[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left”][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

“This patient has presented to the acute medical unit on account of shortness of breath.  Please examine their respiratory system to identify why then tell the examiners what signs you find and discuss your proposed management”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/242964183/”][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”6″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”4″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left”][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has a normal respiratory system with no clinical signs.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]In the respiratory station you will be provided with a brief introduction to a case, and then observed examining a patient with clinical signs (or occasionally a healthy individual without clinical signs).  Typically the introduction will give you few clues as to the underlying pathology – but sometimes may indicate that the patient has a cough, some breathlessness or chest pain.

Typically auscultation in the respiratory station is less challenging than in the cardiovascular station, with more clues arising from inspection of the patient and combining findings with your stethoscope with other observations made during your examination.

In detail

Before starting, ensure your patient is adequately exposed, comfortable, and sitting at 45 degrees on the examination couch.  Introduce yourself and ask permission to examine their lungs.

Inspection

  1. From the bedside or end of the bed look at your patient for:
    1. Cachexia or obesity;
    2. Scars;
    3. Pursed lip breathing;
    4. Any obvious Horner’s syndrome;
    5. Chest wall deformities;
    6. Obvious abnormalities in chest excursion or obvious hyperinflation;
    7. Accessory muscle breathing;
    8. Don’t forget to listen – some patients will cough or have clicks (bronchiectasis) or gurgles (respiratory tract secretions).
    9. Count the respiratory rate for thirty seconds.
  2. Look around the bed-space for:
    1. Inhalers;
    2. Nebulisers;
    3. Sputum pots;
    4. Portable oxygen cylinders.
  3. Inspect the hands for:
    1. Clubbing;
    2. Cyanosis;
    3. Nicotine staining;
    4. Hypertrophic pulmonary osteoarthropathy;
  4. Inspect the patient more closely for:
    1. A phrenic nerve crush scar in the supraclavicular fossae;
    2. Evidence of a raised JVP (raised and fixed in cor pulmonale);
    3. Central cyanosis, by looking at the tongue.

Palpation

  1. Palpate the trachea for any deviation or tub;
  2. Check for lymphadenopathy by standing behind the patient and palpating the cervical, supraclavicular and axillary areas in turn;
  3. Check chest expansion;

Percussion

  1. Percuss at around five levels, starting in the supraclavicular fossae then alternating sides to identify asymmetry;
  2. If you think you identify any dullness to percussion explore further to delineate it’s margins;
  3. Remember, the upper margin of liver dullness is at the sixth intercostal space and resonance below this level may indicate hyperinflation.

Auscultation

  1. First, listen with the bell of your stethoscope in the supraclavicular fossae;
  2. Next auscultate through the anterior chest with the diaphragm, again alternating left and right;
  3. Finally check for vocal resonance by getting your patient to say “Ninety-nine while auscultating.

For a master class in breath sound auscultation be sure to visit our multimedia section with a focus on breath sounds where you can practice with a vast audio library of breath sounds encountered in clinical practice.

Now sit your patient forwards and examine the back of the chest, repeating palpation, percussion and auscultation as above.

Conclusion of examination

  1. Briefly palpate the patient’s ankles for any pedal oedema;
  2. Thank the patient and assist them to get comfortable again;
  3. Turn to face the examiners and tell them:

To conclude the examination I would like check their pulse oximetry and peak expiratory flow rate.

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has a clinically normal respiratory system.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]