History and exam Flashcards
List causes of haemyptosis
Respiratory
- Bronchitis
- bronchail carcinoma
- bronchiectasisi
- pneumonia
- pulmonary infarct
- CF
- Lung Abcess
- TB
- FB
- Good pastures wegeners
- SLE
- Rupture of mucosal vessels
CVS
- mitral stenosis severe
- acute left ventricular failure
Discuss distinguishing features of haemoptysis
Favours haemoptysis
- mixed with sputum
- occurs immediatley after couging
Favours haematemesis
- Follows nasuea
- mixed with vomitus
Discuss Respiratory causes of dyspnoea
AIRWAY 1) Chronic bronchitis and emphysema (COPD) 2) Asthma 3) Bronchiectasis 4) CG 5 Laryngeal or pharyngeal tumour 6) Bilateral cord palsy 7) Tracheal obstruction or stenosis 8) Tracheomalcia
PARENCHYMAL
1) ILD
2) diffuse infection
3) ARDS
4) Infiltrative and metastic tumour
5) Pneumothora
6) pneumoconiosis
PULMONARY CIRC
1) PE
2) Chronic thromboembolic pulmonary hypternsion
3) Pulmonary ateriovenous malformation
4) pulmonary arteritis
CHEST WALL and PLEURA
1) Effusion or massive ascities
2) pleural tumour
3) Fractured Ribs
4) Ankylosing spondylitis
5) Kyphoscoliosis
Discuss non respiratory causes of dyspnoea
CARDIAC
1) LV failure
2) Mitral valve disease
3) CMX
4) pericardial effusion or constricitve pericarditis
5) intracardaic shunt
ANAEMAI
OTHER
1) psychogenic
2) Acidosis
3) hypothalamic
Discuss history for a dyspnoeic patient
1) How long have you been short of breath has it come on quickly
2) how much exercise can you do before your shortness of breath stops you or slows you down
3) have you been woken at night by breahtleness
4) have you had orthopnea
5) have you had fever
6) do you smoke
7) is there a feeling of tightness in the chest when you feel breathless
7) do you get wheezy in the chest
9) is the feeling really one of difficulty gettin a satisfying breath -?ANxiety
10) is it painful to take a big breath
11) did the SOB come on very quickly
Discuss timing of dyspnoea
Seconds to minutes
1) asthma
2) PE
3) pneumo
4) anaphylaxis
5) FB causing airway obstruciton
Hours to days
1) exac of COPD
2) cardiac failure
3) asthma
4) respiratory infection
5) pleural effusion
6) metabolic acidosis
Weeks or longer
1) pulmonary fibrosis
2) COPD
3) pleural effusion
4) Anaemia
Discuss important social, occupational and PMHX for respiratory symptoms
PMHX
- asthma severity
- COPD severity
- HIC
Occupational
- Exposure to asbestos, coal silica irone oxide tin oxide)
- Coal - pneumoconiosis
- silica - silicosis
- asbestos - asbestosis
- talc -talcosis
Social
- Smoker pack years - 20 cig pack a day for a year
- Alcoholism –> greater risk of immunosuppression and klebsiella
- Sexual history – risk fo HIC
- Housing –> risk of infection with over populaiton
Discuss general approach to the respiratory examination
General appearance
- Dyspnoea at rest – RR
- Accessory muscles use
- Pattern of breathing (Kussmauls, Cheyne stoke, hyperventilation, purse lip)
- position adopted - tripoding
- Cyanosis (central is best detected in the toungue) - becomes apparent when absolute concentration of deoxyhaemoglobin is 50g/L
- Any obvious adventitious sounds from the end of the bed (Wheeze, stridor or sturtor)
- Hoarse voice
Hands
- Clubbing
- Staining from cigerettes
- Wasting and weakness
- Pulse rate
- Flapping tremor - dorsiflex the wrists with the arms outstretched and finger spread - flapping tremor with a 2-3 second cycle may occur with severe Co2 retention
FACE
- Nose- polyps enlarged turbinates or deviated septum
- Tounge - cyanosis wasting
- Dentition
- Palpation over sinuses to ellicit tenderness - tranillumiantion
- skinn red leathery wrinkled skin of a smoker.
- Facial plehtora or cyanosis
- HORNERS syndrome (miosis, anhydrosis, ptosis)
TRACEHEA
-Tug or displcament
Discuss examination of the chest
Inspection
1) shape and symmetry of the chest - barrel shaped, pectus carinatum, or excavatum - kyphosis and kyphoscoliosis
- scars suggestive of previous injury or surgery
- subcut emphysema
- prominenet veins
2) Movement
- look for symmetrical rise and fall of the chest
- assess for adequate expansion - unilateral reduction suggest lung firbosis, consolidation/collapse pleural effusion or pneumothorax - bilateral indicates COPD or diffuse ILD
3) Palpation
- Chest expansions
- HOOVER sign - hands at the costal margin – usually should become further apart on inspiration in severe COPD the chest cannot expand in this direction and the fingers come closer together.
- Vocal (tactile) fremitus - no longer routine
- palpate over ribs to elicit any tenderness
- regional limph nodes in - cervical, axillary and supraclavicular
4) percusion
- dull notes over areas of consolidation
- stony dullness over effusion
- normal resonant
- pneumothorax – hyper resonant
- liver dullness is usual at the fifth rib in the right midclavicular line – if it is respnant beyond this it is suggestive of hyperexpansion
Discuss auscultation of the chest
Breath sounds - listen for posterior and anterior in 4 different location on each side + axillae
QUALTIY
Vesicular breath sounds are louder and longer on inspiration than on expiration and there is no gap between the inspiratory or expiratory sounds
Bronchial breath sounds are present when there is turbulence in the large airways without being filtered in the alveoli. They have a hollow blowing quality. THey ar audible throughout expiation and there is often a gap between inspiration and expiration. - Causes include 1) common - lung consolidation 2) uncommon - localised pulmonary fibrosis -pleural effusion (above the fluid) -collapsed lung
INTENSITY
-described as normal or reduced
ADVENTITIOUS SOUNDS
1) Wheeze -
- Important to time with respiratory cycle - inspiratory wheeze implies severe airway narrowing as wheeze is due to continous oscillation of opposing airway walls.
- High pitched wheeze are produced in the smaller bronchi and have a whistling quality
- low pitched wheeze ( somtimes called rhonchi) arise from the larger bronchi
- Variable obsturction such as COPD or asthma tend to have polyphonic wheeze as apposed to fixed obsturction such as Cancer which can have a localised wheeze and tends to be monophonic
2) CREPS
- Early inspiratory creps which cease in the middle of insipration indicate disease of small airways and are characteristic of COPD
- Late or pan crackles suggest disease confinde to alveoli they may be fine medium or course in quality. Fine creps are indicative of interstitial lung disease
Pleural rub can be heard in pleurisy secondary to pulmonary infact or pneumonia.
Discuss other system exam for resp
Cardiac exam
Abdo
Other signs
-Pembertons sign
Discuss bedside adjuncts to resp exam
Forced expiratory time
Peak flow metere - measures the maximal expiratory flow rate of expired air - normal values for young men are 400-600 itres a minutes and 400 for women. These values depend on age sex and height
Spiro
