Respiratory - History, Examination and Bedside Tests Flashcards
Respiratory History
PC/HPC
- Specific respiratory symptoms
- General symptoms which can point to respiratory disease - positives and negatives
PMH/DH
SH
FH
System Rv
ICE
Symptoms of Respiratory Disease (6)
Breathlessness (Dyspnoea)
Cough (Dry or productive)
Sputum (Colour, quantity)
Haemoptysis
Wheeze
Pain
FY1 in Ambulatory medical unit - asked to see a 64 yo man who has been referred by GP with progressive breathlessness
PC
HPC, review of systems
PMH, medication, Drug allergies
Social Hx, Family Hx
What Qs are important?
How long have you been breathless for?
Is it getting worse?
Anything that makes it worse?
Can you still do usual activities?
Pillows at night?
Chest pain?
Cough? Sputum?
Weight loss?
Fever?
Smoker?
Any other health conditions?
Any recent surgery?
Any regular medication?
Any known allergies?
Up to date on vaccinations?
Hay fever or eczema?
Do you work? What occupation?
Alcohol intake?
FH - any relevant?
Whos at home with you?
FY1 in Ambulatory medical unit - asked to see a 64 yo man who has been referred by GP with progressive breathlessness
History so far:
- SOB for 3 months (walking dog), worse over last week (Stopped walking dog), recent cold, no sputum
No chest pain, fevers, weight loss, haempotysis
No ankle swelling, orthopneoa or PND
Smoker
Differentials?
COPD
Pleural effusion
Heart failure
SOB - Heart, Lungs, Blood
Heart
- Decreased CO
- Inability to respond to exercise
Lungs
- Hypoxia
- Increased effort to maintain SpO2
- Inability to respond to exercise
Blood (anaemia)
Metabolic - such as DKA
Brain/Psych (inappropriate hyperventilation) - at rest; on exertion
Breathlessness: Onset and Partial Causes
Sudden ?
Over hours ?
Days ?
Weeks ?
Months ?
Years ?
Sudden - PE, Pneumonia
Over hours - Asthma, pneumonia, LVF
Days - Pneumonia, LVF
Weeks - Pleural effusion, anaemia
Months - Tumours, ILD, Muscle weakness
Years - COPD, ILD, muscle weakness
Calcification on diaphragm?
exposed to asbestos (ILD)
Cough - the most common respiratory symptom; a normal protective mechanism
Which q’s to ask?
Is the patient a smoker?
Acute infection?
Productive?
What drugs are they taking? (ACEi?)
When does the cough happen?
Hx/evidence of asthma?
Hx of acid reflux?
Complications?
Haemoptysis - coughing blood always abnormal
What are the most significant causes?
PE
Lung cancer
TB
alarming for patients but usually not severe
rarely life threatening but can be
Wheeze - due to fast air flow through narrowed airways
Usually is …, diffuse and polyphonic
Sometimes … and monophonic
Wheeze - due to fast air flow through narrowed airways
Usually is expiratory, diffuse and polyphonic - asthma and COPD
Sometimes inspiratory and monophonic - if large central airway is narrowed - e.g by tumour
Wheeze - due to fast air flow through narrowed airways
Usually is …, diffuse and polyphonic
Sometimes … and monophonic
Wheeze - due to fast air flow through narrowed airways
Usually is expiratory, diffuse and polyphonic - asthma and COPD
Sometimes inspiratory and monophonic - if large central airway is narrowed - e.g by tumour
What is stridor?
Different to wheeze
harsh inspiratory noise
high pitch
obstructed airway indicated
emergency - ENT
Chest pain - diseases in lung itself are usually painless, but …
pleuritic pain - sharp, worse on breathing -e.g. pneumonia/pleurisy
Chest wall pain - localised pain and tenderness due to bone, muscle or nerve involvement e.g. rib fracture
General Resp symptoms:
Weight loss is non-specific but important symptom of lung cancer and TB
Fever and riggers may indicate pneumonia even without standard symptoms
PMH - RESP
TB
Pneumonia and pleurisy
Childhood infections - e.g. severe measles, whooping cough
Wheezing, bronchitis, asthma in childhood
hay fever, eczema
Severe prematurity
Injury to the chest
Any recent major surgery (Especially orthopaedic), medical illness leading to immobility or pregnancy
previous X-ray
Drug/medication HX Respiratory
Ask about inhalers as well as tablets
Some meds may cause respiratory symptoms
- Beta blockers for cardiac disease may cause SOB and wheeze
- ACE inhibitors for cardiac disease/ hypertension may cause cough
Some drugs may cause ILD - e.g. amiodarone, nitrofurantoin
Some drugs can cause pleural effusions (methotrexate)
Some meds may interact with ones we want to prescribe e.g. warfarin and Antibiotics, inhaled steroids and anti-viral drug
Always ask about allergies
Family HX respiratory
Useful in suspected asthma if other family have asthma, hay fever or eczema
Important in infectious conditions such as TB (because of likely exposure through close contacT)
Cystic fibrosis and some causes of emphysema have a genetic basis
Social Hx Respiratory
Smoking - current, when started and stopped (pack years, vaping, other drugs)
Occupation, e.g. exposure to asbestos
Pets - mammals and birds
Travel
Sexual Hx
Illicit drugs
Alcohol
Environment changes
Impact of breathlessness on ADLS
Home situation - who is at home
Physical Exam - Respiratory - Signs outside the chest
Around the bed - Oxygen, weight, pursed lips, leaning forward, sats probe, cyanosed, food supplements, sputum pots, inhalers, cannulas, call bell
Physical Exam - Respiratory - Chest
Inspection
Respiratory rate
Appearance of the chest
Movement of the chest - is it adequate? - is it equal on both sides?
