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RESPIRATORY MEDICINE IN AN
HOUR AND A HALF
Objectives
By the end of this session you should be:
 Familiar with potential OSCE scenarios relating to
respiratory medi...
Content
1. OSCE
2. Discuss major topics you need to know
3. SBA practice
OSCE 1
You are a FY1 working in a GP surgery.
This patient has just received a
diagnosis of asthma. You have been
asked to...
OSCE 2
 WIPER
 Introduce and explain purpose of interview
 Check understanding of Asthma and rationale
behind inhaler t...
OSCE 3
1. Check medication date
2. Stand up sit up straight before using inhaler
3. Remove cap and shake inhaler
4. Hold c...
OSCE 4
 Offer spacer if breath holding difficult
 If steroid inhaler it will be a daily dose. Wash mouth
out afterwards
...
Asthma 1: Definition
 Common chronic inflammatory disease of the
airways characterised by variable and recurring
symptoms...
Asthma 2: Mechanism of
obstruction
 Increased inflammatory mediators
 Mast cell activation
 Bronchoconstriction
 Airwa...
Asthma 3: Symptoms
Asthma 3: Symptoms
 Intermittent dyspnoea
 Wheeze
 Cough (often nocturnal)
 Sputum
Asthma 4: History
 Precipitants
 Cold air, exercise, allergens, smoking, pollution, etc.
 Diurnal variation
 Exercise ...
Asthma 5: Signs
Asthma 5: Signs
 Tachypnoea
 Audible wheeze
 Hyperinflated chest
 Hyperresonant percussion
 Diminished air entry
Asthma 6: Investigations
 Monitor PEF
 Spirometry
 Bronchodilator reversibility
 Allergen skin prick tests
 Aspergill...
Asthma 7: Management
 Behaviour: Quit smoking; avoid precipitants
 British Thoracic Society Guidelines…
British Thoracic Society
Guidelines
 Step 1: SABA – PRN (Salbutamol)
 Step 2: + standard-dose inhaled steroid (Beclometa...
Asthma 8: Attack
 Severe Attack
 Can’t finish
sentences
 HR >110
 PEF 33 - 50%
predicted
 Life-threatening
Attack
 S...
Asthma 9: Attack Ix
 PEF
 Sputum culture
 FBC, U&E, CRP, blood cultures
 ABG: normal/high PaCO2; PaO2 <8kPa; low pH (<...
Asthma 10: Attack Management
 Assess severity
 Sit patient up
 High-dose O2 in 100% via non-rebreathing bag
 Salbutamo...
COPD 1: Definition
 Common progressive disorder characterised by airway
obstruction with little or no reversibility.
 FE...
Chronic Bronchitis Emphysema
BLUE BLOATERS
PINK PUFFERS
COPD 2: Signs and Symptoms
COPD 3: Investigations
 Lung function tests:
 Obstructive pattern
  TLC,  RV
 CXR:
 hyperventilation, flat diaphrag...
COPD 4: Management – Acute
Exacerbation
 Controlled O2 therapy – Start at 24-28%
 Nebulized bronchodilators
 Steroids
...
COPD 5: Management – Long-
term
 Lifestyle advice
 Smoking cessation
 Exercise
 Dietary advice
 Vaccinations
 Mild -...
COPD 6: Additional
management
 Consider Long-term O2 therapy if:
 Clinically stable non-smokers
 PaO2 <7.3kPA stable on...
Tuberculosis 1: Definition
 Infectious disease most commonly cause by
Mycobacterium tuberculosis
 Transmission by inhala...
Tuberculosis 2:
Primary TB (10)
 First contact with Bacillus
 Initial lesion in the parenchyma and
subpleural space
 In...
Tuberculosis 3: Signs and
Symptoms: There are loads…
REMEMBER:
• Weight loss
• Night sweats
• Haemoptysis
• Fever
• Travel...
Tuberculosis 4: Investigations
• Latent TB – Mantoux test
• Active TB – CXR
• If suggestive - sputum samples for
acid fast...
