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OSCE: Respiratory Medicine

OSCE: Respiratory Medicine. History. SOB Chest Pain Wheeze Cough Sputum Occupational exposure Exercise tolerance Home NEBS, 02 Childhood illnesses Weight loss Ankle swelling. Examination. Hyperinflated chest Quiet breath sound and/or wheeze Purse lip breathing

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OSCE: Respiratory Medicine

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  1. OSCE: Respiratory Medicine

  2. History • SOB • Chest Pain • Wheeze • Cough • Sputum • Occupational exposure • Exercise tolerance • Home NEBS, 02 • Childhood illnesses • Weight loss • Ankle swelling

  3. Examination • Hyperinflated chest • Quiet breath sound and/or wheeze • Purse lip breathing • Accessory muscle use • Paradoxical lower rib movement • Peripheral cyanosis • Raised JVP • Tar staining • Clubbing • Cachexia • Oedema • Quiet heart sounds; reduced dullness on percussion.

  4. Investigations • Spirometry • CXR • CT thorax – high res/ staging/ CTPA • Bronchoscopy • ECG • Echocardiogram • Pulse oximetry • PEFR • Sputum culture • Alpha 1 antitrypsin • Sleep study • ABG • Routine bloods

  5. Past OSCE questions • Pneumothorax – take a short history from a patient with sudden onset chest pain. Interpret CXR of collapsed lung. Know causes of pneumothorax – spontaneous, PPV, malignancy, COPD. • Asthma – (1) Newly diagnosed asthmatic; talk to the patient for 5 minutes. (2) 22 year old female, known asthmatic, attends A&E with SOB – discuss management. (3) The same patient is now stable and ready for discharge – spend 10 minutes talking to the patient. • Known 63 year old male with COPD visits GP surgery for a routine check up – carry out a focused examination.

  6. 54 year old M attends A&E with cough and recurrent chest infections. Take a focused history. • 65 year old F attends your GP practice complaining of 3/12 Hx of hoarse voice. Take a focused history. • 32 year old F was admitted with a PE and is ready for discharge. Counsel her on Mx. • 19 year old M with sudden onset R sided chest pain. Take a focused history and examination.

  7. Common management • COPD • Asthma • Pneumothorax • PE

  8. Common management options in respiratory disease • Lifestyle factors - smoking cessation!! • Follow up with MDT • Short acting beta agonists act on smooth muscle to dilate airways – poor side effect to benefit ratio in COPD. Long acting eg salmeterol also available. • Anticholinergics – (cholinergic nerves in COPD increase smooth muscle tone in COPD). Dilation of airways and increase in mucocillary clearance. Eg Ipratropium bromide (Atrovent) and tiotropium bromide (Spiriva) • Theophylline – relax smooth muscle and increase diaphragmatic strength. Extra pulmonary benefits ie increasing cardiac output. Narrow therapeutic index – need to monitor levels. • Corticosteroids. • Antibiotics • NEBS • Oxygen therapy • NIV

  9. Case 1 • 30 yr old asthmatic patient becomes suddenly breathless and complains of chest pain. • RR 30 • Pulse 120 • O2 sats 80% room air • BP 85/60

  10. O/E • O/E - Trachea deviated to left, absent breath sounds on the right and hyper resonance on percussion.

  11. Case 2 68 F, day 1 post-DHS. She presents with dyspnoea. Her current medications include aspirin /simvastatin/ frusemide/ rampiril tablets, and salbutamol/ atrovent/ pulmicort nebs. Immediate Mx Differential Dx Investigations

  12. ABG • PH 7.35-7.45 • PaO2 >10.6 • PaCO2 4.7-6.0 • HCO3 24-30 • Acidosis? - ?cause • Hypoxic? • Hypercapnic • Compensation

  13. ABG 1 • PH 7.36 • PO2 6.7 • PCO2 10.3 • HCO3 42.4

  14. ABG 2 • PH 7.08 • PO2 22.1 • PCO2 14.3 • HCO3 20.3

  15. ABG 3 • PH 7.57 • PO2 10.2 • PCO2 2.3 • HCO3 24

  16. ABG 4 • PH 6.94 • PO2 13 • PCO2 2.8 • HCO3 3.0

  17. Thanks Any Questions?

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