Respiratory History and Examination Flashcards
What is taking a patients history
This is when you talk to the patient and obtain information from them
What is the aim of taking a patients history
- guides examination and investigations
- makes a differential diagnosis
- assesses the severity of the problem
- placing the problem in the patients own context
- initiates a management plan
why else do we take a history
Public health
- partner notification
- patterns of disease
- disease legal implications
research
identify and manage sources of anxiety
biomedical model
- make a diagnosis - differential diagnosis and assess clinical condition
- plan examination
- plan investigations
- plan Treatment
illness model
- understanding how the illness affects the patient
- understand how the patient affects the disease
- patients health beliefs
build a therapeutic relationship with the patient
preventative medicien
- screening
- risk factors
- primary prevention
what does - PC - HPC - PMH - DH - SH - FH mean
- PC - presenting complaint
- HPC - history of presenting complaint
- PMH - past medical history
- DH - drug history - medications they take
- SH - social history
- FH - family history
What is the standard structure of a history
- PC – Presenting complaint
- HPC – History of Presenting Complaint
- PMH – Past Medical History
- DH + Allergies – Drug History - Medications they take – Not illicit drugs they use
- SH – Social History
- FH – Family History
- Systems Enquiry
(Clinical) Differential Diagnosis
why do we used a standard structure for history
Ensures nothing forgotten
Standardised documentation
Standard presentation/handover
in what section of the history does smoking history and chest pain come up in
In Lung Cancer or COPD clinic Smoking History comes in HPC
Chest pain in A&E Cardiac Risk Factors come in HPC
if a patient has multiple interlinked comorbidities what may you wish to start with
For a patient with multiple interlinked comorbidities you may wish to start with “Background” before PC
Name the types of questions that you ask in a history
- ask open questions - start with open questions to encourage the patient to tell their story in their own words
- then as the list narrows down start to ask closed questions
list some examples of open questions
Why did you come/are you here?
Can you describe the problem?
What is it that’s worrying you?
List some examples of closed questions
Does your pain come on on exercise?
Does rest make the pain go?
How many pillows do you sleep on?
Do your legs swell?
what is often the presenting compliant in respiratory (PC)
- pneumonia
- PE
- pneumothorax
- pulmonary oedema
- asthma
- pulmonary fibrosis
List the questions to ask
PC – Presenting complaint
- Why did you come here today?
HPC – History of Presenting Complaint
- when did it start
- did it come on suddenly or build up slowly
PMH – Past Medical History
- Has this happened before
- Do you have any other medical conditions
DH + Allergies – Drug History - Medications they take – Not illicit drugs they use
- Are you taking any medication?
- Have you taken any previous. medication for this?
do you have any allergies
SH – Social History
FH – Family History
Systems Enquiry
(Clinical) Differential Diagnosis
what presents at - quick onset - slower onset - slowest onset in respiratory cases
Quick onset
- PE
- pneumothorax
- asthma
slower onset
- pneumonia
- pulmonary oedema
slowest onset
- fibrosis
associated symptoms with
- Chest pain
- fever
- wheeze
- cough
- pulmonary oedema
Chest Pain
- PE
- Pneumothorax
Fever
- Pneumonia
- Asthma
Wheeze
- Asthma
Cough
- Pneumonia
- Asthma
Pulmonary Oedema
- Orthopnoea
- Paroxysmal Nocturnal Dyspnoea
- Swollen Ankles
What are the risk factors for PE
Immobility
Trauma/Surgery
Previous VTE
Abdominal mass
Malignancy
What are the risk factors for pneumothorax
PHx
Smoker
What are the risk factors for pulmonary oedema
Cardiac disease
What are the risk factors for asthma
Past History
Trigger
Atopic disease
family history
what are the risk factors for pulmonary fibrosis
Environmental Exposure
Connective Tissue Disease
What is the order of the respiratory examination
WIPER
- Wash hands
- introduction
- position the patient
- expose patient - chest exposed
- retreat to the end of bed
- Inspection
- hands
- arms
- face
- neck - cervical lymph nodes
- Chest - observe, palpitate, percuss, ausculate
- completing the examination
What does WIPER stand for
Wash your hands
Introduce yourself
Position the patient (45 degree angle)
Expose the patient (chest exposed)
Retreat to the End of the Bed
What are you looking for in the inspection
General inspection from the end of the bed
- oxygen masks
- nebulisers
- inhalers
- sputum pots
- medications
- stats monitor
What does general inspection involve
- Well/Unwell
- Breathing at rest – -Comfortable/Dyspnoea
Added Sounds:
- Cough
- Wheeze
- Stridor
Scars
Chest Shape
Chest Movements
- Asymmetrical Chest Expansion
- Accessory Muscle use
- Sub-Costal/Inter-Costal Recession
Peripheral Oedema
Peripheral Cyanosis
What is pectus excavatum
When the chest has pointed inwards
What is pectus carinatum
when the chest has a point bit outwards
What is barrel chest
rounded, bulging chest that resembles the shape of a barrel
- can be caused by COPD
what are you looking for in the hands
Peripheral Cyanosis
Tar Stains
Clubbing – (ABCDEF)
Resting tremor - caused by beta agonist use
CO2 retention flap
what are the causes of clubbing
Clubbing – (ABCDEF)
- Asbestosis/Abscess
- Bronchiectasis
- Bronchial Carcinoma
- Cystic Fibrosis
- Decreased O2 (hypoxia)
- Empyema
- Fibrosis
What do you palpate in the resp exam
Radial pulse
- Rate
- Rhythm
- Character = Bounding = CO2 Retention
Check Respiratory Rate at same time (whilst patient distracted by pulse check)
= Normal ≈ 12-20 bpm
Temperature change (warm and well perfused?)
