This document provides an overview of content to be covered in a 1.5 hour session on respiratory medicine. It includes objectives to familiarize learners with potential OSCE scenarios and key respiratory conditions, signs, symptoms, investigations, and management. It also provides sample OSCE scenarios and outlines content on topics like asthma, COPD, pneumonia, and tuberculosis that will be discussed, followed by some sample SBA questions for practice.

1. RESPIRATORY MEDICINE IN AN
HOUR AND A HALF

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. Content
1. OSCE
2. Discuss major topics you need to know
3. SBA practice

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. OSCE 2
 WIPER
 Introduce and explain purpose of interview
 Check understanding of Asthma and rationale
behind inhaler therapy
 Inhaler technique…

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. 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

9. 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

10. 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

11. Asthma 3: Symptoms

12. Asthma 3: Symptoms
 Intermittent dyspnoea
 Wheeze
 Cough (often nocturnal)
 Sputum

13. Asthma 4: History
 Precipitants
 Cold air, exercise, allergens, smoking, pollution, etc.
 Diurnal variation
 Exercise tolerance
 Acid reflux (40-60%)
 Other atopic disease

14. Asthma 5: Signs

15. Asthma 5: Signs
 Tachypnoea
 Audible wheeze
 Hyperinflated chest
 Hyperresonant percussion
 Diminished air entry

16. Asthma 6: Investigations
 Monitor PEF
 Spirometry
 Bronchodilator reversibility
 Allergen skin prick tests
 Aspergillus serology

17. Asthma 7: Management
 Behaviour: Quit smoking; avoid precipitants
 British Thoracic Society Guidelines…

18. 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

20. 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

21. 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

22. 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

24. 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.

25. Chronic Bronchitis Emphysema
BLUE BLOATERS
PINK PUFFERS

27. COPD 2: Signs and Symptoms

28. COPD 3: Investigations
 Lung function tests:
 Obstructive pattern
  TLC,  RV
 CXR:
 hyperventilation, flat diaphragms, Large central pulmonary vasculature
 ABG:
 PaO2  +/- hypercapnia
 Blood/sputum culture

29. COPD 4: Management – Acute
Exacerbation
 Controlled O2 therapy – Start at 24-28%
 Nebulized bronchodilators
 Steroids
 Broad spec. Abx
 Look for cause! (Infection, pneumothorax etc.)

30. 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

31. 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

33. 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

34. 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

35. Tuberculosis 3: Signs and
Symptoms: There are loads…
REMEMBER:
• Weight loss
• Night sweats
• Haemoptysis
• Fever
• Travel Hx

36. 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.

37. 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)

39. 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

40. Pneumonia 2: Classification
 CAP vs. HAP
 Lobar vs. Interstitial
 Typical vs. Atypical

41. 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%.

42. Pneumonia 4: Organisms
 Typical CAP Organisms:
 Strep. pneumoniae
 H. influenzae
 Moraxella influenzae
 Staph. aureus

43. Pneumonia 5: Symptoms

44. Pneumonia 5: Symptoms
 Fever
 Pleuritic chest pain
 Dry cough progressing to rusty-sputum producing
cough
 Rapid shallow breathing

45. 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)

46. Pneumonia 7: Investigations

47. Pneumonia 7: Investigations
 CXR: shows consolidation.
 ABG
 Bloods incl. culture
 Sputum microscopy & culture

48. CXR
Lobar Pneumonia:
Focal area of
consolidation. This can be
difficult to differentiate
from pulmonary oedema
and fluid accumulation

49. 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).

50. Pneumonia 8: Management
 Oxygen
 IV fluids
 Analgesia (eg. Paracetamol)
 Antibiotics
 Check for progression/ complications
 F/U at 6 weeks (repeat CXR)

51. Pneumonia 9: Assessing
severity
• C
• U
• R
• B
• 65

52. 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

53. 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

54. 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…)

56. Pleural Effusion 1: Definition
 Excessive accumulation of fluid in the pleural
space.
 Divided into:
 Transudate effusion
 Exudate effusion

57. 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

58. 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

59. Exudate > 30g/L
Production
Reabsorption
 Permeability via inflammatory mediators
• Pneumonia / TB
• Rheumatoid arthritis / SLE
• Malignancy - carcinoma

60. Pleural Effusion 3: Signs and
Symptoms
 Asymptomatic
OR:
 Dyspnoea
 Pleuritic chest pain - sharp and localised
 NB: Look out for signs of associated disease

61. Pleural Effusion 4: Investigations
 CXR
Small = Blunt Costophrenic
angles
Large = Water dense
shadow and concave
upper borders

62. Pleural Effusion 5: Management
 Drainage < 2L/24h
 Pleurodesis - if recurrent
 Thoracoscopic talc pleurodesis
 Surgery

63. SBA PRACTICE
QUESTIONS

64. 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

65. 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

67. 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

68. 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

69. 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

70. 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

71. 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

72. 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

73. 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

74. 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

75. 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

76. 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

78. 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

79. 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

80. 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

81. 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

83. 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

84. 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

85. 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

86. 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

87. ANY QUESTIONS?
Please feel free to contact us:
• Dominic Fenn – dominic.fenn@ucl.ac.uk
• William Stephenson – william.stephenson@ucl.ac.uk

88. 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.