Respiratory

OSCE
AMSA Edinburgh x IMU Y4
Introduction to OSCE
 OUR TEAM

Joseph Lee
UoE Y4 medical student

IMU ME218

LUCAS HO
UoE Y4 medical student
IMU ME119
 CONTENTS
Topics to cover:
1. History taking (slide for what to ask for hopi, systemic review, meds, fam, social hx, how to ask ICE)
2. Possible ddxes/conditions
3. Hx case that came out before
4. Examination
5. Possible examination OSCE stations during exams (eg from past years etc.)
6. Practice history taking station if there’s time at the end
7. Inc marking scheme from Pebble pocket
 1
Respiratory History
Taking
A medical chest specialist is long winded about the short winded.

Kenneth T Bird (b. 1917)

History Taking Components

● Introduction, confirm patient, consent

● Presenting complaint
● HOPI
● Systemic review
● Past medical history
● Drug history
● Family history
● Social history
● ICE
 Impt Q for HOPI
Chief complaint HOPI

Cough Acute cough (< 3 weeks)

● upper respiratory tract infection: common cold, sinusitis (fever, sore throat, slight
headaches)
● Lower respiratory tract infection: pneumonia, bronchitis, exacerbation of COPD
Chronic cough
● COPD (smoking history, worse in morning)
● Asthma (intermittent, wheeze, productive, worse at night, relief with
bronchodilators)
● GORD (lying down, burning central chest pain)
● Upper airway cough syndrome (history of rhinitis, throat clearing, post nasal drip)
● Bronchiectasis (very productive)
● ACEI (dry cough,drug history)
● Cardiac failure (dyspnoea,PND,orthopnoea)
● Interstitial lung disease (chronic dry cough,dyspnoea)
Sputum

White sputum Yellow greenish

Asthma, starting of
infection
sputum
COPD, bronchiectasis,
lobar pneumonia

Foul smelling dark Pink frothy

coloured sputum sputum
Lung abscess with
anaerobic organisms Pulmonary oedema
 HOPI
Dyspnoea Seconds to minutes - favours:
(NYHA classification, Acute exacerbation of asthma, pulmonary embolism (pleuritic chest pain,
mMRC grading) haemoptysis, tachycardia), pneumothorax (quite similar to PE), anaphylaxis

Hours to days - favours:

COPD, cardiac failure, asthma, respiratory infection, pleural effusion

Weeks or longer - favours:

Pulmonary fibrosis, interstitial lung disease, anaemia

Haemoptysis Carcinoma (weight loss, anorexia, hoarseness, superior vena cava syndrome,
Red flag paraneoplastic features)
Tuberculosis (travel history, immunosuppressed)
 Systemic Review
Systemic: fevers, weight change, fatigue

❖ Cardiovascular: chest pain, palpitations, oedema, syncope,

orthopnoea

❖ Gastrointestinal: nausea, vomiting, dysphagia, abdominal

pain

❖ Neurological: visual changes, motor or sensory

disturbances, headache, confusion

❖ Musculoskeletal: chest wall pain, trauma

❖ Dermatological: rashes
Medical History

❖ Long term illnesses (can ask specifically)

❖ Surgeries, hospitalizations
❖ Immunisation history (Influenza, pneumococcal, COVID-19, Tuberculosis)
Drug History

❖ Regular medications, OTC medications, herbal medicines, supplements

❖ Allergies

Family History
Social History

❖ Smoking, alcohol, recreational drugs, diet, exercise, living condition

❖ Travel history
❖ Occupational history (current and previous)
➢ Asbestos mining, naval dockyard workers and sailors, factory
workers, home renovation
➢ Allergic alveolitis (Farmer’s lung, Bird Fancier’s lung)
Ideas, Concerns, Expectations

❖ “How has this been affecting your day to day life?”

