Respiratory history and exam PDF

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A fully summarised respiratory history and exam guide...

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LO 3: Take a history from and an examine a patient with respiratory symptoms and interpret the finding in order to consider a differential diagnosis

Respiratory History Taking Introduction • • • •

Introduce yourself – name / role Confirm patient details – name / DOB Explain the need to take a history and gain consent Ensure the patient is comfortable

Presenting complaint • •

It’s important to use open questioning to elicit the patient’s presenting complaint. Facilitate the patient to expand on their presenting complaint if required.

History of presenting complaint • • • • • • • • •

Onset – When did the symptom start? / Was the onset acute or gradual? Duration – minutes / hours / days / weeks / months / years Severity – e.g. if symptom is shortness of breath – are they able to talk in full sentences? Course – is the symptom worsening, improving, or continuing to fluctuate? Intermittent or continuous? – Is the symptom always present or does it come and go? Precipitating factors – are there any obvious triggers for the symptom? Relieving factors – does anything appear to improve the symptoms e.g. an inhaler Associated features – are there other symptoms that appear associated e.g. fever / malaise Previous episodes – has the patient experienced this symptoms previously?

Key respiratory symptoms: • Dyspnoea – Only on exertion or at rest? / Determine severity • Cough – Dry vs productive / Sputum (volume, colour, consistency) • Wheeze – Time of day / Triggers • Haemoptysis – Volume • Chest pain – Site / Radiation / Character • Systemic symptoms – Fever / Night sweats / Weight loss If any of these symptoms are present, gather further details as shown above (Onset / Duration / Course / Severity / Precipitating factors / Relieving factors / Associated features / Previous episodes) • Pain – if pain is a symptom, clarify the details of the pain using SOCRATES o Site – where is the pain o Onset – when did it start? / sudden vs gradual? o Character – sharp / dull ache / burning o Radiation – does the pain move anywhere else? o Associations – other symptoms associated with the pain o Time course – worsening / improving / fluctuating / time of day dependent o Exacerbating / Relieving factors – anything make the pain worse or better? o Severity – on a scale of 0-10, how severe is the pain?

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Ideas, Concerns & Expectations • • •

Ideas – what are the patient’s thoughts regarding their symptoms? Concerns – explore any worries the patient may have regarding their symptoms Expectations – gain an understanding of what the patient is hoping to achieve from the consultation

Summarising • • • •

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding regarding everything the patient has told you. Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.

Signposting • • •

Signposting involves explaining to the patient: What you have covered – “Ok, so we’ve talked about your symptoms & your concerns regarding them” What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”

Past medical history • • • •

Respiratory conditions –asthma / pneumonia / COPD / PE / malignancy / tuberculosis Other medical co-morbidities – cardiovascular disease / GORD / neuromuscular disease / malignancy Surgical history Acute hospital admissions / ITU admissions?

Drug history •

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Regular medications – often provide useful clues as to patients past medical history o Inhalers – preventer / reliever o Steroids o Diuretics Antibiotics Over the counter drugs / herbal remedies? Home oxygen? Medications with respiratory side effects: o Beta-Blockers / NSAIDS – bronchoconstriction o ACE inhibitors – dry cough o Cytotoxic agents – interstitial lung disease o Oestrogen – e.g. contraceptive pill / HRT – increased risk of PE o Amiodarone / Methotrexate – pleural effusions / interstitial lung disease ALLERGIES – document these clearly

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Family history o Respiratory disease? – asthma / atopy / lung cancer / cystic fibrosis o Recent contact with others who were unwell? –viral infections / pneumonia / TB o History of allergies