Tuberculosis 5:
Management – start without culture results
ETHAMBUTOL - (EYE) Optic neuritis – 1st sign = colour vision da...
Pneumonia 1: Definition
 Inflammation of lung parenchyma, usually as a
result of infection.
 Clinically acute illness.
...
Pneumonia 2: Classification
 CAP vs. HAP
 Lobar vs. Interstitial
 Typical vs. Atypical
Pneumonia 3: CAP vs. HAP
 Community Acquired Pneumonia: Presents in the
community or within 48 hours of attending hospita...
Pneumonia 4: Organisms
 Typical CAP Organisms:
 Strep. pneumoniae
 H. influenzae
 Moraxella influenzae
 Staph. aureus
Pneumonia 5: Symptoms
Pneumonia 5: Symptoms
 Fever
 Pleuritic chest pain
 Dry cough progressing to rusty-sputum producing
cough
 Rapid shall...
Pneumonia 6: Signs
 Temp. up to 39.5 °C
 Rigors
 Malaise
 Anorexia
 Purulent sputum
  O2 sats
 CVS: Tachycardia, h...
Pneumonia 7: Investigations
Pneumonia 7: Investigations
 CXR: shows consolidation.
 ABG
 Bloods incl. culture
 Sputum microscopy & culture
CXR
Lobar Pneumonia:
Focal area of
consolidation. This can be
difficult to differentiate
from pulmonary oedema
and fluid a...
CXR 2
Try to spot air bronchiograms. These
can be hard to spot but they are
essentially round black areas
surrounded by wh...
Pneumonia 8: Management
 Oxygen
 IV fluids
 Analgesia (eg. Paracetamol)
 Antibiotics
 Check for progression/ complica...
Pneumonia 9: Assessing
severity
• C
• U
• R
• B
• 65
Pneumonia 9: Assessing
severity
• Confusion (abbreviated mental test <8)
• Urea (> 7mmol/L)
• Respiratory Rate (>30/min)
•...
Pneumonia 10: CURB 65 Empirical
Treatment
 0-1 treat as an outpatient
 2 consider a short stay in hospital or watch very...
Pneumonia 11: Prevention
• Vaccination and penicillin prophylaxis in those at
high risk
• Hand washing and VAP precautions...
Pleural Effusion 1: Definition
 Excessive accumulation of fluid in the pleural
space.
 Divided into:
 Transudate effusi...
Pleural Effusion 2: Transudate vs.
Exudate
 Pleural fluid: Serous fluid produced by normal
pleura, contained within the c...
Transudate < 30g/L
Production Reabsorption
Production
Reabsorption
 Hydrostatic pressure   Venous Pressure
• Cardiac fa...
Exudate > 30g/L
Production
Reabsorption
 Permeability via inflammatory mediators
• Pneumonia / TB
• Rheumatoid arthritis ...
Pleural Effusion 3: Signs and
Symptoms
 Asymptomatic
OR:
 Dyspnoea
 Pleuritic chest pain - sharp and localised
 NB: Lo...
Pleural Effusion 4: Investigations
 CXR
Small = Blunt Costophrenic
angles
Large = Water dense
shadow and concave
upper bo...
Pleural Effusion 5: Management
 Drainage < 2L/24h
 Pleurodesis - if recurrent
 Thoracoscopic talc pleurodesis
 Surgery
SBA PRACTICE
QUESTIONS
A 45-year-old lady with known chronic obstructive pulmonary disease (COPD) is
admitted to the respiratory ward with shortn...
A 45-year-old lady with known chronic obstructive pulmonary disease (COPD) is
admitted to the respiratory ward with shortn...
A 27-year-old American afro-Caribbean lady undergoes a routine chest x-ray during a
career-associated medical examination....
A 27-year-old American afro-Caribbean lady undergoes a routine chest x-ray during a
career-associated medical examination....
A 16-year-old boy is admitted to A&E with an acute exacerbation of his asthma. He
has a respiratory rate of 30 breaths per...
