Respiratory Flashcards
Possible HPCs for respiratory condition?
Breathlnessness, cough, sputum, haemoptysis
FH for respiratory history?
Infections, allergic conditions e.g. asthma, A1-AT deficiency, CF
PMHx for respiratory history?
Asthma, TB can reactivate, PE, allergies, pneumonia can lead to bronchiectasis or pulmonary fibrosis, home oxygen, inhalers, severe measles/ whooping cough can lead to bronchiectasis
Surgery Qs for respiratory history?
Dental surgery- can lead to aspiration of purulent material or fragments of tooth
Abdominal, pelvic or orthopaedic surgery= RFs for DVT and possible PE
Other Qs for respiratory Hx?
Cardiac disease- may lead to pulmonary oedema- ask about angina, orthopnoea, paroxysmal nocturnal dyspnoea
Immunocompromised e.g. HIV, immunosuppression post-transplant surgery- may predispose to atypical infections
Drug history for respiratory hx?
Inhalers, steroids, antibiotics, ACE-i, amiodarone, beta-blockers, NSAIDs, oxygen therapy
Social history for respiratory hx?
Occupation- industrial hazards e.g. dusts, asbestos, smoking, pets, overseas travel, living conditions e.g. damp, alcohol, exercise, ADLs, independence, hobbies e.g. pigeon fancying, long haul flights
Respiratory causes of chest pain?
Pulmonary embolsim, pneumonia, pneumothorax
Acute causes of SOB? In between causes? Chronic?
PE, asthma attack, pneumonia, pneumothorax
Carcinoma of the lung, pleural effusion, TB
COPD, pulmonary fibrosis, heart failure
Qs for SOB?
How are you normally?
Onset, timing, duration, variability, diurnal variation
Exacerbating factors e.g. allergens, exertion, cold air
Relieving factors e.g. rest, medication
Associated- cough, sputum, haemoptysis, pain, wheeze, night sweats, weight loss, oedema
Severity- at rest, only on exertion, limiting ADLs
Qs for cough?
Onset, timing, duration- < 2 months= acute, variation, diurnal variation, productive/ unproductive
Qs for sputum?
Onset, timing, duration, variation, diurnal variation
Colour e.g. rusty= pneumococcal pneumonia; frothy pink= pulmonary oedema, any haemoptysis?
Consistency, quantity, odour- fetid= bronchiectasis/ lung abscess
Qs for haemoptysis?
Origin, onsent, timing, duration, variation, quantity, colour, consistency, sputum, chest pain, recent trauma, recent/ current DVT, weight loss, fever, night sweats, breathlessness, bleeding/ bruising elsewhere
Other Qs for SOB?
Associated: chest pain, palpitations, orthopnoea/PND, nausea/ vomiting, cough, calf/ ankle swelling/ pain
Important extras for resp hx?
Fevers, night sweats, weight loss, risk factors for VTE
Starting a resp examination?
Wash hands, intro, confirm patient ID, explain, consent, expose-“ general inspection of arms, face and chest before feel of chest and back and having a listen with stethoscope”
Any pain?
Inspect at bedside for?
Inhalers, nebuliser, oxygen mask, sputum pot
Inspect for in patient?
Colour, breathing, comfort, position, purse-lipped breathing in COPD, SOB, nutritional state
Cachexia may suggest what? Age diagnostics?
Malignancy, CF, COPD
Young- asthma/ CF, older- COPD/ interstitial lung disease/ malignancy
Diagnostics for inspection of cough?
Productive- bronchiectasis/ COPD/ CF, dry- asthma/ interstitial lung disease
Dx for additional breath sounds on inspection?
Wheeze(expiratory)= asthma/ COPD/ bronchiectasis, stridor(inspiratory)= upper airway obstruction
Look for what when palms down x6?
Finger clubbing, tar staining, wasting of intrinsic muscles, features of rheumatological disease, fine tremor, flapping tremor
Finger clubbing causes?
Cyanotic heart disease/ cystic fibrosis, lung cancer/ abscess, ulcerative colitis, bronchiectasis, benign mesothelioma, infective endocarditis/ idiopathic pulmonary fibrosis, neurogenic tumours, gastrointestinal disorders
Tar staining may mean what? Wasting of intrinsic muscles? Features of rheumatological disease?
Increased risk of COPD/ lung cancer
T1 nerve invasion by an apical lung cancer
RA ass with pleural effusions and pulmonary fibrosis
Fine tremor? Flapping tremor?
