Respiratory OSCE

Question 1

Diaphragm used for

Answer 1

high pitched sounds

Question 2

Bell used for

Answer 2

low pitched sounds

Question 3

Artefact clues

Answer 3

inhalers, peak flow meter, IV drips, sputum pots

Question 4

Accessory muscles

Answer 4

Characteristic of patients with COPD and severe asthma
Sternocleidomastoids + scalenus + pectoralis major and minor (inspiration) and internal intercostal and abdominal (expiration)- shoulders move up with inspiration

Question 5

Finger clubbing

Answer 5

Change in angle of nail bed associated with

• Tumours- benign or malignant eg Bronchial cancer, mesothelioma
• ILD: idiopathic pulmonary fibrosis, asbestosis
• Sepsis: bronchiectasis, CF, lung abscess, empyema, bacterial endocarditis
• AV shunting: AV malformations in the lung, cyanotic congenital heart disease

Question 6

Palmar erythema

Answer 6

Redness of thenar and hypothenar eminences associated with a hyperdynamic circulation (high output states such as pregnancy, hyperthyroidism, rheumatoid arthritis, cirrhosis)

Question 7

Cyanosis

Answer 7

Deoxyhaemoglobin causes skin and mucous membranes to appear blue when greater than 5g/dL
Hypoxaemia
Prevent adaquate gas transfer and oxidation of the blood- COPD, pulmonary oedema, pneumonia PE, acute severe asthma can result in peripheral cyanosis
Peripheral vasoconstriction due to cold and circulatory disorders, beta blockers
Sat

Question 8

Fine tremor

Answer 8

Beta agonist (salbutamol)

Question 9

Flapping tremor

Answer 9

CO2 Flap, respiratory failure/acidosis (CO2 retention)

Also CNS, drugs, liver and renal failure and electrolyte disturbance

Question 10

Pursed lip breathing

Answer 10

Increase end expiratory pressure as can reduce alveolar collapse at the end of expiration

Question 11

JVP

Answer 11

internal jugular vein which passes just medial to the clavicular head of the sternocleidomastoid up behind the angle of the jaw to the earlobes

(45 degrees, bifid and non-palable, enhanced by hepatojugular reflex)

Question 12

Raised JVP

Answer 12

Vertical height above the sternal angle, raised if >4 cm

Raised in COPD, if intrathoracic P is raised in tension pneumothorax or severe asthma, massive PE

Question 13

DVT

Answer 13

Redness, oedema, warm to touch, painful, tenderness/heavy ache

Question 14

Oxygen saturation

Answer 14

94-100% is normal

Target: 94-98%, in those at risk of type II respiratory failure due to significant COPD= 88-92%

Question 15

FiO2

Answer 15

Fraction of inspired oxygen (room air has an FiO2 of 21%)

Question 16

Nasal cannula

Answer 16

Indication: low oxygen requirement
+ves: Patient can speak and eat, cheap, comfortable,
no rebreathing
-ves: Dislodged,
no mouth cover so depends on breathing pattern
Flow rate: 2-6 L/min
FiO2: 24-50%

Question 17

Simple face mask/Hudson

Answer 17

Indication: short term, low oxygen needs
\+ves: Cheap, allows CO2 to escape
-ves: Uncomfortable
Flow rate: 5-10 L/min
FiO2: Variable

Question 18

Venturi mask

Answer 18

Indication: Risk of type II and need exact FiO2
Flow rate: as stated on device
FiO2: 24-60% (blue=24%, white=28%, yellow=35%, red=40%, green=60%)

Question 19

Reservoir mask

Answer 19

Indication: Critical illness
Flow rate: 15L/min
FiO2: 60-80%

Question 20

PEFR

Answer 20

Mild >75%, moderate 50-75%, severe 33-50%, life threatening

Question 21

Breath sounds

Answer 21

Vesicular, bronchovesicular, bronchial, tracheal

Question 22

Respiratory rate

Answer 22

12-20 is normal (but 20 is quite high)

Question 23

Heart Rate

Answer 23

60-100 bpm is normal (expect 60-80 bpm)

Question 24

Plethoric

Answer 24

Redness of cheeks caused by raised Hb conc with elevated haematocrit (polycythaemia, vasodilation, vascular overload)

Question 25

Lymph nodes to check

Answer 25

Submittal, 
      Submandibular,
      Anterior triangle,
      Posterior triangle,
      Pre-auricular,
      Post-auricular,
      Occipital,
      Supraclavicular