❖ “Do you have any idea yourself what might be causing this?”
❖ “Do you have anything you are particularly worried that this might be?”
❖ “What were you hoping I’d be able to do for you today?”
Reporting History
Findings
❖ SBAR
❖ DDx
❖ I would like to..
➢ Perform a full respiratory examination
➢ Do bedside observations (RR, SpO2, Temp, BP, HR)
➢ Blood tests (FBC, U&Es, LFTs)
➢ Other tests (spirometry, bronchodilator reversibility, CXR, HRCT, US,
sputum culture and sensitivity, PET scan, pleural aspiration, CTPA, ECG,
D- dimer, pulmonary function test)
 Possible Dx/ OSCE
Stations

1 Asthma Hx
Followed by explanation 3 A-E station
Pneumothorax,
and possible management anaphylaxis,
Exacerbation of asthma

2 Lung cancer Hx
Identify red flags, refer 4 Motivational interview
Stop smoking for COPD
urgently patient
UOE Marking Scheme
(from pebblepad)
 2
Physical Examination
Overview
● Introduction & consent
● General examination
● Bedside
● Hands
● Face
● Neck
● Chest
● Legs
● Posterior chest & lymph nodes
Components of PE
Introduction
● Wash hands + PPE
● Check patient’s FULL name, age, DOB
● Do not spend too much time explaining procedure
● Spare the “private and confidential” fluffing
● Chaperone

General
● Pain - Ask before starting examination
● Cyanosis, respiratory distress/effort

Bedside
● Oxygen supplementation, inhalers, nebuliser, NIV, sputum pots
● Other - NEWS chart, CXR, Kardex
NEWS CHART
 Components of PE
Hands
● Pulse - 15s x 4 OR “Ideally I’d measure it for 15 seconds…” and
move on
● Flapping tremor
● Usual - Cyanosis, tobacco stains, fine tremor, clubbing, etc

Face
● Eyes - Conjunctival pallor, horner’s syndrome
● Nose - Generally for any obstruction
● Mouth - Central cyanosis, pharyngeal erythema, tonsillar
exudate, candidiasis

Neck
● Cricosternal distance
● Tracheal deviation
● JVP - Not required to measure with a ruler
● Lymph nodes - Expected to perform Elevated JVP
Tracheal deviation
 Components of PE
Chest
● Inspection - Symmetry, deformity, scars Carinatum
Excavatum
● Palpation - Heave & apex, chest expansion (Pigeon chest)

● Percussion
● Auscultation - Breath sounds, vocal resonance (99/111)
● Tactile fremitus - OMIT

Legs
Erythema Nodosum
● Oedema
● Deep vein thrombosis (Palpate) - Pain, erythema, swelling
● Erythema nodosum - Painful rash DVT

Posterior chest
● Same steps as anterior chest examination
● MOST of the time the examiner will instruct to do one side (anterior OR
posterior); Otherwise, examine both sides
Chest scars

Posterolateral
thoracotomy

Clamshell incision
Reporting PE Findings
Background
● Name, age, presentation, relevant medical history (if any)
“Today I performed a respiratory examination on Mr Smith, a 52 year old patient who
presented with cough”

General (From bedside)

● Current state, bedside apparatus (if any)
“Mr Smith appeared well. He was alert and oriented”

Positive and negative findings

● Focus on important findings only
“There was no peripheral stigmata of any respiratory disease”
“Lungs were resonant to percussion and there was bilateral vesicular breath sounds
on auscultation”

Impression & differentials

● 1 main diagnosis and 2 differentials
“My impression is that this is an infective exacerbation of COPD. However my
differentials include a community acquired pneumonia or bronchiectasis”
Investigations
● ALWAYS - Take a full clinical history and a full sets of observations
● Bloods - FBC, U&Es, LFT, CRP
● Spirometry/peak flow
● Chest X-ray
● Sputum culture
● ABG
● Other Ix specific to the conditions you’re suspecting
“I would like to complete my examination by taking a full clinical history and a full
sets of obs. I would also order a set of bloods which includes FBC, U&Es…”

Plan
● Commonly tested - CURB65 (Pneumonia), Sepsis 6 protocol, Wells score
(DVT/PE)
● Smoking cessation, pulmonary rehabilitation
Mark Scheme
Case 1
Mrs Smith, a 55 year old patient comes into the hospital with breathlessness
and pleuritic chest pain.

You are allowed to take a short history from the patient.

Perform a respiratory exam and answer any questions that the patient might
have.

Summarise the findings to the examiner.

Case 2
Mr Smith, a 65 year old patient comes in for
a routine health check-up.

Perform a respiratory examination

 3
Practice History Taking
References
● Geeky medics
● Radiopaedia
● Passmed
● OSCEstop
● Talley and O'Connor’s Clinical Examination
QUESTIONS?
Feedback Form + Certificate
[Link]
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