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<div>==Before you start some definitions==<br />
<br />
Emphysema - dilation and destruction of air spaces distal to bronchioles<br />
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Chronic bronchitis - airway narrowing and mucous production<br />
*chronic cough<br />
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<br />
And now a stepwise approach to the OSCE examination<br />
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1. Knock on the door, walk in and introduce yourself. Wash hands and make sure the patient is comfortable then begin the examination.<br />
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==General==<br />
*ABCs<br />
**as a general rule, if the patient can talk to you their airway and breathing are okay<br />
*LOC<br />
*Pulse rate<br />
*Respiratory rate, rhythm and depth<br />
*Effort of breathing<br />
**Use of accessory muscles - sternocleido mastoid, pec minor<br />
***arms braced on knees or table<br />
**speaking in full sentences<br />
**Pursing of lips<br />
**Nasal flaring<br />
**Paradoxical abdominal breathing<br />
**Sweating<br />
**Tracheal tug<br />
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==Inspection==<br />
*Look for cyanosis<br />
**Central - look at lips, oral mucosa and tongue<br />
**Peripheral - nails, hands and feet<br />
*Look at fingers for cigarette tar stains and clubbing of fingernails<br />
*Shape of chest<br />
**Chest wall deformities or trauma<br />
**Asymmetries of shape or movement<br />
**Barrel chest has increased AP diameter - common in COPD<br />
*Look for intercostal, subcostal and supraclavicular indrawing<br />
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==Palpation==<br />
*Feel for tracheal position and presence of a downward tug<br />
*Feel for range and symmetry of movement on inspiration - decreased range with hyperinflated lungs of COPD<br />
*Feel for tactile fremitus - decreased in COPD<br />
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==Percussion==<br />
*Percuss anterior and posterior, comparing left to right - hyperresonance with COPD<br />
*Estimate diaphragmatic excursion by noting the difference in the level of dullness on percussion with inspiration and expiration - normal is 5-6cm, but is decreased with hyperinflated lungs of COPD<br />
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==Auscultation==<br />
*listen to each of the five lung lobes and compare findings between sides<br />
**Air entry - decreased in COPD<br />
**Adventitious sounds<br />
***wheezes, crackles, other<br />
***generalized versus localized<br />
***loud vs soft<br />
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==Make diagnoses==<br />
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==Differences between emphysema and chronic bronchitis on exam==<br />
===Inspection===<br />
*emphysema: pink puffer (SOB and tachypnea), hyperinflation, SOBOE, respiratory distress<br />
*chronic bronchitis: blue bloater, cyanotic, peripheral edema (RVF), mild SOB post cough<br />
===Percussion===<br />
*emphysema: hyperresonant, decreased diaphragmatic excursion<br />
*chronic bronchitis: normal<br />
===Auscultation===<br />
*emphysema: decreased breath sounds, no egophony<br />
*chronic bronchitis: crackles and wheezes<br />
<br />
==CXR== <br />
*hyperinflated lungs with flattened diaphragms<br />
*retrosternal airspace<br />
*heart shadow long and narrow or enlarged if RVF/cor pulmonale<br />
*may see bullae with emphysema<br />
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==ABGs==<br />
*both have decreased PaO2 and increased PaCO2 (retainers) (low pH) but chronic bronchitis is worse than emphysema.<br />
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==CBC==<br />
*Hct normal in emphysema, increased in CB<br />
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==PFTs==<br />
*Emphysema<br />
**TLC increased (barrel chest)<br />
**RV increased<br />
**VC decreased<br />
**FEV1 < 50%<br />
**DLCO decreased (because alveoli destroyed) <br />
*Chronic bronchitis<br />
**TLC normal<br />
**RV slightly increased<br />
**VC slightly decreased<br />
**FEV1 < 50%<br />
**DLCO slightly decreased or normal<br />
*cor pulmonale if FEV1 < 25%<br />
==Other OSCE modules==<br />
{{OSCE2}}<br />
[[Category:OSCE]]<br />
[[Category:Medicine]]</div>82.39.96.218