MRCP PACES Pastest lectures - RESPIRATORY STATION Topics and Cases Covered ➢ Optimising Examination Skills ➢ Cases • COPD • Pulmonary Fibrosis • Bronchiectasis • Dullness at lung base Optimising Physical Examination Skills RESPIRATORY SECTION 1 Physical Examination: Introduce, correctly position and expose patient General Inspection: End of the bed. Look for: Cyanosis (hands and lips): If central cyanosis think chronic hypoxia e.g. COPD, Pulmonary fibrosis, Bronchiectasis, pulmonary hypertension (with cor pulmonale) Count respiratory rate: 15 seconds (x 4): Is the patient tachypnoeic at rest? If not, are they when examination complete? Ask the patient to take deep breath in and out twice: Is expansion symmetrical? Yes – then is it also reduced. If yes, you are looking at a diffuse disease process (classically think COPD, Bronchiectasis, pulmonary fibrosis) [In COPD the AP diameter will also be increased so look at the chest side on:] Is Expansion Asymmetrical: The hemithorax that expands less is where the disease is. Is a Thoracotomy scar (located Posteriorly) present –then the diagnosis likely to be a: lobectomy or pneumonectomy? If not think: Pleural effusion Lobe/lung collapse Raised Hemidiaphragm Pleural thickening (extensive) [Often in pleural thickening, mild to moderate pleural effusions, lobar collapse, and raised hemidiaphragm – expansion on inspection from the end of the bed can appear normal. So always confirm your suspicions about expansion abnormalities by palpitation from the front and back]. Visualisation of Tracheal Position: Ask patient to tilt head upwards. Look at the Adam’s apple and trace the trachea down between the sternal head of sternocleidomastoid. Is the trachea central? (For Tracheal position and disease processes see cases) Finally from the end of the bed look for: Oxygen, sputum pot, inhalers, nebuliser, portable ventilator, wheelchair and walking aids End of Bed Recap: Expansion symmetrically reduced with: • Increased AP diameter – think COPD or Bronchiectasis Presence of crackles will help differentiate between the two (N.B. both will cause wheeze) • Normal AP diameter likely to be pulmonary fibrosis, but can be Bronchiectasis (Trachea is usually central, however, can be deviated if there is apical fibrosis, which is more on one side e.g. T.B.) Expansion Asymmetrical with: • Thoracotomy scar – pneumonectomy or lobectomy Trachea will be deviated to the side of non-expansion in pneumonectomy. In lobectomy usually central. In pneumonectomy there will be no expansion of the hemithorax as there is no lung there. In lobectomy there is reduced asymmetrical expansion of the lower half of the hemithorax (irrespective of the lobe removed) • No Thoracotomy Scars: Pleural effusion (trachea deviated away if large effusion) Pleural thickening (trachea central) Raised hemidiaphragm (trachea central) Lumbar or lung collapse (trachea deviated to hemithorax which has reduced expansion if collapse large or affects upper lobes, otherwise trachea central) In the hands look for: Nicotine stained – think COPD Clubbed – Consider pulmonary fibrosis, Bronchiectasis, cystic fibrosis (mesothelioma can cause clubbing but is less likely in MRCP) [COPD only causes clubbing if there is lung cancer or mixed disease i.e. COPD and Bronchiectasis or pulmonary fibrosis.] Central Cyanosis: • Sputum pot and crackles – Bronchiectasis • Reduced symmetrical expansion, increased AP diameter and wheeze- COPD • Reduced symmetrical expansion, normal AP diameter, crackles – pulmonary fibrosis or Bronchiectasis [Central cyanosis usually implies that cor pulmonale will be present and that this patient has chronic severe lung disease.] Confirm Tracheal Position by Palpitation. Percussion: Remember to Percuss and auscultate the axillae. If there is dullness on precussion and/or asymmetrical expansion you must remember to perform tactile vocal fremitus and vocal resonance. TVF and VR: These are the same thing (you can do either but it is sensible to do both as the senses are better than one). The mark sheet says to perform these tests when appropriate therefore if you think there is a pleural effusion, consolidation, collapse, raised hemidiaphragm or significant pleural thickening or evidence of pneumonectomy or lobectomy. These tests should be performed. Auscultation: If you hear a wheeze: think COPD, asthma. If you hear a wheeze plus crackles: Bronchiectasis, mixed disease, COPD and pulmonary fibrosis or COPD and Bronchiectasis If you hear just crackles: Pulmonary fibrosis:- do not change on coughing classically, but not always fine or late inspiratory . Bronchiectasis:- Usually coarse and change in quality on coughing (do not necessarily disappear.) Cases: COPD Section 2 Patient is tachypnoeic at rest (or after examination) Maybe cyanosed (usually overweight in chronic Bronchitis) In patients who are not cyanosed look for pursed lip breathing (predominant emphysema) There is intercostal recession with use of accessory muscles. Chest expansion is symmetrically reduced with increased AP diameter Percussion note is hyperresonant (but maybe normal in patients with predominant chronic bronchitis) Breath sounds: Wheeze and Prolonged expiration – due to small airways airflow obstruction Reduced air entry – symmetrical Do not miss: Oxygen dependency, nicotine stained fingers, purpura and round faces of steroid dependency and signs of cor pulmonale. Section 3 Likely Discussion Points are: • Treatment options: These can be split in to acute and chronic presentations. Remember as well as pharmacotherapy to include smoking cessation, vaccination and pulmonary rehabilitation. • Investigations: Remember to qualify your investigations so the examiners understand