Respiratory examination – pulmonary fibrosis

Please examine this patient’s respiratory system. They presented with breathlessness over many years. Present your findings to the examiner as you go.

After 6 minutes you will be asked to summarise and asked a series of questions by the examiner.

You are John Briggs, a 50 year old patient who has come to an outpatient clinic. The consultant as asked if you are happy for a medical student to examine you.

Please do not ask any questions or chat to the candidate.

Please feel free to stop the examination if the student causes any pain or discomfort to yourself.

  • If the candidate examines your hands/nails: show them this picture (click image):

  • When the candidate auscultates the bases of your lungs posteriorly, play this sound clip:
Category Question
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school / Year / grade
Clarifies who they are talking to
Asks patient for preferred name

Examination étique Examination étique
Washes hands
Asks about any pain
Exposes patient correctly
Patient positioned at 45 degrees
Examination from right hand side
Treats patient with dignity and respect

Inspection General inspection
General appearance
Pursed lip breathing
Use of accessory muscles
Oxygen (nasal, mask, high flow)
Inhalers / medications at bedside
Walking aids at bedside

Hands Comments on hands
Temperature/capillary refill
Peripheral cyanosis
Tar staining
Finger clubbing

Hands - pathology photo_camera Show this photo when the candidate looks at the patient's hands
Identifies finger clubbing

Arm Arm
CO2 retention tremor (flapping tremor)
Fine physiological tremor (e.g salbutamol)
Radial pulse (bounding is a sign of CO2 retention)
Respiratory rate

Face Face
Conjunctival pallor
Central cyanosis
Cushingoid changes
Signs of connective tissue disorders (e.g. butterfly rash, telangiectasia/microstomia)

Neck Neck
Examines for cervical lymph nodes
Trachea position

Inspection Closer inspection
Scars (e.g. thoracotomy scars)
Chest wall movements
Breathing pattern
Chest wall deformities

Palpation Palpation
Chest expansion (comment on symmetry)

Percussion Percussion
Percusses at 6 sites
Directly compares both sides at same intercostal level
Comments on percussion note as normal, dull, stony dull, hyperresonant
Both anterior and posterior chest examined

Auscultation Auscultation
Asks patient to breathe in and out through an open mouth
Directly compares both sides at same intercostal level
Vocal resonance or whispering pectoriloquy assessed
Both anterior and posterior chest examined

Auscultation - pathology photo_camera After the candidate auscultates the lungs posteriorly, play this clip
Identifies fine end-inspiratory crepitations

Peripheral examination Calves
Pitting oedema
Signs of DVT

Closing Closing examination
Thanks patient
Invites patient to get re-dressed
Washes hands

Patient Patient
Candidate did not cause any pain to patient
Candidate was polite throughout examination

Question What is the diagnosis and possible differentials?
Idiopathic pulmonary fibrosis
Reasonable differentials may include: left ventricular failure, other causes of pulmonary fibrosis

Question What are the causes of lower zone pulmonary fibrosis and are there any signs may suggest each cause?
Idiopathic pulmonary fibrosis (clubbing)
Connective tissue disorders, e.g. rheumatoid arthritis (joint disease), systemic sclerosis (telangiectasia, sclerodactyly, microstomia)
Drugs, e.g. nitrofurantoin, amiodarone, methotrexate, cyclophosphamide, sulfasalazine

Question What investigations would you initiate?
Chest x-ray
High-resolution CT chest
Autoimmune screen

Submit your answers to get your score.

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