A 16-year-old boy is admitted to A&E with an acute exacerbation of his asthma. He
has a respiratory rate of 30 breaths per...
A 55-year-old male presents to the pespiratory outpatients department with a dry
cough and increasing breathlessness. On e...
A 55-year-old male presents to the respiratory outpatients department with a dry
cough and increasing breathlessness. On e...
A 36-year-old telephonist with a 5-year history of sarcoidosis admits to increasing
shortness of breath over the past 4 we...
A 36-year-old telephonist with a 5-year history of sarcoidosis admits to increasing
shortness of breath over the past 4 we...
A 55-year-old lady presents to hospital with shortness of breath and lethargy. On
clinical examination there are moderate ...
A 55-year-old lady presents to hospital with shortness of breath and lethargy. On
clinical examination there are moderate ...
As part of the investigation of breathlessness, a patient has spirometry performed.
The following results are available:
W...
As part of the investigation of breathlessness, a patient has spirometry performed.
The following results are available:
W...
A 21-year old sportsman attends A&E acutely short of breath accompanied by right-
sided pleuritic chest discomfort. His on...
A 21-year old sportsman attends A&E acutely short of breath accompanied by right-
sided pleuritic chest discomfort. His on...
A 30-year-old patient presents with shortness of breath and a productive cough. On
examination the pulse is 90, BP 130/78 ...
A 30-year-old patient presents with shortness of breath and a productive cough. On
examination the pulse is 90, BP 130/78 ...
A 32-year-old Bangladeshi man currently being treated for tuberculosis presents to
his GP with generalised joint pain.
Wha...
A 32-year-old Bangladeshi man currently being treated for tuberculosis presents to
his GP with generalised joint pain.
Wha...
ANY QUESTIONS?
Please feel free to contact us:
• Dominic Fenn – dominic.fenn@ucl.ac.uk
• William Stephenson – william.step...
Objectives
By the end of this session you should be:
• Familiar with potential OSCE scenarios relating to
respiratory medi...
Respiratory Tutorial
Respiratory Tutorial
Respiratory Tutorial
Respiratory Tutorial
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Respiratory Tutorial

  1. 1. RESPIRATORY MEDICINE IN AN HOUR AND A HALF
  2. 2. Objectives By the end of this session you should be:  Familiar with potential OSCE scenarios relating to respiratory medicine.  Familiar with the must know respiratory conditions in relation to: definition, signs and symptoms, investigations and management.  Be able to attempt some sample SBA questions on topics covered.
  3. 3. Content 1. OSCE 2. Discuss major topics you need to know 3. SBA practice
  4. 4. OSCE 1 You are a FY1 working in a GP surgery. This patient has just received a diagnosis of asthma. You have been asked to discuss the condition and medication with the patient including how to use their inhaler.
  5. 5. OSCE 2  WIPER  Introduce and explain purpose of interview  Check understanding of Asthma and rationale behind inhaler therapy  Inhaler technique…
  6. 6. OSCE 3 1. Check medication date 2. Stand up sit up straight before using inhaler 3. Remove cap and shake inhaler 4. Hold canister vertical for delivery of drug 5. Exhale fully 6. Put mouthpiece in mouth at start of inspiration 7. Press canister down with index finger at the same time as breathing in 8. Inhalation should be slow and deep 9. Hold breath for 10 seconds 10. Wait about 30 seconds before administering the next dose 11. Close cap
