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Respiratory > Respiratory history for dental examination > Flashcards

Respiratory history for dental examination Flashcards

1
Q

Quantify impact of resp disease

A 
Sob?
-MRC scale
-triggers
Hx of sudden wheeze/ sob? 
-triggers
Cough?
-dry/ productive
-sputum colour
Haemoptysis
-chest pain
PND
-orthopnea
-SOA
Courses of abx and oral CS in 12/12?
GORD
-hayfever and eczema
Admissions to ED/ Hospital/ ITU
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2
Q

Drug history

A 
Allergies inc aspirin sensitivity
Inhalers (?presence of ICS)
Anticoagulants (rivaroxaban, warfarin)
Oxygen use (LTOT, Amb, SBOT)
Nebulisers
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3
Q

Social history

A 
Occupation			-joiner, baker, miner
Smoking Hx
Etoh consumption
Pets/birds
Asbestos
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4
Q

Asthma

A

Sob/ wheeze/ cough
Has triggers
Classically affects young and middle aged

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5
Q

COPD

A

Sob/ wheeze on exertion
Cough
>35 years
Smoker

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6
Q

Bronchiectasis

A

Chronic sputum production
May have associated wheeze/ sob
Recurrent LRTIs

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7
Q

Pulmonary emboli

A

Sob/ pleuritic pain/ haemoptysis
May be on warfarin (min 6/12)
Long term if recurrent VTE/ risk factors

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8
Q

Interstitial lung disease

A

Soboe/ occ. dry cough

May be on steroids/ immunosuppressants

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9
Q

Obesity hypoventilation syndrome

A

Own CPAP machine; supplemental O2

Daytime somnolence

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10
Q

Repiratory muscle weakenss

A

Non-invasive ventilation

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11
Q

Lung cancer symptoms

A

Weight loss
Sob
Cough +/- haemoptysis (tumour near airways)
Chest pain
Extra-pulmonary symptoms
If post chemoRx (palliative) - risk of neutropenic sepsis

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12
Q

Taking a drug history

A

Confirm medications that can be indicative

  • inhalers for Asthma & COPD only
  • SABA nebules for severe asthma
  • SABA & SAMA nebules sometimes given for COPD but may not reflect severity
  • oral steroids for immunesuppresion in severe asthma & certain ILD processes
  • amiodarone & methotrexate
  • warfarin & rivaroxaban/Apixaban
  • aspirin/NSAID hypersensitivity
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13
Q

Taking a social history

A 
Smoking
- >10PYH significant
- (CPD x yrs smoked) / 20
Etoh (alcohol) use
-XS use - poor dentition
-risk of endocarditis
-risk of lung abscess
Own pets
-household pets drive asthma
-bird exposure - EAA
Job exposure
-coal miner
-asbestos
-baker/ dust exposure
-farmer
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14
Q

How to identify the unwell pt

A

Change from baseline

  • exacerbation of chronic lung disease
  • > breathlessness
  • worsening cough
  • more sputum production
  • change in sputum colour
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15
Q

NICE COPD Guidelines 2010

A

An exacerbation is a sustained worsening of the patient’s symptoms from his or her usual stable state that is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. The change in these symptoms often necessitates a change in medication

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16
Q

More sputum production and change in sputum colour

A

Bacterial infection - antibiotics needed

17
Q

Respiratory examination

A

General inspection at the end of the chair

  • is the pt comfortable
  • what is the resp rate? (14-16/min)
  • is there cyanosis
  • peripheral +/- central
  • accessory muscles being used?
18
Q

Peripheral cyanosis

A

Blue discolouration to peripheries

  • hypoxia
  • poor peripheral circulation
  • polycythemia
19
Q

Central cyanosis

A

Look at tongue (good blood supply)

  • reflects significant deoxygenated blood
  • SpO2 <90% with obvious cyanosis (with normal Hb)
20
Q

Accessory muscles

A

Sternocleidomastoids
Platysma
Strap muscles
XS use elevation of chest with > expansion

21
Q

Inspection specific to COPD

A

Breathing through pursed lips
> AP diameter vs lateral diameter
-“barrel chest”
-hyperinflation

