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Phase 2b > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Topic 1

A

Taking a respiratory history

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2
Q

Why is it important to know the age of the patient when taking a respiratory history?

A

Different diseases affect different ages. E.g. airflow obstruction in a 20 yr old vs 65 year old smoker

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3
Q

Why is it important to know the occupation of the patient when taking a respiratory history?

A

Many resp. occupations are associated with lung disease. E.g. baker, metal worker
Asbestos

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4
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A
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5
Q

What open questions could you ask the patient?

A

What can I help you with today?
What is the biggest problem for you?
Fit and well as a child? Premature? Asthma?
(Sat out in games, went to open-air school)

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6
Q

If the patient complains of breathlessness, what aspects should you consider?

A

Onset
Duration
Intermittent
Relieving/exacerbating factors?
Diurnal variation
Associated factors e.g. chest pain, palpitations
Progression? stable/up and down/improving/speed of progression/exacerbations
Relationship to other symptoms?

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7
Q

How can you determine the severity of breathlnessness?

A

MRC Dyspnoea scale
Grade 1 - only SOB on severe exercise
Grade 2 - Short of breath when hurrying on a level or when walking up a slight hill
Grade 3 -Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace
Grade 4 - Stops for breath after walking 100 yards, or after a few minutes on level ground

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8
Q

If the patient complains of breathlessness, what aspects should you consider?

A

Onset
Duration
Alleviating/exacerbating factors
Inspiration/expiration - inspiratory wheeze is stridor
Diurnal variation

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9
Q

If the patient presents with a cough, what aspects should you consider?

A

Onset
Duration
Alleviating/ exacerbating factors
Is the cough productive or dry?
Sputum
Nature
Volume
Hemoptysis - infection e.g. pneumonia and bronchiectasis, needs further investigation

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10
Q

If the patient complains of chest pain, what aspects should you consider?

A

Site
Onset
Nature
Duration
Alleviating/exacerbating factors
Association with breathlessness?
Association with cough?

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11
Q

What other resp symptoms can the patient present with?

A

Tiredness/malaise
Fever/night sweats
Weight loss
Collapses, blackouts, falls

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12
Q

What patient history should you investigate?

A

Past Medical History
Drug history

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13
Q

How would you check a patient’s past medical history?

A

Check with patient and GP letter/Integrated clinical portal
Other medical problems (diagnosed and undiagnosed)
‘Cured’ cancers?

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14
Q

How would you check a patient’s drug history?

A

Ask patient – clues to adherence?
Then check…
GP letter
Repeat prescription list
Summary care record
Anything over the counter /Herbal/traditional
Implanted: contraceptives, other hormones etc.

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15
Q

What are some common drugs that cause respiratory side effects?

A

Clopidogrel<Ticagrelor – unexplained breathlessness
Aspirin/NSAIDs – asthma
ACE inhibitors - cough
Betablockers – wheeze
Amiodarone – pulmonary toxicity
Methotrexate – pneumonitis>fibrosis
Nitrofurantoin – pneumonitis
Steroids/immunosuppressants – risk of opportunistic infection
Contraceptives – increase thromboembolism
Slimming pills (anorectogens) – Pulmonary hypertension

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16
Q

What other system diseases can cause respiratory symptoms?

A

Rheumatological: Raynaud’s, joint pain/swelling, muscle aches/weakness
Dermatological: rashes, lumps and bumps, unusual bruises
Ophthalmological: itchy eyes, dry eyes (mouth)
Gastrointestinal: acid in back of throat, heartburn, dysphagia, (bowels)
Neurological: fits, faints and funny turns, weakness
Urological: Polyuria
(cardiological history = respiratory history?)

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17
Q

What personal/social questions could you ask?

A

Smoker?
”Pack years”
Started age 15, stopped age 45, pack-a-day = 30pkyrs
Just tobacco? Marijuana is more powerful than cigarettes
Drinker?
Lives with? Cares for/cared for?
Pets – esp. birds, (asthma, pneumonitis)
Hobbies – horses,(pneumonitis to fungal antigens), electronics, classic cars (asthma-like symptoms) etc.
Foreign travel

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18
Q

Why is it important to investigate the patient’s family history?

