Respiratory Flashcards
Topic 1
Taking a Patient’s History in Respiratory Medicine
- Introduction
WIPE
Wash hands
Introduce yourself - “Hello, my name is …., I’m a medical student on the ward…”
Patient details - Confirm you have the right patient. Ask their name, DOB, address, check their wristband.
Establish rapport - smile, shake hands, eye contact.
(Find out who sent the patient into hospital i.e. GP, ED)
- Presenting Complaint (PC)
Ask the patient “So what has brought you in today?”. Establish what their main concern is.
Listen to what the patient has to say.
Then ask “Would you like to tell me anything more about this problem?”
Tip: Summarise back to the patient to check that you have accurately captured their concern before moving on.
When taking a respiratory history what presenting symptoms may the patient have or complain about?
Respiratory symptoms:
Cough
Sputum production
Breathlessness
Chest pain
Haemoptysis
Wheezing
Systemic symptoms:
Weight loss
Malaise
Night sweats
Note: acuity of onset, changes over time, change in symptoms with location.
- History of Presenting Complaint (HPC)
Obtaining a chronological description of the problem.
If the patient complains of pain - use
SOCRATES: site, onset, character, radiation, associated symptoms, timing, exacerbating
and relieving factors, severity.
In the meantime, you need to start developing your differential diagnosis. Enquire about: risk factors for any particular disease and any treatment they have had and their response to this treatment.
What could you say to the patient to link HPC to their background health check?
“Thank you for sharing everything so far. I don’t have any more questions about your main concern. What I’m going to do next is ask you some background health questions and your family history.”
- Past Medical History
Obtaining a detailed health record.
Ask the patient about:
- any significant illnesses they’ve had before.
- any previous operations and other procedures like angioplasty, stenting
- ask about mental health
- childhood history: prematurity, childhood infections such as whooping cough or measles.
Run through a screening checklist of illnesses with the patient using the mnemonic MJ THREADS (myocardial infarction, jaundice, TB, hypertension & heart disease, rheumatic fever, epilepsy, asthma & COPD, diabetes, stroke and TIA) - However, adapt to the patient you’re taking a history from.
- Drug history
Obtaining a detailed record of prescribed, OTC or complementary therapies.
Ask about responses to these
Is the patient complaint?
What are some common drugs with respiratory side effects?
Clopidogrel<Ticagrelor – unexplained breathlessness
Aspirin/NSAIDs – asthma
ACE inhibitors - cough
Beta-blockers – wheeze
Amiodarone – pulmonary toxicity
Methotrexate – pneumonitis>fibrosis
Nitrofurantoin – pneumonitis
Steroids/immunosuppressants – risk of opportunistic infection
Contraceptives – increase thromboembolism
Slimming pills (anorectogens) – Pulmonary hypertension
- Allergies
Asking the patient if they have any known allergies to drugs, food, elastoplast, latex etc.
If so, what reaction does the patient have?
Itching, rash, swelling, anaphylaxis, or other?
Have they had to stop any medications due to side effects?
- Family history (FH)
Ask about first-degree relatives, their age, their state of health or cause of death.
Ask about any diseases that run in the family e.g. emphysema, bronchiectasis or cystic fibrosis.
Ask about specific diseases relevant to their presenting complaint e.g. for asthma ask if any relatives have asthma, eczema, hay fever, nasal polyps .
- Social history (SH)
(Needs to be adapted according to the age of the patient and their medical problem.)
- ask if the patient lives with anyone and if so, whom?
- does the patient have any dependents?
- ask the patient about their accommodation e.g. house, bungalow, tenth-floor flat?
- do they go out at all? ask about hobbies
- able to carry out their ADLs?
- do they have social services support?
- are they working? ask about occupational exposure, especially in respiratory history. Focus on any exposure to asbestos, organic materials e.g. hay, mushrooms, cotton or animals, coal dust.
- any recent overseas travel? - relevant for TB
- do they have pets?
- do they drink alcohol? Note how often, units per week, perform CAGE if you suspect a problem.
- smoking history - duration of smoking and no. of cigarettes per day, attempts made to give up including replacement substances such as nicotine patches and e-cigarettes.
- recreational drug use - e.g. use of cannabis
What are the “top 10” respiratory conditions?
Acute and chronic cough
Asthma
Chronic obstructive pulmonary disease (COPD)
Pneumonia
Pulmonary tuberculosis
Pneumothorax
Pleural effusions
Lung cancer
Bronchiectasis
Interstitial lung disease
“Top ten” concepts in respiratory medicine?