Are there scars from previous surgery or trauma?
Palpation
Is the trachea central?
Chest expansion - often less reliable than inspection
Any lumps or tender areas
Percussion - Compare the degree of resonance over the same sites on each side
Percussion over normal lung is resonant, with dullness over the heart and the liver
Auscultation - listening with the stethoscope
Causes of dullness to percussion (3)
Lung consolidation eg pneumonia
Lung collapse eg due to blocked bronchus
Pleural effusion eg due to infection, tumour or heart failure (NB This is common. Often “stony dull”)
Percussion over normal lung is …, with …. over the heart and the liver
Percussion over normal lung is resonant, with dullness over the heart and the liver
Auscultation - listening with the stethoscope (RESP)
The breath sounds are generated by turbulent air in the larynx and transmitted through the airways and lung tissue to the chest wall
Breath sounds are attenuated as they pass through normal lung
Normal breath sounds are called “vesicular”
Compare the same place on each side, front and back, top to bottom
Auscultation - breath sounds
Breath sounds are decreased if there is fluid or collapsed lung present
Breath sounds are increased if there is consolidated lung between a bronchus and the chest wall - “bronchial breathing (sounds like listening over trachea)
Added sounds - Auscultation
Wheeze - musical sound caused by air passing through narrowed airways, usually expiratory
- polyphonic versus monophonic
Crackles - usually inspiratory, due to popping open of blocked small airways e.g. lung fibrosis, pulmonary oedema
Pleural rub - creaking sound caused by friction of inflamed pleural surfaces e.g. pleurisy due to infection. May be inspiratory and expiratory
Stridor
Is different to wheeze
Harsh inspiratory noise
High pitched
Indicates significantly obstructed airway-supraglottis, glottis, subglottis, trachea
You can hear it from end of the bed
Emergency-ENT asap
Voice sounds
Ask the patient to say “ninety-nine”, or “one, one, one”
Reduced vocal resonance is caused by pleural fluid or lung collapse
Increased vocal resonance occurs in the same situations as bronchial breathing. When extreme there may be “whispering pectoriloquy”
Voice vibrations can also be felt “tactile fremitus”
… vocal resonance occurs in the same situations as bronchial breathing. When extreme there may be “whispering pectoriloquy”
Increased vocal resonance occurs in the same situations as bronchial breathing. When extreme there may be “whispering pectoriloquy”
… vocal resonance is caused by pleural fluid or lung collapse
Reduced vocal resonance is caused by pleural fluid or lung collapse
At the bedside/bedside tests - RESP
Oxygen saturations
Target saturations and prescribe oxygen
94-98% if no history of COPD
88-92% if COPD, controlled oxygen
PEFR
Monitoring treatment of patients with asthma
To see of asthmatics meet criteria for D/C
Bedside spirometry (FEV1, FVC, FEV1/FVC)
Obstructive
Restrictive
Peak Flow Rate - RESP - useful for?
Easy to perform
Useful for:
Supporting Diagnosis of asthma
Monitoring day to day variation
Picking up exacerbations-personalised asthma action plan
Assessing response to treatment
Needed for patients with asthma in hospital
PEF - Morning Dips & ICS
Arterial Blood Gases
- Measuring a number of different things
- pH: Acid-Base status
- Gas tensions
–O2
–CO2
- But also lactate, Hb, electrolytes, glucose, carbon monoxide
- Be methodical-look at all the information
- Record % inspired oxygen ABG was taken on
What is shown here?
Right pneumothorax