  7. 7. OSCE 4  Offer spacer if breath holding difficult  If steroid inhaler it will be a daily dose. Wash mouth out afterwards  Ask if any questions  Offer leaflet
  8. 8. Asthma 1: Definition  Common chronic inflammatory disease of the airways characterised by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm  Clinically: Paroxysmal wheezing and SOB caused by acute, reversible narrowing of airways  5~8% population
  9. 9. Asthma 2: Mechanism of obstruction  Increased inflammatory mediators  Mast cell activation  Bronchoconstriction  Airways also become hyperresponsive  Increased mucus production  In severe cases structural changes may lead to irreparable damage  Mucus plugging may also occur
  10. 10. Asthma 3: Symptoms
  11. 11. Asthma 3: Symptoms  Intermittent dyspnoea  Wheeze  Cough (often nocturnal)  Sputum
  12. 12. Asthma 4: History  Precipitants  Cold air, exercise, allergens, smoking, pollution, etc.  Diurnal variation  Exercise tolerance  Acid reflux (40-60%)  Other atopic disease
  13. 13. Asthma 5: Signs
  14. 14. Asthma 5: Signs  Tachypnoea  Audible wheeze  Hyperinflated chest  Hyperresonant percussion  Diminished air entry
  15. 15. Asthma 6: Investigations  Monitor PEF  Spirometry  Bronchodilator reversibility  Allergen skin prick tests  Aspergillus serology
  16. 16. Asthma 7: Management  Behaviour: Quit smoking; avoid precipitants  British Thoracic Society Guidelines…
  17. 17. British Thoracic Society Guidelines  Step 1: SABA – PRN (Salbutamol)  Step 2: + standard-dose inhaled steroid (Beclometasone)  Remember mouth hygiene  Step 3: + LABA (Salmeterol)  If benefit but still inadequate control, increase steroid dose  Step 4: Consider trials of: beclometasone up to 1000 μg/12h; modified-release oral theophylline; modified- release oral ß2-agonist.  Step 5: + Prednisolone PO. Refer to asthma clinic
  18. 18. Asthma 8: Attack  Severe Attack  Can’t finish sentences  HR >110  PEF 33 - 50% predicted  Life-threatening Attack  Silent chest  Cyanosis  Bradycardia  Exhaustion – feeble resp effort  PEF <33% predicted
  19. 19. Asthma 9: Attack Ix  PEF  Sputum culture  FBC, U&E, CRP, blood cultures  ABG: normal/high PaCO2; PaO2 <8kPa; low pH (<7.35)  If PaCO2 is raised, transfer to ITU for ventilation  CXR
  20. 20. Asthma 10: Attack Management  Assess severity  Sit patient up  High-dose O2 in 100% via non-rebreathing bag  Salbutamol 5mg + ipatropium bromide 0.5mg nebulised with O2  Hydrocortisone 100mg IV or prednisolone 40-50mg PO or both  Consider magnesium sulphate  CXR
  21. 21. COPD 1: Definition  Common progressive disorder characterised by airway obstruction with little or no reversibility.  FEV1 < 80% predicted; FEV1/FVC < 0.7  Umbrella term for emphysema and chronic bronchitis  Emphysema – defined histologically as enlarged airspaces distal to terminal bronchioles with destruction of alveolar walls.  Bronchitis defined clinically as cough, sputum production on most days for 3/12 of 2 successive years.
  22. 22. Chronic Bronchitis Emphysema BLUE BLOATERS PINK PUFFERS
  23. 23. COPD 2: Signs and Symptoms
  24. 24. COPD 3: Investigations  Lung function tests:  Obstructive pattern   TLC,  RV  CXR:  hyperventilation, flat diaphragms, Large central pulmonary vasculature  ABG:  PaO2  +/- hypercapnia  Blood/sputum culture
  25. 25. COPD 4: Management – Acute Exacerbation  Controlled O2 therapy – Start at 24-28%  Nebulized bronchodilators  Steroids  Broad spec. Abx  Look for cause! (Infection, pneumothorax etc.)