Beta-2 agonist use (salbutamol)
Coarse flapping tremor- CO2 retention
Inspect for what when palms up x3?
Skin changes- bruising/ thinning of skin are associated with long-term steroid use(ILD/ asthma/ COPD)
Colour- peripheral cyanosis suggest hypoxia
Temperature- cool peripheries can suggest poor perfusion/ peripheral vasoconstriction
What pulses?
Radial pulse- bounding in CO2 retention, assess RR for 15 seconds whilst palpating the pulse, normal= 12-20 breaths/ min
Pulsus paradoxus- pulse wave volume decreases with inspiration in asthma/ COPD
How to measure JVP? Raised when?
Patient at 45 degrees, ask patient to turn head to their left side, observe neck for JVP in line with sternocleidomastoid, measure JVP- number of cm from sternal angle to upper border of pulsation
Normal= 2-4cm
Raised with fluid overload/ pulmonary HTN
Observe for what in eyes?
Conjunctival pallor- anaemia
Central cyanosis
Horner’s syndrome- ptosis/ constricted pupil(miosis)/ anhidrosis on affected side (Pancoast tumour)
What scars to look for?
Small mid-axillary scars= chest drains, horizontal postero-lateral scars= thoracotomy from lobectomy/ pneumonectomy
Other things to look for?
Skin changes- recent/ previous radiotherapy
Facial swelling
Asymmetry- major surgery
Deformities- barrel chest in COPD, pectus excavatum (chest sticks in,) pectus carinatum (chest sticks out,) severe kyphoscoliosis (hunched back)
Facial swelling seen in what? Pneumonectomy usually for what? Thoracoplasty for what?
SVC obstruction
Cancer
Rib removed/ previously used to treat TB
Things to palpate for? Feeling for tracheal position?
Tracheal position, apex beat, chest expansion, tactile vocal fremitus
Neck relaxed, dip index finger into thorax beside trachea, gently apply side pressure to locate trachea, compare this space to other side
Away from tension pneumothorax/ large pleural effusions
Towards lobar collapse, pulmonary fibrosis and pneumonectomy
Where is apex beat? Right ventricular heave in what?
5th IC space, MC line
In cor pulmonale
How to measure chest expansion?
Ask pt to exhale fully, place around chest inferior to nipples, wrap fingers around either side of chest, bring thumbs together in midline, ask patient to take 2 deep breaths, should move equally apart (3-5cm)
One moves less<2cm, reduced expansion on that side?, lung collapse/ pneumonia
How to measure tactile vocal fremitus?
Ask patient to say “99” as you place lateral side of hand on chest
Increased in consolidation
Decreased with effusion/ pneumothorax
How to percuss?
Side to side for comparison- supraclavicular, infraclavicular, chest wall- 3-4 locations bilaterally, axilla
Resonant= normal
Dullness= increased tissue density; consolidation/ fluid/ tumour/ collapse
Stony dullness- pleural effusion
Hyperresonant= opposite of dullness, suggested of decreased tissue density, pneumothorax
How to auscultate?
Ask patient to take deep breaths through mouth
Supraclavicular, infraclavicular, chest wall- 3-4 locations bilaterally, axilla
Vesicular= normal
Bronchial(harsh)- inspiration and expiration= equal with pause between associated consolidation
Volume- quiet suggests reduced air entry; consolidation/ collapse/ pleural effusion
Added sounds= wheeze in asthma/ COPD, coarse crackles in pneumonia/ bronchiectasis/ fluid overload, fine crackles in pulmonary fibrosis
Assess for changes after coughing as crepitations due to secretions will alter after coughing
How to assess vocal resonance?
Ask to say “99” as you place stethoscope on chest (dullness to percussion from pleural effusion and consolidation)
Increased volume and dull percussion note= consolidation/ tumour/ lobar collapse, decrease= fluid outside lung (pleural effusion/ pneumothorax)
If consolidation- whispering pectoriloquy 2-2-2= more loud in area of consolidation
Extras in respiratory exam?
Lymph nodes- anterior and posterior triangles, supraclavicular region, axillary region- lung cancer/ TB/ sarcoidosis
Sacral oedema- fluid overload in cor pulmonale
Legs- pitting oedema, calves for DVT, evidence of erythema nodosum(sarcoidosis)
How to present a resp exam?
Comfortable at rest- no peripheral stigmata, pulse and RR was
Evidence of tremor, palpation there was … chest expansion and mediastinal shift, on percussion lung fields were…., on auscultation …breath sounds were present
FURTHER= sputum pot, peak flow, spirometry, BP, O2 saturations
