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

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.

2. 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

3. Inspection

• Look for cyanosis
  • Central - look at lips, oral mucosa and tongue
  • Peripheral - nails, hands and feet
• Look at fingers for nicotine 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

4. 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

5. 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

6. 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

7. 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