  26. 26. COPD 5: Management – Long- term  Lifestyle advice  Smoking cessation  Exercise  Dietary advice  Vaccinations  Mild - Antimuscarinic (Ipratropium bromide) or B2 agonist (Salbutamol) PRN  Moderate - Regular antimuscarinic +/- long acting B2 agonist Salmeterol + inhaled corticosteroids  Severe - LABA + inhaled corticosteroid + anticholingeric  Consider PO prednisolone trial
  27. 27. COPD 6: Additional management  Consider Long-term O2 therapy if:  Clinically stable non-smokers  PaO2 <7.3kPA stable on two separate occasions  If PaO2 7.3-8.0 kPa + pulmonary hypertension + cor pulmonale
  28. 28. Tuberculosis 1: Definition  Infectious disease most commonly cause by Mycobacterium tuberculosis  Transmission by inhalation of droplet nuclei from infected individuals  1/3 of world’s population infected
  29. 29. Tuberculosis 2: Primary TB (10)  First contact with Bacillus  Initial lesion in the parenchyma and subpleural space  Involvement of draining hilar lymph nodes  Leads to formation of the GHON COMPLEX  Usually asymptomatic and most cases heal by scar formation Secondary TB (20)  Result of activation of latent 10 TB.  GHON COMPLEX  ASSMANN FOCUS 10 TB (pulmonary) 20 TB (reactivation) Progressive TB 75% active cases
  30. 30. Tuberculosis 3: Signs and Symptoms: There are loads… REMEMBER: • Weight loss • Night sweats • Haemoptysis • Fever • Travel Hx
  31. 31. Tuberculosis 4: Investigations • Latent TB – Mantoux test • Active TB – CXR • If suggestive - sputum samples for acid fast bacilli • Active non-pulmonary TB – find relevant clinical sample and send for cultures + CXR to exclude co-existing pulmonary TB Consolidation Cavitation Fibrosis + calcification esp. in the apices.
  32. 32. Tuberculosis 5: Management – start without culture results ETHAMBUTOL - (EYE) Optic neuritis – 1st sign = colour vision damage RIFAMPICIN - Red/orange discolouration of tears and urine + inactivation of the OCP + flu- like syndrome ISONIAZID - Neuropathy, agranulocytosis ( WCC – mainly neutrophils) PYRAZINAMIDE – Arthalgia (CI = Acute gout or porphyria)
  33. 33. Pneumonia 1: Definition  Inflammation of lung parenchyma, usually as a result of infection.  Clinically acute illness.  Signs and symptoms consistent with consolidation of the lungs
  34. 34. Pneumonia 2: Classification  CAP vs. HAP  Lobar vs. Interstitial  Typical vs. Atypical
  35. 35. Pneumonia 3: CAP vs. HAP  Community Acquired Pneumonia: Presents in the community or within 48 hours of attending hospital. Mainly caused by bacteria, although can also be caused by viruses.  Hospital Acquired Pneumonia: Presents 48hrs or more after admission to hospital. Occurs in up to 5% of all admissions.  Ventilator Associated pneumonia is a subset of HAP and has a mortality of between 50-60%.
  36. 36. Pneumonia 4: Organisms  Typical CAP Organisms:  Strep. pneumoniae  H. influenzae  Moraxella influenzae  Staph. aureus
  37. 37. Pneumonia 5: Symptoms
  38. 38. Pneumonia 5: Symptoms  Fever  Pleuritic chest pain  Dry cough progressing to rusty-sputum producing cough  Rapid shallow breathing
  39. 39. Pneumonia 6: Signs  Temp. up to 39.5 °C  Rigors  Malaise  Anorexia  Purulent sputum   O2 sats  CVS: Tachycardia, hypotensive, cyanosis  Resp.: Dyspnoea, tachypnoea, signs of consolidation (reduced expansion, dull percussion note, increased resonance, bronchial breathing, pleural rub)
  40. 40. Pneumonia 7: Investigations
  41. 41. Pneumonia 7: Investigations  CXR: shows consolidation.  ABG  Bloods incl. culture  Sputum microscopy & culture
  42. 42. CXR Lobar Pneumonia: Focal area of consolidation. This can be difficult to differentiate from pulmonary oedema and fluid accumulation
  43. 43. CXR 2 Try to spot air bronchiograms. These can be hard to spot but they are essentially round black areas surrounded by white consolidation (representing consolidation surrounding bronchioles).
