investigations, and management strategies. Key areas of focus are the respiratory examination, common signs and causes of conditions like clubbing, crackles, and reduced breath sounds, investigating and treating issues like pneumonia, COPD, and lung cancer. The goal is to thoroughly examine patients and utilize clinical clues and testing to accurately diagnose and manage respiratory diseases.
7. Breathing Pattern
• Count respiratory rate
• Tachypnoea
• Pursed lipped breathing
• Use of accessory muscles
8. Cough
• Do first as part of inspection
• Dry Cough
– Pulmonary fibrosis
– Pleural effusion
• Purulent cough/productive
– Bronchiectasis/CF
– Pneumonia
18. Pleural Effusion
• Signs
– Reduced expansion
– Trachea away from effusion
– Stony dull percussion note
– Absent tactile vocal fremitus
– Reduced air entry and breath sounds
• Signs to identify cause
– Cancer: clubbing and lymphadenopathy
– CCF: Raised JVP
– Chronic liver disease: spider naevi, leuconychia
– Chronic renal failure: AV fistula
– Connective tissue disease: rheumatoid hands
19. Pleural Effusion
• CXR
• Pleural Aspiration – Ultrasound guidance
– Protein
– LDH
– pH – if < 7.2 consistent with empyema
• Transudate (protein <30g/L)
– CCF
– Chronic renal failure
– Chronic liver failure
• Exudate (protein >30g/L)
– Malignancy – primary or secondary
– Infection
– Infarction
– Inflammation: RA and SLE
20. Pleural Effusion Treatment
• Transudate
– Treat the cause
• Exudate
– Pleural fluid cytology
– May need CT thorax
– Intercostal drainage may be appropriate
– Consider pleurodesis
23. Bronchiectasis
• Signs
– Cachexia and tachypnoea
– Clubbing
– Mixed crackles that alter with coughing
– Occasional squeaks and wheeze
– Sputum +++
• Investigations
– Sputum culture
– CXR
– High resolution CT thorax
• Treatment
– Physiotherapy
– Prompt antibiotic thearpy
– Bronchodilators
24. Pulmonary Fibrosis
• Signs
– Clubbing, central cyanosis and tachypnoea
– Fine end inspiratory crackles
– No sputum
• Investigations
– CXR
– Lung function tests: Restrictive pattern, Low TLC, Low KCO
– High resolution CT
– Lung biopsy
• Treatment
– Immunosuppression, eg. Steroids and azathioprine
– Single lung transplant
– Beware:- Unilateral fine crackles and contralateral thoracotomy
scar with normal breath sounds
32. If you get stuck!
• Say what you hear
• Don’t make up a diagnosis
• Look for bedside clues
• Common respiratory investigations:
– CXR
– CT thorax/high resolution CT thorax
– Lung function tests – obstructive or restrictive
– Peak flow – asthma only
– Sputum culture