- Smoking cessation
- Self-management of chronic conditions
- Admission avoidance
- Home oxygen therapy
- MDT cancer care
- Respiratory failure
- Atopy
- The “treatment ladder” approach to asthma and COPD
- Management of chest drains
- Diagnosis and staging of lung cancer
What are the “top ten” respiratory medications?
- Oxygen
- Beta-agonists
- Antimuscarinics
- Oral and inhaled corticosteroids
- Combination inhalers
- Antihistamines
- Leukotriene receptor antagonists
- Mucolytics
- Monoclonal antibodies
- Antifibrotics
Topic 2
Performing a Patient Examination in Respiratory Medicine
How would you start the examination?
WIPER
Wash hands
Introduce yourself
Patient details (ask for at least 3)
Explain the procedure and gain consent
Risks - tell the patient if there are any
What would you do after WIPER?
- General inspection of the bed area e.g. inhalers, nebulisers, oxygen masks, sputum.
- End-of-the-bed-o-gram e.g.
- posture: lying flat or raised?
- colour: cyanosed?
- respiratory rate
- pain on breathing? pleuritic?
- fever
- cachexia (unintentional weight loss)
- pursed-lipped breathing in COPD
- nutritional state (obesity may indicate obstructive sleep apnoea or Pickwickian syndrome)
Inspection - what does this include?
Inspection of the:
- Hands and arms
- Face - general, eyes and mouth
- Chest
- Posterior chest
Signs of respiratory disease on inspection of the hands (and arms) ?
Clubbing
Tar staining
Wasting of the intrinsic muscles (a sign of T1 nerve invasion by apical lung cancer)
Fine tremor (a sign of beta-agonist use e.g. salbutamol)
Flapping asterixis (get patient to cock their wrists back, if positive = respiratory failure)
Pulse rate, rhythm, and character (e.g. bounding in CO2 retention)
Pulsus paradoxus - an exaggeration of the normal decrease in bp on inspiration (seen in severe obstructive airways disease and cardiac tamponade)
Raised JVP (suggests cor pulmonale)
A raised non-pulsatile JVP may be seen in SVC obstruction due to lung cancer - oedema will be present in the neck and face
Peripheral cyanosis
Signs of respiratory disease on inspection of the face?
Horner’s syndrome
Chemosis/ conjunctival oedema: swelling of the conjunctiva, hypercapnia secondary to COPD.
Pursed lips
Nose: beaky
Facial swelling: seen in SVC obstruction
Dental caries (may cause lung abscess)#
Central cyanosis
Signs of respiratory disease on inspection of the chest?
Shape: deformity, hyperinflation (emphysema), barrel chest
Severe kyphoscoliosis: spinal curvature that makes the spine look rounder than normal
Severe pectus excavatum (funnel chest)
Pectus carinatum (pigeon chest) +/- Harrison’s sulci
Colour
Breathlessness
Scars
Symmetry of movement
Abdominal paradox (diaphragm weakening)
Prominent veins (SVC obstruction)
Intercostal indrawing: use of accessory muscles
Signs of respiratory disease on inspection for symmetry?
Scars
Muscle wasting
Chest versus abdominal (diaphragmatic) breathing
Use of accessory muscles
Recession (common in children and adults with tracheal obstruction)
Signs of respiratory disease from inspection of sputum?
Increased volume of sputum = bronchiecstasis
Mucopurulent (infection)
Purulent (green = infection)
Haemoptysis/ bloody (cancer, pulmonary embolism, tuberculosis, bronchiecstasis)
What are you assessing when palpating the chest?
Tracheal position
(deviation occurs towards the side of the pathology in pulmonary fibrosis or collapse but away from the side of the pathology in a pneumothorax or massive effusion)
Apex beat
Assess chest expansion (normal = 3-5cm, abnormal less than 2cm). Remember to ask the patient to exhale fully before assessing expansion.
Assess tactile vocal fremitus “say 99”
Cricosternal distance
Tenderness: costochdritis, rib fracture
Liver: position (low lying), enlargement
What else should you palpate?
Lymph nodes!
Submental
Submandibular
Pre-auricular
Post-auricular
Superficial cervical
Deep cervical
Posterior cervical
Supraclavicular
How would you percuss the chest?
Starting at the apices (highest point of the lungs - protrudes above the first costal cartilage and the medial third of the clavicle)
percuss from side to side
Ensure you have percussed every lobe of the lungs.
What are you assessing when percussing the chest?