  44. 44. Pneumonia 8: Management  Oxygen  IV fluids  Analgesia (eg. Paracetamol)  Antibiotics  Check for progression/ complications  F/U at 6 weeks (repeat CXR)
  45. 45. Pneumonia 9: Assessing severity • C • U • R • B • 65
  46. 46. Pneumonia 9: Assessing severity • Confusion (abbreviated mental test <8) • Urea (> 7mmol/L) • Respiratory Rate (>30/min) • Blood pressure (systolic< 90, diastolic< 60) • 65 yrs and above  0-1 = Mild  2 = Moderate  3-5 = Severe
  47. 47. Pneumonia 10: CURB 65 Empirical Treatment  0-1 treat as an outpatient  2 consider a short stay in hospital or watch very closely as an outpatient  3-5 requires hospitalization possibly ITU  MILD/MODERATE  Amoxicillin or Clarithromycin   SEVERE  Coamoxiclav plus clarithromycin  Benzylpencillin plus clarithromycin  Clarithromycin plus rifampicin for Legionnaires
  48. 48. Pneumonia 11: Prevention • Vaccination and penicillin prophylaxis in those at high risk • Hand washing and VAP precautions • Hyperchlorination of water and heating (prevent Legionaires • Stop smoking (mucocillary paralysis etc…)
  49. 49. Pleural Effusion 1: Definition  Excessive accumulation of fluid in the pleural space.  Divided into:  Transudate effusion  Exudate effusion
  50. 50. Pleural Effusion 2: Transudate vs. Exudate  Pleural fluid: Serous fluid produced by normal pleura, contained within the cavity to aid lung function.  Transudate – Excess fluid with protein < 30g/L  Exudate – Excess fluid with protein > 30g/L
  51. 51. Transudate < 30g/L Production Reabsorption Production Reabsorption  Hydrostatic pressure   Venous Pressure • Cardiac failure • Fluid Overload • Constrictive pericarditis Hypoproteinaemia   Oncotic pressure • CLD - Cirrhosis • Nephrotic syndrome • Malabsorption
  52. 52. Exudate > 30g/L Production Reabsorption  Permeability via inflammatory mediators • Pneumonia / TB • Rheumatoid arthritis / SLE • Malignancy - carcinoma
  53. 53. Pleural Effusion 3: Signs and Symptoms  Asymptomatic OR:  Dyspnoea  Pleuritic chest pain - sharp and localised  NB: Look out for signs of associated disease
  54. 54. Pleural Effusion 4: Investigations  CXR Small = Blunt Costophrenic angles Large = Water dense shadow and concave upper borders
  55. 55. Pleural Effusion 5: Management  Drainage < 2L/24h  Pleurodesis - if recurrent  Thoracoscopic talc pleurodesis  Surgery
  56. 56. SBA PRACTICE QUESTIONS
  57. 57. A 45-year-old lady with known chronic obstructive pulmonary disease (COPD) is admitted to the respiratory ward with shortness of breath, cough and wheeze. On examination she appears unwell, short of breath and there is an audible wheeze. On examination her respiratory rate is 30 breaths per minute and oxygen saturations are 90% on room air. She reports that she is able to leave the house but that she has to stop for breath after walking approximately 100m. What grade on the MRC dyspnoea scale would this patient be recorded as having? A. 1 B. 2 C. 3 D. 4 E. 5
  58. 58. A 45-year-old lady with known chronic obstructive pulmonary disease (COPD) is admitted to the respiratory ward with shortness of breath, cough and wheeze. On examination she appears unwell, short of breath and there is an audible wheeze. On examination her respiratory rate is 30 breaths per minute and oxygen saturations are 90% on room air. She reports that she is able to leave the house but that she has to stop for breath after walking approximately 100m. What grade on the MRC dyspnoea scale would this patient be recorded as having? A. 1 B. 2 C. 3 D. 4 E. 5
  59. 59. A 27-year-old American afro-Caribbean lady undergoes a routine chest x-ray during a career-associated medical examination. The chest x-ray report reveals bilateral hilar lymphadenopathy. On closer questioning the patient admits to symptoms of fatigue and weight loss and painful blue-red nodules on her shins. What is the likely diagnosis in this case? A. Tuberculosis B. Sarcoidosis C. Lung cancer D. Pneumonia E. Mesothelioma