22
Q

Audible wheee

A

Asthma/ COPD/ Vocal Cord Dysfunction

23
Q

Stridor

A

Think upper aiway obstruction emergency

24
Q

Hoarseness

A

Think recurrent laryngeal nerve injury and cancer

25
Q

Check radial pulse

A

Assess for rate
>100bpm may reflect underlying disease
Also associated with anxiety

26
Q

Inspection - hands

A

Clubbing – cancer/ bronchiectasis/ fibrosis
Flapping tremor – severe CO2 retention (late sign)
Wasting of muscles of hands
-bilateral – cachexia assoc. with COPD/ cancer/ motor neurone disease (late sign)
-unilateral - compression of lower brachial plexus (pancoast tumour)

27
Q

Inspection of face

A

Pallor – check conjuctiva for anaemia
Check tongue colour
Think possible lung abscess or pneumonia as result of rotten tooth
Obese/collar>17” – OSA; at risk of ventilatory failure
Moon face – chronic oral steroid use (Asthma/ILD) (see upper panel)
Rare:
-facial plethora – SVCO (panel A&B)

28
Q

ABCD

A 
Is the airway patent?
How is the breathing? 
-RR
-SpO2
-chest movement
-cyanosis
How is the circulation?
-pulse
-blood p
-peripheral circulation
How is the neurological status?
-disability
-GCS
29
Q

Unwell pt

A 
Respiratory rate>20/min
Difficulty completing sentences
Using accessory muscles
Cyanosis
Audible Wheeze
30
Q

PEF meter

A 
Peak Expiratory Flow (PEF) Meter
In benefit in pts with asthma
Good correlation with symptoms
-normal>75% of either predicted 
or best for pt
Best of x3 blows; 
Standing position
“like blowing out candles”
31
Q

Pulse oximetry

A

Noninvasive measurement of arterial Hg saturation
Uses differential absorbance of light by oxyhemoglobin and deoxyhemoglobin to estimate the oxygensaturation
SpO2 92% roughly equal to 8kPa
Below 90-92% correlation to pO2 less reliable

32
Q

Asthma: if PEF <75%

A

give Short Acting Brochodilator
Give 4 puffs (inhaler) via spacer
Give 2 puffs/2mins & assess response up to 10puffs
or
Salbutamol 5mg nebuliser (ideally by 6l/min O2)
Consider oral steroids
Consider immediate referral to GP/ walk-in centre/ 999

33
Q

COPD: if sob/ wheezy

A

Give (salbutamol) ventolin 5mg dose & (ipratropium bromide) 500mcg
via nebuliser driven (not via oxygen)
If nebuliser not to hand – administer 4 puffs of short acting beta agonist via spacer
Less likely COPD patients to develop acute bronchospasm post dental intervention compared to asthma patients
Consider referring immediately to GP/walk-in centre/999

34
Q

Oxygen delivery

A

The initial oxygen therapy is nasal cannulae at 2–6 l/min (preferably) or simple face mask at 5–10 l/min unless stated otherwise.
For patients not at risk of hypercapnic respiratory failure who have saturation <85%, treatment should be commenced with a reservoir mask at 10–15 l/min.
The recommended initial oxygen saturation target range is 94–98%.
If oximetry is not available, give oxygen as above until oximetry or blood gas results are available.
Change to reservoir mask if the desired saturation range cannot be maintained with nasal cannulae or simple face mask (and ensure that the patient is assessed by senior medical staff).
If these patients have co-existing COPD or other risk factors for hypercapnic respiratory failure, aim at a saturation of 88–92% pending blood gas results but adjust to 94–98% if the PaCO2 is normal (unless there is a history of previous hypercapnic respiratory failure requiring NIV or IPPV) and recheck blood gases after 30–60 min.

35
Q

COPD: if infective exacerbation (LRTI)

A

Aminopenicillin
Tetracycline
Macrolide
Oral course of prednisolone (if dyspnea impact on daily life)
GP review/refer to A&E/walk-in centre
(see NICE COPD guidance 2010)

36
Q

Pneumonia

A

Difficult to delineate from LRTI without clinical examination or CXR
Re-visit treatment for infective exacerbation of COPD (minus steroids) but ideally need assessment by GP/Walk-in centre/999

Respiratory (5 decks)

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