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

Respiratory History and Examination Flashcards by Sarah-Louise Watson

What is taking a patients history

This is when you talk to the patient and obtain information from them

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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

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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

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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

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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

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why do we used a standard structure for history

Ensures nothing forgotten

Standardised documentation

Standard presentation/handover

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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

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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

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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

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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?

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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?

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what is often the presenting compliant in respiratory (PC)

pneumonia
PE
pneumothorax
pulmonary oedema
asthma
pulmonary fibrosis

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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

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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

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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

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What are the risk factors for PE

Immobility

Trauma/Surgery

Previous VTE

Abdominal mass

Malignancy

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What are the risk factors for pneumothorax

PHx

Smoker

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What are the risk factors for pulmonary oedema

Cardiac disease

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What are the risk factors for asthma

Past History

Trigger

Atopic disease

family history

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what are the risk factors for pulmonary fibrosis

Environmental Exposure

Connective Tissue Disease

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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