Block 1 - Respiratory Flashcards by Kitty Eichner

What are 7 common respiratory complaints?

Cough/sputum
Haemoptysis
Pain
Dyspnoea
Wheeze
Stridor
Sleep apnoea
Other - fever, rigors, hoarseness, night sweats, weight loss, lethargy

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How to do a smoking pack history?

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What are some red flag symptoms for the respiratory history and possible differentials for them?

Never forget your red flag systemic symptoms – fevers, sweats and weight loss.
Be sure to think of TB in night sweats and fever. Differentials include malignancy and pneumonia. Time course will help differentiate.

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In a respiratory history, what questions should you ask about the person’s past medical history? (6)

**Respiratory - Personal medical history
**
1. Surgical/Medical + Active/Inactive
2. History of respiratory illness –> Asthma? Pneumonia? TB? PE?
2. Exposure to TB in early life?
3. Immune suppression?
4. Malnutrition (e.g. elderly patients) as latent TB can often re-emerge at these times.
5. Any respiratory ixs - CXR, spirometery?
6. Venous thrombolic events & risk factors (oral contraceptive pill)?
7. Malignancy?

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In a respiratory history, what questions should you ask about asthma? (4)

Asthma history
1. Ectopic Diathesis = asthma, eczema and hay fever, allergies to food/environmental?
2. Triggers e.g. viral URTI, cold air, exercise, pollens, if they know them
3. Asthma tx?
4. Hx of hospitalisation, especially ICU admissions?

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In a respiratory history, what questions should you ask about medications? (6)
- Which meds are associated with a cough? (2)
- Which meds are associated with a wheeze? (5)
- Which meds are associated with a pulmonary fibrosis?
- Which meds are associated with a PE? (3)
- Which meds are associated with a pleural disease? (3)

**Respiratory - Medications:
**
1. Puffers - preventers and relievers
2. Contraceptive pills/implant?
3. Other medications?
4. Over the counter?
5. Alternative/Complementary?
6. Allied health - e.g. physiotherapy?

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In a respiratory history, what questions should you ask about family history? (4)

**Respiratory - Family history
**
1. Atopy?
2. Asthma?
3. Cystic fibrosis?
4. Emphysema in a younger person without much smoking history consider α1 antitrypsin deficiency.

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In a respiratory history, what questions should you ask about occupation? (4)

Respiratory - Occupational history
1. Dusts and chemicals - e.g. mining industry/factories
2. Animals - eg. birds, organic dusts such as from mouldy hay - e.g. farmers, abattoir workers
3. Infectious diseases - e.g. childcare workers, prison workers, healthcare workers
4. Use of protective equipment - eg. asbestos.

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In a respiratory history, what questions should you ask about social history? (6)

Respiratory - Social history
1. In an elderly person it is important to establish living arrangements such as own house, hostel or nursing home and independence with activities of daily living,
2. Exercise tolerance - normal vs. now? “How far can you walk normally (in metres)?” and “How far can you walk with this illness?”
3. “If how you feel on a normal day is 100%, how do you feel today?“
4. Smoking?
5. Sick contacts?
6. Recent travel?

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Take a history from someone presenting with a cough.
- 5 specific questions?

Cough:
1. Character - e.g. barking, bovine?
2. Duration - acute vs chronic?
3. Recent changes?
4. Dry/productive?
5. Pattern - day/night?

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Differentials for a cough?

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Take a history from someone presenting with sputum production.
- 7 specific questions?

Sputum:
1. Colour?
2. Consistency?
3. Presence of blood (haemoptysis)?
4. Volume?
5. Recent changes?
6. Odour?
7. Foul tasting?

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Differentials for haemoptysis?

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Take a history from someone presenting with dyspnoea.
- 6 specific questions?

**Dyspnoea: (Shortness of breath)
**
1. Timing of onset?
2. Duration of episodes
3. Severity?
4. Pattern - paroxysmal, exertional, orthopnoea? - How many pillows do you sleep with? Do you ever wake at night short of breath?
5. Exacerbating and relieving factors?
6. Exercise tolerance - e.g. How far can you walk? Has this changed recently?

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Differentials for dyspnoea?

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Take a history from someone presenting with a wheeze.
- 4 specific questions?

**Wheeze:
**
1. Onset
2. Does it clear with coughing?
3. Expiratory/respiratory?
4. Precipitating and relieving factors?

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Take a history from someone presenting with a wheeze.
- 4 specific questions?

**Wheeze:
**
1. Onset
2. Does it clear with coughing?
3. Expiratory/respiratory?
4. Precipitating and relieving factors?

Take a history from someone presenting with respiratory pain.
- 4 specific questions?

Pain: SOCRATES
1. Location
2. Character
3. Exacerbating and relieving factor
4. Onset
5. Duration
6. Radiation
7. Hx of trauma?

Take a history from someone presenting with sleep apnoea.
- 4 specific questions?

Sleep Apnoea:
1. Snoring?
2. Daytime tiredness?
3. Gasping for breath at night?

Differentials for stridor?

Less musical sounding than a wheeze, stridor is a high-pitched, turbulent sound that can happen when a person inhales or exhales. Stridor usually indicates an obstruction or narrowing in the upper airway, outside of the chest cavity.

What is the protocol for a respiratory examination?

What is involved in the introduction of a respiratory exam? (4)

**Respiratory Exam Protocol
**
1. Introduce self
2. Wash hands
3. Gain consent
4. Confirms name and age

“Hi, my name is Kitty and i’m one of the medical students from the university of Notre Dame. Today i’ve been asked to come and examine you for any respiratory/lung problems which will involve me having a look, listen and feel of your chest if thats ok with you? It shouldn’t take too long and if you’re uncomfortable at any point we can stop.”
“Before we get started please can I confirm your name & age? And is there anything I can do to make you more comfortable before we start?”
“As we go along I will just be describing my findings to the doctor but I will explain everything to you at the end.”