  60. 60. A 27-year-old American afro-Caribbean lady undergoes a routine chest x-ray during a career-associated medical examination. The chest x-ray report reveals bilateral hilar lymphadenopathy. On closer questioning the patient admits to symptoms of fatigue and weight loss and painful blue-red nodules on her shins. What is the likely diagnosis in this case? A. Tuberculosis B. Sarcoidosis C. Lung cancer D. Pneumonia E. Mesothelioma
  61. 61. A 16-year-old boy is admitted to A&E with an acute exacerbation of his asthma. He has a respiratory rate of 30 breaths per minutes, pulse rate of 113 beats per minute, and he is unable to complete full sentences. What would be the most appropriate first line of management for this patient? A. Give their usual bronchodilator B. Contact senior help and the intensive care unit C. Give salbutamol by oxygen driven nebuliser D. Give high oxygen concentration (>60%) E. Give IV magnesium sulphate
  62. 62. A 16-year-old boy is admitted to A&E with an acute exacerbation of his asthma. He has a respiratory rate of 30 breaths per minutes, pulse rate of 113 beats per minute, and he is unable to complete full sentences. What would be the most appropriate first line of management for this patient? A. Give their usual bronchodilator B. Contact senior help and the intensive care unit C. Give salbutamol by oxygen driven nebuliser D. Give high oxygen concentration (>60%) E. Give IV magnesium sulphate
  63. 63. A 55-year-old male presents to the pespiratory outpatients department with a dry cough and increasing breathlessness. On examination the physician notes finger clubbing, central cyanosis and fine end-inspiratory crackles on auscultation. A chest x-ray reveals reticular shadows and peripheral honeycombing. Respiratory function tests reveal a restrictive pattern (reduced lung volumes, but normal FEV1:FVC ratio). A diagnosis of pulmonary fibrosis is made due to drug therapy. Which of the following medications could be responsible for causing the gentleman’s pulmonary fibrosis? A. Aspirin B. Ramipril C. Bleomycin D. Spironolactone E. Simvastatin
  64. 64. A 55-year-old male presents to the respiratory outpatients department with a dry cough and increasing breathlessness. On examination the physician notes finger clubbing, central cyanosis and fine end-inspiratory crackles on auscultation. A chest x-ray reveals reticular shadows and peripheral honeycombing. Respiratory function tests reveal a restrictive pattern (reduced lung volumes, but normal FEV1:FVC ratio). A diagnosis of pulmonary fibrosis is made due to drug therapy. Which of the following medications could be responsible for causing the gentleman’s pulmonary fibrosis? A. Aspirin B. Ramipril C. Bleomycin D. Spironolactone E. Simvastatin
  65. 65. A 36-year-old telephonist with a 5-year history of sarcoidosis admits to increasing shortness of breath over the past 4 weeks when attending respiratory outpatients. This is his fourth episode of this nature since his diagnosis. He has previously responded well to tapered doses of oral steroids. What initial test would be most helpful before prescribing steroids to assess his current pulmonary status objectively? A. CXR B. Pulmonary function tests with transfer factor C. ABG D. Serum ACE level E. High-resolution CT of chest
  66. 66. A 36-year-old telephonist with a 5-year history of sarcoidosis admits to increasing shortness of breath over the past 4 weeks when attending respiratory outpatients. This is his fourth episode of this nature since his diagnosis. He has previously responded well to tapered doses of oral steroids. What initial test would be most helpful before prescribing steroids to assess his current pulmonary status objectively? A. CXR B. Pulmonary function tests with transfer factor C. ABG D. Serum ACE level E. High-resolution CT of chest
  67. 67. A 55-year-old lady presents to hospital with shortness of breath and lethargy. On clinical examination there are moderate left sided pleural effusions. A pleural aspirate is performed on the ward. Analysis is shown: What is the most likely cause of the pleural effusion? A.Mesothelioma B.Hypothyroidism C.Pneumonia D.Bronchial carcinoma E.Pulmonary embolus
