OSCE - Respiratory

Question 1

Examination - JACCO

Answer 1

• Jaundice - Yellowing of skin and sclera of eyes. Can be caused by the build-up of Bilirubin (yellow/brown - the product of red blood cell breakdown):
  
  • Gallstones
  • Alcoholic Liver Disease
  • Pancreatitis
  • Hepatitis
  • Sickle Cell
• Anaemia - Pallor in mucous membranes or dull, pale skin caused by lack of red blood cells.
• Cyanosis - Bluish discolouration of the skin due to poor circulation/inadequate oxygenation of the blood. Peripherally caused by low O₂ in the red blood cells, or problems getting oxygenated blood to the body. Cold temps. can lead to blood vessel narrowing & temporarily blue-tinged skin. Central cyanosis is more serious and can be caused by low cardiac output.
• Clubbing - Deformity of the finger or toenails associated with a number of diseases, mostly of the heart & lungs.
• Oedema - Condition characterised by an excess of watery fluid collecting in the cavities or tissues of the body. Note lower leg/ankle (?sacral?) oedema could be an indication of heart failure

Question 2

Inspection - Face/Neck

Answer 2

• Colour - assess for cyanosis, pallor or flushed appearance.
• Trachea - central trachea is normal, deviated position indicates pneumothorax, tracheal tug indicates respiratory distress.
• Jugular veins - distention and pulsating JV indicates raised jugular venous pressure, which can indicate acute heart failure.
• Accessory muscle use - tripoding/not speaking in sentences are indications of respiratory distress.
• Audible sounds - are any sounds openly heard - wheeze, stridor, cough.
• Sputum - Present/not present? Colour, clear=good/green=infection/brown=blood.

Question 3

Inspection - Hands

Answer 3

• Warm - indicative of good perfusion.
• Dry - indicative of dehydration, not clammy.
• Perfused - pallor or cyanosis?
• Tremor - indicative of neurological conditions such as Parkinson’s.
• Splinter Haemorrhage - indicative of infectious endocarditis. ?fever/heart murmur/petechiae/anaemia.
• Nicotine staining - note yellowing of fingers.
• Xanthomas - fatty growths develop under the skin, caused by high levels of blood lipids/fats, a symptom of an underlying condition - hyperlipidaemia/high cholesterol.
• Capillary refill - over 2 seconds indicates of poor perfusion

Question 4

Inspection - Chest

Answer 4

• Shape - Trauma, barrel-chested(emphysema), scoliosis(spinal curvature), kyphosis(hunch back) all of which may cause postural breathing difficulty.
• Symmetry - equal chest rise? unequal could indicate trauma or pneumothorax.
• Rate - count & comment
• Scars - previous trauma or surgery.
• Recession - Indicates respiratory distress, time-critical feature.

Question 5

Palpation

Answer 5

• Lumps/Lesions - injuries, tumours, growths.
• Deformity - trauma, large tumours, congenital defects.
• Tenderness - muscular + bony tenderness. ? pain on chest expansion.
• Skin Temp/Moisture - hot, cold, clammy(? cardiac), dry(? dehydrated), pyrexia(? infection).
• Chest Expansion - able to fully expand? what limits it? Is there pain?
• Tactile Fremitus - palpable vibrations when the words blue balloon are spoken indicates consolidation, mass or fluid.

Question 6

Percussion

Answer 6

• Good Technique - looking for good finger strike
• Correct Locations - start on clavicle to identify solid noise, move around, front, back, sides.
• Dullness - indicates growth, consolidation, fluid.
• Hyperresonance - occurs in the chest as a result of over-inflation of the lung such as in emphysema or pneumothorax.
• Other findings

Question 7

Auscultation

Answer 7

There are 2 normal breath sounds. Bronchial & Vesicular. Sounds heard over the tracheobronchial tree are called bronchial breathing. Sounds heard over the lung tissue are called vesicular breathing.

• Good Technique
• Correct Location
• Front
• Back - Avoid scapula - ask the patient to hug themselves while leaning forward slightly.
• Sides - Lower lobe
• Tracheal Sounds - listen and identify bronchial breathing sounds for the individual. Bronchial breathing heard anywhere other than over the trachea, R-clavicle or R-interscapular space is abnormal. Presence of bronchial breathing could suggest:
  
  • consolidation
  • mass between the chest wall and large airways
  • tension pneumothorax
  • pleural effusion
• Vesicular Sounds - low pitched and softer than bronchial breathing. Expiration is shorter and there is no pause between inspiration and expiration. Abnormal findings present as intensity of breath sounds. Breath sounds markedly decreased in emphysema.
• Absent/reduced sounds - note the absence or reduced sounds. Could be an indication of air or fluid in/or around the lungs(? pneumonia, heart failure, pleural effusion), increased thickness of the chest wall.
• Wheeze/reduced sounds - wheeze caused by narrowing/bronchospasm of small airways in the lungs. Inflammation in the throat or large airways can cause wheezing.
• Stridor - inspiratory stridor suggests airway obstruction above the glottis(epiglottis), whilst expiratory stridor suggests obstruction in the lower trachea(croup).
• Pleural Rub - an indication of pleurisy(pleura irritated and inflamed), resulting in the 2 layers of the pleural membrane rubbing against each other like sandpaper, causing pain when the patient inhales and exhales.
• Crackles - often associated with inflammation or infection of the small bronchi, bronchioles or alveoli. Crackles that do not clear after a cough may indicate pulmonary oedema or fluid in the alveoli due to heart failure, pulmonary fibrosis, or acute respiratory distress syndrome.

Question 8

Special Tests

Answer 8

All of the following may be used as tests to confirm the presence of the likes of consolidation, fluid, or fibrosis:

• Egophony - the increased resonance of voice sounds heard on auscultation. Ask the patient to say ‘E’ and it will sound like an ‘A’.
• Whispered Pectoriloquy - increased loudness of whispering heard on auscultation. Normally whispering would barely be able to be heard during auscultation.
• Bronchophony - abnormal transmission of sounds from the lungs/bronchi. The sound of spoken voice heard when not auscultating over the bronchus or large airways.

Question 9

Further Tests

Answer 9

• JVP - the most common cause of a raised JVP is congestive cardiac failure, in which the raised venous pressure reflects a right ventricular failure:
  
  • position the patient at an angle of 45°
  • ask the patient to turn their head to the left
  • observe the level of the jugular venous pulsations just above the clavicle
• Oedema - in the lower legs is a sign of heart problems. If the heart isn’t working well, blood flow slows and backs up in the veins of the legs. This, in turn, causes fluid build up in the tissues, and the excess salt causes the body to retain water, which then leaks into the interstitial spaces, where it appears as oedema. Medications can also cause pitting oedema. The most common local conditions that cause oedema are varicose veins and thrombophlebitis(inflammation of the veins) of the deep leg veins.
• ECG
• Any suggested by scenario