View source for Archive:COPD Examination

==Before you start some definitions==

Emphysema - dilation and destruction of air spaces distal to bronchioles

Chronic bronchitis - airway narrowing and mucous production
*chronic cough
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And now a stepwise approach to the OSCE examination

1. Knock on the door, walk in and introduce yourself.  Wash hands and make sure the patient is comfortable then begin the examination.

==General==
*ABCs
**as a general rule, if the patient can talk to you their airway and breathing are okay
*LOC
*Pulse rate
*Respiratory rate, rhythm and depth
*Effort of breathing
**Use of accessory muscles - sternocleido mastoid, pec minor
***arms braced on knees or table
**speaking in full sentences
**Pursing of lips
**Nasal flaring
**Paradoxical abdominal breathing
**Sweating
**Tracheal tug

==Inspection==
*Look for cyanosis
**Central - look at lips, oral mucosa and tongue
**Peripheral - nails, hands and feet
*Look at fingers for cigarette tar stains and clubbing of fingernails
*Shape of chest
**Chest wall deformities or trauma
**Asymmetries of shape or movement
**Barrel chest has increased AP diameter - common in COPD
*Look for intercostal, subcostal and supraclavicular indrawing

==Palpation==
*Feel for tracheal position and presence of a downward tug
*Feel for range and symmetry of movement on inspiration - decreased range with hyperinflated lungs of COPD
*Feel for tactile fremitus - decreased in COPD

==Percussion==
*Percuss anterior and posterior, comparing left to right - hyperresonance with COPD
*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

==Auscultation==
*listen to each of the five lung lobes and compare findings between sides
**Air entry - decreased in COPD
**Adventitious sounds
***wheezes, crackles, other
***generalized versus localized
***loud vs soft

==Make diagnoses==

==Differences between emphysema and chronic bronchitis on exam==
===Inspection===
*emphysema: pink puffer (SOB and tachypnea), hyperinflation, SOBOE, respiratory distress
*chronic bronchitis: blue bloater, cyanotic, peripheral edema (RVF), mild SOB post cough
===Percussion===
*emphysema: hyperresonant, decreased diaphragmatic excursion
*chronic bronchitis: normal
===Auscultation===
*emphysema: decreased breath sounds, no egophony
*chronic bronchitis: crackles and wheezes

==CXR== 
*hyperinflated lungs with flattened diaphragms
*retrosternal airspace
*heart shadow long and narrow or enlarged if RVF/cor pulmonale
*may see bullae with emphysema

==ABGs==
*both have decreased PaO2 and increased PaCO2 (retainers) (low pH) but chronic bronchitis is worse than emphysema.

==CBC==
*Hct normal in emphysema, increased in CB

==PFTs==
*Emphysema
**TLC increased (barrel chest)
**RV increased
**VC decreased
**FEV1 < 50%
**DLCO decreased (because alveoli destroyed) 
*Chronic bronchitis
**TLC normal
**RV slightly increased
**VC slightly decreased
**FEV1 < 50%
**DLCO slightly decreased or normal
*cor pulmonale if FEV1 < 25%
==Other OSCE modules==
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[[Category:OSCE]]

[[Category: Clinical Skills]]
[[Category:Respiratory medicine]]