Respiratory examination – pulmonary fibrosis

Candidate instructions
Actor instructions
Mark sheet
Score

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	Done	Excellent
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 JVP 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) Asbestosis Drugs, e.g. nitrofurantoin, amiodarone, methotrexate, cyclophosphamide, sulfasalazine
Question	What investigations would you initiate? Chest x-ray Spirometry High-resolution CT chest Autoimmune screen

Submit your answers to get your score.

Respiratory examination – pneumonectomy

Abdominal examination – chronic liver disease

Respiratory examination – pulmonary fibrosis

Submit your answers to get your score.

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