Resonant: normal
Dullness: consolidation and collapse
Stony dullness: fluid (effusion)
Hyper resonant: pneumothorax
How would you auscultate the chest?
Start at the apices, and auscultate from side to side anteriorly and laterally with open-mouthed breathing (clavicle to 6th rib, mid-clavicular line; axilla to 8th rib, mid-axillary line)
What are you assessing when auscultating the patient?
Vesicular (normal) breath sounds
Bronchial breathing
Wheeze: monophonic (single large airway obstruction) and polyphonic (narrowing of small airways)
Crackles/crepitations: coarse (consolidation, bronchiectasis)
fine, late inspiratory (pulmonary oedema, lung fibrosis)
Pleural rub
Vocal resonance
- get the patient to cough, and auscultate again, noting any changes.
- get the patient to “say 99” and auscultate again (transmission is reduced across a pleural effusion or pneumothorax)
- if you suspect an area of consolidation perform whispering pectoriloquy.
What do you do after auscultating the chest?
Repeat inspection, palpation, percussion and auscultation (spine of scapula to 11th rib) on the back with the patient sitting forward
How would you end the respiratory examination?
Palpate the cervical lymph nodes.
Palpate the ankles for oedema (right heart failure and secondary to pulmonary hypertension), look for DVT
Check sputum pot (volume, consistency, colour, odour, and haemoptysis)
Assess peak flow (state that you would do this in the OSCE)
Thank the patient and tell them to redress
Wash your hands
Topic 3
Chest x-ray interpretation
- Preliminaries
Patient details:
which patient, how old and when was the image taken?
X-ray details:
Posteroanterior or anteroposterior projection?
Is the patient rotated?
Is there adequate penetration?
Has the patient taken an adequate breath?
Compare to previous x-rays if available
- Trachea
Normal x-ray:
It should be widely patent and central in the chest.
Abnormalities: the trachea may be pulled towards areas of fibrosis or collapse. May be pushed by masses (e.g. a goitre, lymphadenopathy, large pleural effusion or a tension pneumothorax)
- Mediastinum
Normal x-ray:
- Heart size
- Diaphragm
- Pleura
- Lungs
- Bones
- Soft tissue
- Misc
Topic 4
Anatomy of the respiratory system (recap!)
What is the principal function of the respiratory system?
Extract oxygen from the external environment and to dispose of carbon dioxide
How is gas exchange achieved?
By exposing thin-walled capillaries to the alveolar gas and matching ventilation to blood flow through the pulmonary capillary bed.
Other functions of the pulmonary circulation?
- Host defence is a key function. Large surface area of the lung being exposed to the external environment for gas exchange - dusts gases and infective agents
- Acts as a blood pool reservoir allowing the body to respond readily to increased oxygen demands in exercise.
- Innate immunity: de-priming neutrophils
- speech, the passage of air through the vocal cords is necessary for phonation
Anatomy of the trachea
- 10-12cm length
- lies slightly to the right of the midline
- divides at the carina into r + l main bronchi
- carina lies under the junction of the manubrium sterni and the second right costal cartilage
Why is inhaled material more likely to end up in the right lung?
It is shorter and more vertical than the left.
What does the right main bronchus divide into?
The upper lobe bronchus and the intermediate bronchus.
The intermediate bronchus further subdivides into the middle and lower lobe bronchi.
What does the left main bronchus divide into?
The upper and lower lobe bronchi only.
What do each lobar bronchi further divide into?
Segmental and subsegmental bronchi.
What is the order of branching from the trachea to the alveolus?
Trachea > bifurcation > main bronchi > lobar bronchi > segmental bronchi > bronchi of sixth generation > terminal bronchioles > respiratory bronchioles > alveolar duct > alveolar sac > alveolus
(after sixth generation, the passageways are too narrow to be supported by the cartilage and thus are called bronchioles)
25 divisions in between the trachea and the alveoli.
What features do the first 7 divisions of the bronchi have?
- walls consisting of cartilage and smooth muscle
- an epithelial lining with cilia and goblet cells
- submucosal mucus-secreting glands
- endocrine cells
25 divisions in between the trachea and the alveoli.
What features do the next 16-18 divisions of the bronchi have?
- no cartilage and a muscular layer that progressively becomes thinner
- a single layer of ciliated cells but very few goblet cells
- granulated Clara cells that produce a surfactant-like substance.
What is the function of ciliated epithelia?
Key defense mechanism.
Each cell bears approximately 200 cilia beating at about 1000 beats per min in waves of contraction. It moves mucus (containing macrophages, cell debris, bacteria, and inhaled particles) toward the larynx