What do you check in the arms
- blood pressure
What do you check in the face
Eyes
- conjunctival pallor
- Horner’s syndrome
Face
- plethora
- cushingoid facies = moon face with cushings syndrome
mouth
- central cyanosis
What are the signs of hornets syndrome
- Ptosis
- Miosis
- Anhidrosis
- Possible apical ‘Pancoast’s’ Tumour
What do you look for in the neck
Observe: JVP: - Raised ?Cor Pulmonale - Raised + Fixed - ?SVC Obstruction
Obvious lymph nodes +/- discharging sinuses
Palpate:
Trachea:
- Position
- Tug
Name the cervical lymph nodes
- Preauricular
- Posterior auricular
- Occipital
- Posterior cervical chain
- Supraclavicular
- Submandibular
- Submental
What are the causes of enlarged lymph nodes
- Infection - TB
- malignancy
What do you do on the chest
Observe
Palpate - apex, right ventricular heave, chest exemption, tactile vocal fremitus
Percuss
Auscultate
- go anterior, lateral and posterior
where is the apex
most inferior lateral pointed cardiac impulse
- 5th intercostal space
- mid clavicular line
what does it mean if the apex is displaced
- Pleural effusion
- Pneumothorax
Where is the right ventricular heave
- ulnar border of the hand
- left sternal edge
when do you get a right ventricular heave
- right ventricular hypertrophy
How do you assess tactile fremitus
saying 99
what does a wheeze and crepitations mean
Wheeze = Expiratory Crepitations = Inspiratory
what are the breath sounds
vesicular - normal
bronchial
What is the difference between vesicular and bronchial breath sounds
Vesicular
- have inspiration and then expiration and then silence
- inspiration is longer than expiration
bronchial
- inspiration then science then expiration
- inspiration and expiration are the same amount of time
how do you assess sacral and peripheral oedema
Sacral Oedema
= Gently press lower back
Peripheral Oedema
= Gently press feet/shins
what is the presentation of consolidation
- trachea
- expansion
- percussion
- vocal fremitus
- breath sounds
- vocal resonance
- additional sounds
- trachea = central
- expansion = decrease in effected side
- percussion = dull
- vocal fremitus = increase in affected side
- breath sounds = bronchial
- vocal resonance = increase
- additional sounds = inspiratory crackles
what is the presentation of pleural effusion
- trachea
- expansion
- percussion
- vocal fremitus
- breath sounds
- vocal resonance
- additional sounds
- trachea = displaced away
- expansion = decreased affected side
- percussion = stony, dull over the fluid
- vocal fremitus = no
- breath sounds = decrease or no
- vocal resonance = decrease
what is the presentation of pneumothorax
- trachea
- expansion
- percussion
- vocal fremitus
- breath sounds
- vocal resonance
- additional sounds
- trachea = displaced away
- expansion = decreased in affected side
- percussion = hyperresonoance if large
- vocal fremitus = decrease
- breath sounds = decrease or none
- vocal resonance = decrease
what is the presentation of fibrosis
- trachea
- expansion
- percussion
- vocal fremitus
- breath sounds
- vocal resonance
- additional sounds
- trachea = displaced towards
- expansion = decrease
- percussion
- vocal fremitus = increased
- breath sounds = bronchial
- vocal resonance = increase
- additional sounds = fine inspiratory crackles over affected lobes
what are bedside investigations
O2 Saturations
Temperature
Peak flow