your thoughts. e.g. I would undertake a FBC to look for polycythaemia oxygen saturations to look for hypoxemia, arterial blood gases to look for type II respiratory failure. In a young individual I would perform –1- antitrypsin level Spirometry to look for obstructive airways disease and lung volumes and transfer factor, which would show, air trapping and reduce gas exchange respectively. I would undertake an HRCT thorax if the patient was a candidate for lung volume reduction surgery or transplantation or the diagnosis was in doubt. • Treatment of an acute exacerbation • Role of non-invasive ventilation Pulmonary Fibrosis Section 2 60% of patients are clubbed and are often cyanosed. There is symmetrical reduced expansion with classically late inspiratory crackles (“Velcro” like), which do not change in character on coughing. Patients often have signs of cor pulmonale, stigmata of steroid usage and oxygen dependency. Section 3 1. What are the common causes? - Idiopathic - Autoimmune - Iatrogenic – especially Amiodarone, Methotrexate, nitrification, Bleomycine etc. - Occupational: asbestosis, extrinsic allergic alveolitis - Progressive massive fibrosis - Sarcoid 2. How would you investigate? Qualify your investigations - Autoimmune serology includes rheumatoid factor, ENA and double stranded DNA. - Full lung function tests showing a restrictive spirometry with reduced lung volumes and transfer factor - CXR – to look for reticulonodular shadowing - HRCT thorax which may help differentiate the cause of fibrosis (in a young patient lung biopsy may be needed to diagnose the cause of disease) 3. How would you measure function? - History: MRC Dyspnoea Score - Oxygen saturation on air and ambulation - Serial full lung function tests CT correlates poorly to function Bronchiectasis Section 2 Patient may be cyanosed and often mildly tachypnoeic at rest. Often they are clubbed with cyanosis. They may have yellow nails (syndrome). Expansion is symmetrically reduced. Breath sounds have coarse inspiratory crackles whose character changes on coughing, but does not usually disappear totally? [Most commonly the crackles are basal but maybe apical and anterior in: Bronchopulmonary aspergillosis or Post TB Bronchiectasis] Patient also often has a wheeze due to concomitant small airways obstruction. Also look for cor pulmonale (especially if patient cyanosed) sputum pot, oxygen, inhalers and nebulisers. Section 3 • What are the Common Causes? Post-infective: TB (anterior apical crackles), Childhood infections: measles, whooping cough, and pneumonia. Genetic: Cystic fibrosis – think of this especially if your patient is young Kartagener’s Syndrome – autosomal recessive accompanied by dextocardia and situs Inversus Hypogammaglobuinaemia Allergic: Bronchopulmonary aspergillosis – signs are apical and anterior. Bronchial obstruction usually due to foreign body inhalation. What investigation would you perform to investigate cause? - Immunoglobulins with IgG subclasses to look for deficiency status. - IgE aspergillus and aspergillus precipitants - Cystic fibrosis serology - CXR to help confirm diagnosis - HRCT could help define cause as in ABPA Dullness at lung base: Section 2 This can be split into: 1. With a Thoracotomy care – lobectomy or pneumonectomy Or 2. Without a Thoracotomy scar - Pleural effusion - Collapse/consolidation - Raised hemidiaphragm - Pleural thickening With a Thoracotomy Scar Pneumonectomy (Right ® ) Trachea is deviated – to the side of non-expansion ® The whole ® hemithorax does not move on deep inspiration Check supraclavicular nodes There is a ® posterior Thoracotomy scar PN is dull ® hemithorax TVF/VR are absent B/S absent (sometimes can hear transmitted sounds at the apex) But the most important point is the whole hemithorax does not expand Lobectomy right sided ® Trachea is usually central ® Hemithorax expansion is reduced but still present (Reduction of expansion most pronounced at base. Check supraclavicular nodes There is a ® posterior Thoracotomy scar PN: Dull Posteriorly below the scar TVF/VR absent Posteriorly below scar B/S absent at the base best noted Posteriorly below scar Most important issue is that the hemithorax excursion is reduced but still occurs Important to look for clubbing, sputum pots Section 3: Dullness at Lung Base with Thoracotomy Scar 1. What are the likely reasons for the: Pneumonectomy Lobectomy Lung Cancer Lung Cancer Localised Bronchiectasis Localised abscesses 2. If the patient presents with a haemoptysis would you investigate them? History: Look for sinister symptoms: - Weight loss - Haemoptysis especially if protracted and no obvious infective cause - Previous TB - Night sweats Investigations: - FBC to ensure not anaemic - Biochemistry to ensure there is no renal impairment, LFT’s are not abnormal (as may imply metastatic disease) and serum calcium is normal. - CXR to look for a cause of bleeding such as tumour, Bronchiectasis, evidence of TB - Staging CT thorax to stage the cancer - Bronchoscopy – to derive Histology Section 2 - Dullness at the Lung Base with no Thoracotomy Scar Physical examination: Reduced expansion of the hemithorax from the end of the bed (however this is not always obvious on purely inspection especially with lobar collapses, mild to moderate pleural effusion and pleural thickening) but your inspection suspicions of reduced expansion will be confirmed by palpitating for expansion. Check for supraclavicular nodes PN will be dull TVF/VR absent. (Increased in consolidation however consolidations are uncommon in the MRCP exams as these patients are usually acutely unwell). B/S absent
Posted on: Wed, 01 Oct 2014 08:05:31 +0000
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