Respiratory History & Examination Flashcards
History of Breathlessness
N O E R A S
How is patient normally (is this acute, chronic, acute on chronic)
Onset (timing, duration, variability - is this diurnal or linked to anything)
Exacerbating factors (e.g. triggers, exertion, cold air)
Relieving factors (rest, medications)
Associated symptoms (e.g. cough, sputum, haemoptysis, pain, wheeze, night sweats, weight loss, oedema)
Severity (SOB at rest? with exertion? limiting ADLS?)
History of Cough
cOP
Onset (timing variation and duration)
–> less than 2 months = acute, over 2 months = chronic)
–> diurnal variation?
Productive or Dry?
History for Sputum
O C H Q C O
Onset (timing, duration, variation)
Colour (e.g. rusty - pneumococcal pneumonia, frothy pink - pulmonary oedema)
Haemoptysis
Consistency (viscous, mucous, purulent, frothy?)
Quantity (teaspoon, cupful etc)
Odour (fetid = bronchiectasis or lung abscess)
History for Haemoptysis
Ddx: cancer, TB, Trauma, DVT/PE, bleeding disorder
Origin (was it coughed up or haematemisis)
Onset (timing, duration, variation)
Quantity
Colour (fresh or dark altered blood)
Consistency
Sputum
Chest pain
Trauma
DVT Hx
Weightloss, fever, night sweats
SOB
Bleeding or bruising elsewhere
History for pain
SOCRATES
PMH for resp
Previous problems
- Pneumonia can give bronchiectasis or pulmonary fibrosis
- TB can reactivate
- Whooping cough can give bronchiectasis
- Asthma
Recent surgery
- dental surgery can have aspiration of fragments
- abdo / pelvic / orthopaedic are risk for DVT and PE
Cardiac disease
- Pulmonary oedema (ask about angina, orthopnoea, nocturnal dyspnoea)
Immunocompromised (e.g. HIV, immunosuppressed post-transplant) may give atypical infections
DH for resp
Inhalers Steroids Abx ACE inhibitors Amiodorone (pulmonary fibrosis) Beta-blockers (worsen airway obstruction NSAIDS (trigger some asthma) O2 therapy
SH for resp
SPOTA
Occupation (dusts, coal, asbestos) smoking (pack years) Pets (can cause hypersensitivity reactions) Overseas travel / origin Living conditions (damp) Alcohol Exercise, ADL ability
FH for resp
Infections in family currently
Atopy
A1AT (emphysema in younger)
Resp general observations
Inspect bed area:
- Inhalers
- Nebs
- Oxygen mask
- Sputum pot
Observations
- Colour, breathing, comfort, position,
- Purse lipped breathing (COPD)
- nutritional state ( obesity may suggest Apnoea)
Inspection of hands
Clubbing
Tar staining
Muscle wasting (T1 innervation affected by Pancost tumour)
Tremor: flapping/asterixis is rest failure, tremor in beta-blocker use
Peripheral inspection resp
Hands
Pulse:
- bounding in CO2 retention
- pulses paradoxus: radial pulse disappears during inspiration due to dec BP (severe airways disease and tamponade)
Resp rate & effort
BP
JVP - raised in cor pulmonale, if non pulsatile could be SVC obstruction in lung Ca
Eyes and mouth signs resp
Eyes
- Horner’s seen in lung ca
- Chemosis (conjuctival oedema in CP2 retention)
Facial swelling in SVC obstruction
dental carries can cause lung abscess on inhalation
Central cyanosis
Chest inspection
symmetry (in shape and in expansion)
Scars
Muscle wasting
Chest or abdominal (diaphragmatic) breathing
Use of accessory muscles
Recessions (seen in laryngeal/tracheal obstructions)
Tracheal tug
Palpation in Resp
Trachea: deviation
Apex beat: deviation
Cervical LNs
Chest expansion (3-5 cm is normal)
Vocal fremitus (say 99 - inc transmission with consolidation, dec with effusion or pneumothorax as lung tissue separate from chest wall
