Information Sheet for Candidates

One of your regular patients, a usually healthy

40 year old Spanish lady, Mrs. Garcia, brings her
66 year old father who has just arrived for a 6
months holiday in Australia into your surgery.
The daughter had not seen her father for 10
years and is concerned about his breathing and
that her father gets easily short of breath.

Your task is to:

 Take a brief history
 Perform a respiratory system examination
Take a history - the father does not speak English

??? INTERPRETER??? (You should NOT use a family member as interpreter,

please contact the interpreting service!!!!)

The father has had mild asthma since childhood, no hospital admissions, on and
off on ventolin puffers, usually when he gets a cold. He has had recurrent chest
infections over the last 3 – 5 years.
No other significant history.

 Perform a respiratory examination

Give commentary outlining what you are doing and what you are trying to find as
you proceed.

!!!APPROACH!!!!
LOOK - LISTEN - FEEL !!!

Peripheral signs:
hands, flap, pulse, cyanosis (central – warm skin, mucous membranes vs.
peripheral – cold skin , more O2 extracted by tissues), JVP, clubbing, nasal
flaring, “Horner’s syndrome” (constricted pupil, partial ptosis and loss of
sweating sec. to apical lung tumour)

Chest inspection:
Shape, rate, rhythm / pattern (Cheyne-Stokes), amplitude / chest expansion,
accessory muscles, posture, trachea, cyanosis, ‘breathlessness’.

Breathing noise:
Snoring, stridor, wheeze, hoarse voice (recurrent laryngeal nerve!)

Palpation:
Lymphglands, chest expansion, vocal vibrations (tactile vocal fremitus, “99”).

Percussion:
Resonant, dull, tympanic / hyper-resonant
Auscultation:
1. Breath sounds:
a) normal – low pitched, vesicular
b) diminished or absent breath sounds
c) bronchial breath sounds
2. Voice sounds:
a) normal voice
b) diminished voice sounds
c) bronchial voice sounds (“sixty-six”)
3. Adventitious sounds:
a) Rales or crackles: these sounds are made when fluid is present in either
the bronchioles or alveoli. They are most often auscultated on
inspiration and are graded as either fine or coarse.
b) crepitations (fine crackling – lung oedema)
c) rhonchi (loud coarse noises – bronchitis) sounds are made by the flow
of air through fluid filled narrow airways. They can be heard on
inspiration, expiration or continuously. These sounds are often
described as gurgling or rattling and may be either high or low pitched.
d) wheezes are rhonchi with a high pitched somewhat musical sound.
They are heard predominantly on expiration.
e) pleural friction rub

Chest X ray

PEFR: Peak Expiratory Flow Rate

This is a simple method of measuring airway obstruction and it will detect
moderate or severe disease. The simplicity of the method is its main advantage. It
is measured using a standard Wright Peak Flow Meter or mini Wright Meter. The
needle must always be reset to zero before PEF is measured.
Normal values are related to the patient's height as follows:
Height
PEFR (L/min)*
(cm)
120 215
130 260
140 300
150 350
160 400
 170 450
180 500
* mean; 2 SD = ±100
An easy to remember approximation is: PEFR (L/min) = [Height (cm) - 80] x 5

Lung Function Test:

FVC = forced vital capacity
FRC = functional residual capacity
TLC = total lung capacity
RV = residual volume
ERV = expiratory reserve volume

FEV1 = forced expiratory volume during the first second of FVC ( > 75%)

Spirometry often differentiates between the two major types of pulmonary

Dysfunction – obstructive and restrictive pulmonary disease.