How should you position the patient for a respiratory exam?

**Respiratory Exam Protocol
**
“Do you feel well enough to sit up?
I’ll just need you to take your shirt off if thats ok? You can leave any underwear on.”

What things are you looking for on general inspection of the patient in a respiratory exam? (9)

**Respiratory Exam Protocol - Inspection
**
1. General Condition: well/unwell
2. Pale?
3. Cachexia?
2. Short of breath?
3. Signs of respiratory distress?
3. Ability to speak sentences?
4. Stridor?
5. Pursed lips?
6. Note any O2 therapy devices - inhalers, nebulisers,
7. Sputum cup (asks if available)?
8. Counts respiratory rate?
9. Ask the patient to cough

What things are you looking for in the hands of the patient in a respiratory exam? (8)

**Respiratory Exam Protocol - Hands ** 1. Clubbing - put index fingers back to back to see diamond created by bases 2. Wrist tenderness --> Hypertrophic pulmonary osteoarthropathy 2. Nicotine stains 3. Palmer crease pallor - anaemia 4. Peripheral cyanosis 5. Pulse - character of pulse 6. Flapping tremor (asterixis) (Co2 retention) 7. Small muscle wasting --> Compression/ infiltration by a peripheral lung tumour of a lower trunk of the T1 nerve root

What things are you looking for in the head & neck of the patient in a respiratory exam? (5) - 3 causes of tracheal displacement?

**Respiratory Exam Protocol - Head & Neck ** 1. **Eyes** --> Evidence of Horner’s (unilateral: pupil constriction, loss of sweat, ptosis) --> pical lung carcinoma (Pancoast’se tumour) compressing the sympathetic nerves in the neck 2. **Neck** --> Thick neck, receding chin (sleep apnoea), SVC obstruction (Pemberton’s sign) 3. Palpates position of **trachea** (observe or feel tracheal tug) 4. **Mouth** --> Central cyanosis - under tongue, URTI (pharynx & tonsils), oral health, crowded pharynx 5. **Palpation of the lymph nodes** = submental, submandibular, preauricular, postauricular, posterior cerival chain, occipital, anterior cervical chain, supraclavicular.

What things are you looking for upon inspection of the patient's chest and back in a respiratory exam? (5)

**Respiratory Exam Protocol - Chest & Back - Inspection ** 1. Shape – pectus excavatum, pectus carinatum, Harrison’s sulci, Barrel chest, kyphoscoliosis (can only be assessed after looking from the front and the side). 2. Symmetry of chest wall movement 3. Accessory muscles use 4. Scars 5. Lesions (all sides including the back)

What do you do for Palpation, Percussion and Ausculation of the back in a respiratory exam?

**Palpation**: 1. Palpates cervical lymph nodes including supra clavicular lymph nodes. 2. Posterior Chest expansion >5cm *Moves scapulae out of the way (asks patient to raise and cross arms infront of themselves) for all the following:* **Percussion**: Fingers horizontal between the ribs 1. Upper, middle, lower lobes 2. Axilla **Auscultation**: (ask patient to breathe in and out normally through an open mouth.) 1. Stethoscope = Upper, middle, lower lobes, Axilla *Comments: on air entry, breath sounds and adventitious sounds.* - "There are no unsual breath sounds or adventitous sounds." 2. Auscultates for vocal resonance (asks patient to say 99 on each auscultation using a normal voice ‘not whispering’, using medium to low volume voice though to ensure it is heard through the stethoscope and not through ones ears )

What do you do for Palpation, Percussion and Ausculation of the chest in a respiratory exam?

**Palpation**: 1. Anterior chest expansion. **Percussion**: 2. Supraclavicular 3. Upper lobes 3. Lower lobes 4. Clavicles (fingers only) **Auscultation**: 1. Auscultates breath sounds, comments on air entry and adventitious sounds. 2. Auscultates for vocal resonance (asks patient to say 99 on each auscultation)

Which components of the cardiovascular exam would you perform in a respiratory exam? (4)

1. **JVP** - bed at 45degrees <3cm 2. **Apex** **beat** - 5th Intercostal space, mid-clavicular line 3. **Palpate** **precordium** - for thrills and heaves - hand is vertical for parasternal heave (right ventricular hypertrophy) and horizontal for thrills (palpable murmurs) in all 4 cardiac areas. 4. **Auscultate** **precordium** - bell then diaphragm in the mitral --> tricuspid --> pulmonary --> aortic --> carotid "Heart sounds are dual with no added murmurs, thrills or heaves, apex beat was normal in character and location, JVP was not raised."

ABCDEF of CXR interpretation?

In which patients should you consider spirometry?

Obstructive vs. Restrictive vs. Mixed picture on spirometry?

6 Symptoms & 7 Signs of Pneumonia?

**Symptoms** 1. Cough (painful and dry at first). 2. Fever and rigors (shivers). 3. Pleuritic chest pain. 4. Dyspnoea. 5. Tachycardia. 6. Confusion. **Signs** 1. Expansion: reduced on the affected side. 2. Vocal fremitus: increased on the affected side (in other chest disease this sign is of very little use!). 3. Percussion: dull, but not stony dull. 4. Breath sounds: bronchial. 5. Additional sounds: medium, late or pan-inspiratory crackles as the pneumonia resolves. 6. Vocal resonance: increased. 7. Pleural rub: may be present.

7 Signs & 3 causes of ATELECTASIS (COLLAPSE)?

5 Signs of pleural effusion?

5 Signs of Tension pneumothorax?

Signs of Asthma?

COPD Signs?