Resp Osce

Question 1

What order do you present a resp exam?

Answer 1

• The patient was (dyspnoeic / comfortable) at rest breathing air and was (cyanosed / not cyanosed)
• The resp rate was ______ breaths per minute.
• Always comment on clubbing, lymphadenopathy and mediastinal shift. Mention other positive findings.
• Comment on percussion, breath sounds, added sounds and vocal resonance
• Give differential diagnosis
• Comment on presence / absence of cor pomunale in the context of chronic lung disease (COPD, ILD)

Question 2

What are the causes of interstitial lung disease?

Answer 2

1) idiopathic
- Cryptogenic fibrosing alveolitis
2) Due to inhaled antigen
- Bird fanciers lung
- Farmers lung
3) Due to an inhaled irritant
- Asbestosis / silicosis
- Coal worker’s pneumoconiosis (occupational lung disease that is restrictive caused by inhalation of dust often in mines)
4) Associated with systemic diseases
- SLE
- RA
- Sarcoid
- Systemic sclerosis
5) Drug induced
- Methotrexate
- Amiodarone (rate control)

Question 3

Ddx for the causes of Horner’s syndrome

Answer 3

1) Central lesion
- Stroke / Tumour / Multiple sclerosis
- Syringobulbia
2) T1 root lesion
- spondylolysis
- Neurofibroma
3) Brachial plexus
- Pancoast tumour
- Cervical rib
- Trauma / birth injury (Klumpke’s)
4) Neck
- Tumour
- Carotid artery aneurysm
- Sympathectomy
5) With cluster headaches

Question 4

What would you expect to find if you examined a patient with a lobectomy or a pneumonectomy and what are the indications for it?

Answer 4

Given away by a thoracotamy scars
It is indicated in 
    - Bronchogenic carcinoma, 25% of non-SCLC is                              resectable, 
    - Bronchiectasis
    - Trauma 
    - Old treatment for TB

Question 5

What are the complications of a lobectomy and pneumonectomy?

Answer 5

• Elevated diaphragm and lung
• Fistula between pleural and oesophagus
• Empyema

Question 6

What pathology would cause a decrease in breath sounds and vocal resonance and how would you differentiate?

Answer 6

A collapse
   - mediastinal shift towards
   - dull on percussion
An Effusion
   - Mediastinal shift away if big
   - Stony dull on percussion
Pneumothorax
   - Away if tension
   - tympanic percussion

Question 7

What are the expected clinical findings in a person who has undergone a pneumonectomy?

Answer 7

• Mediastinal shift towards the resected lung
• Dull on percussion
• Absent breath sounds
• Absent vocal resonance

Question 8

Causes of pleural effusion

Answer 8

Transudate (protein < 30 g/L)
   - CCF
   - Volume overload
   - Hypoalbuminaemia
   - Meigs syndrome
Exudate (Protein > 30 g/L)
   - Infection (Pneumonia, TB)
   - Infarction (P.E.)
   - Inflammation (RA, SLE)
   - Malignancy (Bronchogenic or mesothelioma)

Question 9

Differentials for bibasal crepitations

Answer 9

• Pulmonary Oedema
• ILD
• Bronchiectasis
• Cystic fibrosis

Question 10

what does a bronchial breath sound indicate

Answer 10

• Consolidation