A

Alpha-1 antitrypsin
Asthma
Primary cilia dyskinesias etc…
Important for future understanding - 100 thousand genomes

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19
Q

Topic 2

A

Respiratory examination

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20
Q

What is the importance of an examination?

A

A dynamic, intellectual process in which you integrate your clues from the history
a recognition of physical sign
to arrive at an assessment of
diagnostic possibilities
and a problem list: the patient’s state/ wellbeing/ needs
You need to think

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21
Q

Summary of approach to examination

A
  1. Start with “wide angle lens” to make sure you pick up all the obvious peripheral clues first
  2. “Spiral in” on the region of interest i.e. the chest
  3. You should have the diagnosis before you use your stethoscope!
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22
Q

Overall schema for respiratory examination?

A
  1. Introduce yourself - WIPER
  2. Inspect the hands and the arms
  3. Inspect the face and neck, palpate the neck for lymph nodes.
  4. Inspect the chest and the back.
  5. Examine the front of the chest: palpation, percussion and auscultation.
  6. Examine the back of the chest - as before
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23
Q

Initial impression - what things can be picked up on?

A

Cough (and its nature)
Wheeze (expiratory whistling noise)
Stridor (inspiratory noise)
Laboured breathing
(raised rate = “tachypnoea” not breathlessness)
Pursed-lipped breathing in COPD
Nutritional state: obesity may suggest a hypoventilation syndrome
“Paraphernalia” - inhalers, nebulisers, sputum pots

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24
Q

General approach to examination?

A

Inspection
Palpation
Percussion
Auscultation

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25
Q

What does inspection include?

A

Face and skin
Hands and feet
Neck
Expose the chest - inspect chest wall and study breathing movements

26
Q

What should you look for when inspecting the hands?

A
  1. Digital clubbing - the commonest cause of this is lung cancer. DC is found in 29% of patients with lung cancer. Can also be seen in other resp. diseases e.g. pulmonary fibrosis, bronchiectasis and empyema
  2. Tremor - flapping (asterixis) in resp. failure and fine tremor with beta-2 agonists
  3. Warmth
  4. Oedema
  5. Tobacco stains
  6. Coal dust tattoos
  7. Pink/red - shows not anaemic
  8. Pulse - “bounding” with warm peripheries: CO2 retention
  9. Resp. rate
27
Q

What should you look for when inspecting the face and neck?

A
  1. Complexion, cyanosis - look at the base of the tongue
  2. Eyes - anaemia
  3. Neck - JVP is elevated with peripheral oedema in cor pulmonale and superior vena cava obstruction. Trachea - deviation? tracheal tug? 3 fingers underneath cricoid cartilage are normal anything less is abnormal
28
Q

Sign of respiratory failure during inspection?

A
  • Central cyanosis (tongue, lips) due to arterial desaturation (low PaO2)
  • Peripheral cyanosis is much less reliable: reaction to cold, poor perfusion, anxiety etc.
29
Q

What should you look out for when inspecting the chest wall?

A
  1. Deformity, under- and over-inflation, kyphoscoliosis, barrel chest in COPD, flattening
  2. Scars, radiotherapy changes, aspiration wounds
  3. Dilated veins - SVC obstruction
  4. Chest wall movement - rate, pattern, prolonged expiration, movement patterns e.g. symmetry, chest vs abdominal, use of accessory muscles, assess expansion with your fingertips along the mid-axillary line and thumbs as pointers
30
Q

What are some causes of reduced chest wall movement?

A

Can be any lung, pleural or chest wall disease. E.g. kyphoscoliosis, ankylosing spondylitis, neuromuscular

31
Q

What areas should you palpate during the examination?

A
  1. Neck (lymph nodes and trachea), notch-cricoid distance
  2. Axillae
  3. Apex beat
  4. Chest wall movement
32
Q

What is tactile vocal fremitus and how to test for it?

A

The vibration of the chest wall that results from sound vibrations created by speech or other vocal sounds.
To test get patient to say “99” then feel vibrations with side of your hands.

33
Q

How should you carry out percussion of the chest and back?