  68. 68. A 55-year-old lady presents to hospital with shortness of breath and lethargy. On clinical examination there are moderate left sided pleural effusions. A pleural aspirate is performed on the ward. Analysis is shown: What is the most likely cause of the pleural effusion? A.Mesothelioma B.Hypothyroidism C.Pneumonia D.Bronchial carcinoma E.Pulmonary embolus
  69. 69. As part of the investigation of breathlessness, a patient has spirometry performed. The following results are available: Which of the following is the most likely cause? A.Asthma B.Emphysema C.Bronchiectasis D.Allergic bronchopulmonary aspergillosis E.Asbestosis
  70. 70. As part of the investigation of breathlessness, a patient has spirometry performed. The following results are available: Which of the following is the most likely cause? A.Asthma B.Emphysema C.Bronchiectasis D.Allergic bronchopulmonary aspergillosis E.Asbestosis
  71. 71. A 21-year old sportsman attends A&E acutely short of breath accompanied by right- sided pleuritic chest discomfort. His only past medical history is of childhood asthma and a collapsed lung aged 17. On examination – RR 22bpm, SpO2 95%. CXR: right- sided pneumothorax – 30% loss of lung volume. What is the most suitable course of action? A. Needle aspiration B. Chest drain placement C. Needle aspiration followed by chest drain insertion D. Observation and daily CXR E. Refer to thoracic surgeons for pleurodesis
  72. 72. A 21-year old sportsman attends A&E acutely short of breath accompanied by right- sided pleuritic chest discomfort. His only past medical history is of childhood asthma and a collapsed lung aged 17. On examination – RR 22bpm, SpO2 95%. CXR: right- sided pneumothorax – 30% loss of lung volume. What is the most suitable course of action? A. Needle aspiration B. Chest drain placement C. Needle aspiration followed by chest drain insertion D. Observation and daily CXR E. Refer to thoracic surgeons for pleurodesis
  73. 73. A 30-year-old patient presents with shortness of breath and a productive cough. On examination the pulse is 90, BP 130/78 mmHg, saturations 96% on air, respiratory rate 25/min. Chest radiograph shows consolidation at the left base. Blood tests show show WCC 11.6 x109/L. urea 4.5 mmol/L. Which of the following would be the most appropriate treatment? A. Oral amoxicillin B. IV cefotaxime C. IV clarithromycin D. Oral ciprofloxacin E. Oral trimethoprim
  74. 74. A 30-year-old patient presents with shortness of breath and a productive cough. On examination the pulse is 90, BP 130/78 mmHg, saturations 96% on air, respiratory rate 25/min. Chest radiograph shows consolidation at the left base. Blood tests show show WCC 11.6 x109/L. urea 4.5 mmol/L. Which of the following would be the most appropriate treatment? A. Oral amoxicillin B. IV cefotaxime C. IV clarithromycin D. Oral ciprofloxacin E. Oral trimethoprim
  75. 75. A 32-year-old Bangladeshi man currently being treated for tuberculosis presents to his GP with generalised joint pain. What is the most likely cause of his complaint? • Rifampicin • Ethambutol • Pyrazinamide • Isoniazid • None of the above
  76. 76. A 32-year-old Bangladeshi man currently being treated for tuberculosis presents to his GP with generalised joint pain. What is the most likely cause of his complaint? • Rifampicin • Ethambutol • Pyrazinamide • Isoniazid • None of the above
  77. 77. ANY QUESTIONS? Please feel free to contact us: • Dominic Fenn – dominic.fenn@ucl.ac.uk • William Stephenson – william.stephenson@ucl.ac.uk
  78. 78. Objectives By the end of this session you should be: • Familiar with potential OSCE scenarios relating to respiratory medicine. • Familiar with the must know respiratory conditions, in relation to definition, signs and symptoms, investigations and management. • Be able to attempt some sample SBA questions on topics covered.

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