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Before you start some definitions
==Before you start some definitions==


Emphysema - dilation and destruction of air spaces distal to bronchioles
Emphysema - dilation and destruction of air spaces distal to bronchioles
Chronic bronchitis - airway narrowing and mucous production
Chronic bronchitis - airway narrowing and mucous production
*chronic cough
*chronic cough
{{ntnes}}


And now a stepwise approach to the OSCE examination


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


2.  General
==General==
*ABCs
*ABCs
**as a general rule, if the patient can talk to you their airway and breathing are okay
**as a general rule, if the patient can talk to you their airway and breathing are okay
Line 25: Line 27:
**Tracheal tug
**Tracheal tug


3. Inspection
==Inspection==
*Look for cyanosis
*Look for cyanosis
**Central - look at lips, oral mucosa and tongue
**Central - look at lips, oral mucosa and tongue
**Peripheral - nails, hands and feet
**Peripheral - nails, hands and feet
*Look at fingers for nicotine stains and clubbing of fingernails
*Look at fingers for cigarette tar stains and clubbing of fingernails
*Shape of chest
*Shape of chest
**Chest wall deformities or trauma
**Chest wall deformities or trauma
Line 36: Line 38:
*Look for intercostal, subcostal and supraclavicular indrawing
*Look for intercostal, subcostal and supraclavicular indrawing


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


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


6. Auscultation
==Auscultation==
*listen to each of the five lung lobes and compare findings between sides
*listen to each of the five lung lobes and compare findings between sides
**Air entry - decreased in COPD
**Air entry - decreased in COPD
Line 53: Line 55:
***loud vs soft
***loud vs soft


7. Make diagnoses
==Make diagnoses==


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


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


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


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


*PFTs
==PFTs==
**Emphysema
*Emphysema
***TLC increased (barrel chest)
**TLC increased (barrel chest)
***RV increased
**RV increased
***VC decreased
**VC decreased
***FEV1 < 50%
**FEV1 < 50%
***DLCO decreased (because alveoli destroyed)  
**DLCO decreased (because alveoli destroyed)  
**Chronic bronchitis
*Chronic bronchitis
***TLC normal
**TLC normal
***RV slightly increased
**RV slightly increased
***VC slightly decreased
**VC slightly decreased
***FEV1 < 50%
**FEV1 < 50%
***DLCO slightly decreased or normal
**DLCO slightly decreased or normal
**cor pulmonale if FEV1 < 25%
*cor pulmonale if FEV1 < 25%
==Other OSCE modules==
{{OSCE2}}
[[Category:OSCE]]
[[Category:OSCE]]
[[Category: Clinical Skills]]
[[Category:Respiratory medicine]]

Latest revision as of 17:56, 8 June 2009

Before you start some definitions

Emphysema - dilation and destruction of air spaces distal to bronchioles

Chronic bronchitis - airway narrowing and mucous production

  • chronic cough


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

v • d • e
Observed structured clinical examination

Acute Confusion - Acute Coronary Syndrome Orders - Anemia - Arterial Blood Gasses - Asthma - Blood Pressure - Chest pain - Chest XRay - CHF - Coma - COPD - Cranial Nerves - Diabetic History - Diabetic Foot - Dysphagia - EKGs - Gallbladder and Liver - Liver Disease - Gait and Balance - Headache - Hematemesis - Hypertension - Jugular Venous Pulses - Knee Exam - Lymph Nodes - Community Acquired Pneumonia - Parkinson Disease - Peripheral Arterial Insufficiency - Pneumonia Examination - Precordial Exam - STD's - Spleen - Swollen Leg Exam - Thyroid Exam - Upper vs Lower Motor Neuron Lesions - Urinary Incontinence

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