Resp history and exam Flashcards
What questions to ask in a resp exam?
Sob - MCR scale, triggers History of sudden wheeze/sob - triggers Cough - dry/productive, sputum colour Haemoptysis - chest pain PND - orthopnea, SOA Courses of abx and oral CS in 12/12 GORD - hayfever and eczema Admissions to ED/hospital/IDU
What is the MRC breathlessness scale?
1 = no breathlessness except on exercise 2 = SOB when hurrying 3 = Walks slower than most people 4 = Stops for breath after 100yrs 5 = too breathless to leave house
What drug history to ask?
Allergies inc aspirin sensitivity Inhalers Anticoagulants Oxygen use Nebulisers Confirm med histories
Social history?
Occupation Smoking Hx Alcohol consumption Pets/birds Asbestos
How to take their med history linking to resp conditions?
Asthma - sob/wheeze/cough - triggers, affects young and middle aged
COPD - sob/wheeze on exertion/cough, >35yrs;smokers
Bronchiectasis - chronic sputum production
PE - sob/pleuritic pain/may be on warfarin
IDL (lung disease) - occasional dry cough/may be on steroids/immunosuppressants
Symptoms of OSA?
Daytime somnolence
Own CPAP machine; supplemental O2
Resp muscle weakness
Lung cancer symptoms?
Weight loss SOB Cough +/- haemoptysis Chest pain Extra-pulmonary symptoms If post chemoRx
How to take a drug history?
Inhalers for asthma and COPD only SABA nebules for severe asthma Oral steroids for immunosuppression in severe asthma and ILD processes Amiodarone and methotrexate Warfarin and rivaroxaban/apixaban Aspirin/NSAID hypersensitivity
What questions to ask the pt?
Exacerbation of chronic lung disease Increased breathlessness Worsening cough More sputum production Change in sputum colour
How to do a general inspection for a resp exam?
At end of the chair: Is the patient comfortable? What is the respiratory rate? 14-16/min Is there cyansosis? Peripheral +/- central? Accessory muscles being used?
What is cyanosis?
Blue discolouration of peripheries +/- tongue
Tongue reflects deoxygenated blood
SpO2 <90% with obvious cyanosis (with normal Hb)
What muscles to examine during a resp exam?
Accessory muscles
Sternomastoids
Platysma
Strap muscles
What does an audible wheeze indicate?
Asthma/COPD/Vocal cord dysfunction
What does stridor indicate?
Upper airway obstruction emergency
What does hoarseness indicate?
Recurrent laryngeal nerve injury and cancer
What pulse should be checked?
Radial pulse
>100bpm = underlying disease relating to anxiety
What to inspect regarding hands?
Clubbing - cancer, bronchiectasis/fibrosis
Flapping tremor - severe CO2 retention
Wasting of muscles of hands
(Bilateral - cachexia associated with COPD, cancer, motor neurone disease
Unilateral - compression of lower brachial plexus
How to examine the face?
Pallor - check conjunctiva for anaemia Tongue colour Lung abscess or pneumonia due to carious tooth Obese = risk of ventilatory failure Moon face - chronic oral steroid use
How to identify the unwell pt?
Is the Airway patent?
How is the Breathing? RR/SpO2/Chest mvmt/cyanosis/
How is the circulation? Pulse/BP/peripheral circulation
How is the neurological status? (Disability/GCS
Signs of an unwell pt?
Respiratory rate>20/min Difficulty completing sentences Using accessory muscles Cyanosis Audible Wheeze
How to treat asthma?
If PEF<75% give Short Acting Brochodilator
Give 4 puffs (inhaler) via spacer
Give 2 puffs/2mins & assess response up to 10puffs
or
Salbutamol 5mg nebuliser (ideally by 6l/min O2)
Consider oral steroids
Consider immediate referral to GP/walk-in centre/999
How to treat COPD?
If sob/wheezy
Give (salbutamol) ventolin 5mg dose & (ipratropium bromide) 500mcg via nebuliser driven (not via oxygen)
If nebuliser not to hand – administer 4 puffs of short acting beta agonist via spacer
Less likely COPD patients to develop acute bronchospasm post dental intervention compared to asthma patients
Consider referring immediately to GP/walk-in centre/999
If infective exacerbation (LRTI)
Aminopenicillin
Tetracycline
Macrolide
Oral course of prednisolone (if dyspnea impact on daily life)
GP review/refer to A&E/walk-in centre
How to give oxygen?
Initial = nasal cannulae 2-6 l/min or simple face mask 5-10l/min
Pt not at risk of hypercapnic resp failure who have saturation <85% = reservoir mask at 10-15l/min
Recommended initial O2 saturation rate = 94-98%