A
  1. Compare left vs right and one space to the next in a “square wave” pattern.
  2. Resonance implies aerated lung tissue below.
  3. Horizontal sounding finger
  4. If uncertain about whether dullness is present, do tactile vocal fremitus.
  5. Normal: cardiac and hepatic dullness present
  6. Cardiac and hepatic dullness are absent in emphysema.
34
Q

Resonance is lost in…

A

Pleural effusion (“stony” dull)
Consolidation/collapse/fibrosis
Raised diaphragm
Over the liver and heart except in emphysema

35
Q

Resonance is increased in…

A

Emphysema
Pneumothorax

36
Q

Where should you percuss anteriorly?

A

Over the clavicles
In the mid-clavicular line (4-5 times each side)

37
Q

Where should you percuss posteriorly?

A

Over the trapezius
4-5 times each side
Lateral chest walls (3-4 times each side)

38
Q

Tips on using the stethoscope

A

“Everytime I put my stethoscope on your chest, take a breath in and out through an open mouth”
Hold your breath if you ask them to
“Don’t talk” while listening to carotids
Warm stethoscope in your hands while talking to patient
Know where the cleaning stuff is before taking your stethoscope into a patient bedspace
Don’t store it rolled up
Practice on yourself and others

39
Q

How to auscultate?

A

Use the diaphragm because most of the sounds are high pitched
Ask the patient to take deep breaths through the mouth (demonstrate)
Compare one side with the other
Listen
over trapezius
4-5 times each side posteriorly (patent bending forward with arms forward)
in the mid-clavicular line (4-5 times each side)
over the lateral chest walls (3-4 times each side)

40
Q

Auscultation: normal breath sounds

A

Called normal “vesicular”
Loudest on inspiration, fading smoothly into expiration and dying out

41
Q

Auscultation: “bronchial” breathing

A

Higher pitched with distinct inspiratory and expiratory phases
Heard over fibrotic or consolidated lung, above a pleural effusion
Associated with “whispering pectoriloquy”

42
Q

What does wheezing suggest?

A

Airflow obstruction

43
Q

What do crackles suggest?

A

More noticeable at the bases (small airway closure)
Can be caused by: secretions in airways (clear or change on coughing), consolidation, fibrotic lung disease, heart failure

44
Q

What is whispering pectoriloquy?

A

Whispered pectoriloquy is a bedside examination method used in the diagnosis and assessment of respiratory problems.

During the examination, the patient whispers a phrase while a healthcare provider auscultates their chest with a stethoscope, listening for changes in clarity and volume.

Whispered pectoriloquy is used to evaluate for the presence of lung consolidation, causes of which include cancer and pneumonia.

45
Q

Topic 3

A

Pulmonary Function Testing

46
Q

Sleep psychology

A

Sleep apnoea is a condition where your breathing stops and starts while you sleep.

Risk factors include:
Male
Age
over-weight
Neck circumference
Family history
Use of alcohol or sedatives
Smoking
anatomy of upper airway- large base of tongue, adenoids, soft palate, tonsils etc restrict space in upper airway
Menopause

Symptoms
Unrefreshed sleep
Daytime somnolence
Witnessed apnoea
Morning headaches
Increased appetite
Low mood/energy
Nocturia
Heartburn
Loss of libido
Snoring
Nighttime choking
Dry mouth

47
Q

Why are reference values important?

A

Know what to expect with different patients.
Takes into account height, age and sex.

Global Lung Index (GLI) reference equations currently used for adults.

ECCS is secondary values (ECCS reference equations used for adults, please note there are different reference equations for children, which can be very important if you are trying to interpret spirometry results from a CF transition clinic – where little change in absolute value of FEV1, but %change looks substantial)

Ethnic origin (12% correction for volumes only)

48
Q

What are some contraindications for pulmonary function tests?

A

Recent MI
Recent abdominal, thoracic or eye surgery
Pulmonary embolism
Haemoptysis of unknown origin
Pneumothorax
Thoracic, abdominal or cerebral aneurysms
Acute disorders affecting performance (e.g nausea)
Pregnancy

49
Q

What does spirometry measure?

A

Measures dynamic volumes

FEV1, FVC, FEV1/FVC % and PEF

50
Q

What is spirometry?

A

Method of assessing lung function by measuring the volume of air that the patient can expel from the lungs after a maximal inspiration’ (GOLD 2010)

Basis of all pulmonary function tests

Used in diagnosis, monitoring, measurement of an intervention and pre-operatively to evaluate risk

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Phase 2b (7 decks)

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