Social history o Lifestyles o Smoking – How many cigarettes a day? How long have they smoked for? o Alcohol – How many units a week? – be specific about type / volume / strength of alcohol o Recreational drug use – e.g. Cannabis (increased risk of lung cancer) o Living situation: o House / Flat – stairs / adaptations / home oxygen o Who lives with the patient? – important when considering discharging home from hospital o Any carer input? – what level of care do they receive? o Activities of daily living: o Is the patient independent / able to fully care for themselves? o Can they manage self hygiene / housework / food shopping? o Occupation: o Shipyard / Construction / Plumber – Asbestos o Miners – Pneumoconiosis o Farmer – Allergic extrinsic alveolitis o Hobbies – Bird fancier – Allergic extrinsic alveolitis o Travel history o High risk areas for TB? – India / Pakistan o Recent long haul flights? – Pulmonary embolism

Systemic enquiry Systemic enquiry involves performing a brief screen for symptoms in other body systems. o Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema o Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain o GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit o Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence o CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion o Musculoskeletal – Bone and joint pain / Muscular pain o Dermatology – Rashes / Skin breaks / Ulcers

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Respiratory Examination Move through: Inspection, Palpation, Percussion, Ausculation

Subject steps 1. Begin by washing your hands, introduce yourself and clarify the patient’s identity. Explain what you would like to do and gain the patient’s consent. Offer a chaperone for this examination  2. The patient should be sitting up and exposed from the waist up. Make a general observation of the patient. • Check whether they are comfortable at rest o Are the sitting up-right in the tri-pod position o In real distress, they will lead forward, resting their hands on their knees • Do they look tachypnoeic (abnormally rapid breathing >20) • Are they using accessory muscles • Any obvious abnormalities of the chest o Pectus excavatum: congenital posterior displacement of lower aspect of sternum (hollowed out appearance) o Barrel chest: associated with emphysema and lung hyperinflation o Spinal issues: scoliosis or kyphosis • Check for any clues around the bed such as inhalers, oxygen masks, or cigarettes.  3. Move to the hands. • Hot, pink peripheries may be a sign of carbon dioxide retention. • Look for any signs of clubbing or nicotine staining, peripheral cyanosis, palmar creases. • Ask the patient to extend their arms and cock their wrists to 90 degrees. o Observe the hands in this position for 30 seconds; o A coarse flap may also be a sign of carbon dioxide retention. § https://www.youtube.com/watch?v=w6mcR2nxmzU 4. At the wrist you should take the patient’s radial pulse. • Rate rhytmn, character o A bounding pulse may indicate carbon dioxide retention. • After you have taken the pulse it is advisable to keep your hands in the same position and subtly count the patient’s respiration rate. This helps to keep it as natural as possible. 

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5. Move up to the face. • Ask the patient to stick out their tongue o Note its colour checking for anaemia or central cyanosis. o Remember to ask them to raise their tongue up and check underneath.  • Plethora, pallor, cyanosis  6. Look for any use of accessory muscles • Such as the sternocleidomastoid muscle. • Also palpate for the left supraclavicular node (Virchow’s Node). o This drains the thoracic duct so an enlarged node (Troisier’s Sign) may suggest metastatic cancer   7. The examination now moves onto the chest. • Take time to observe the chest looking for any abnormalities o Such as changes in rib cage shape, or scars. o Remember these may be in the axillae or on the back.   8. Now palpate the chest. • Firstly feel between the heads of the two clavicles for the trachea. • If it is deviated, it may suggest a tumour or pneumothorax (abnormal collection of air in the pleural space that causes uncoupling of the lung from the chest wall) 9. Feel for chest expansion. • Place your hands firmly on the chest wall with your thumbs meeting in the midline. • Ask the patient to take a deep breath in and note the distance your thumbs move apart. • Normally this should be at least 5 centimetres. You should measure this at the top and bottom of the lungs as well as on the back.

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10. Perform percussion on both sides and on the back, comparing similar areas on both sides. • You should start by tapping on the clavicle which gives an indication of the resonance in the apex. • Then percuss normally for the entire lung fields o Work down the alley that exists between the scapula and the vertebral column o Strike with distal inter-phalangeal joint of your left middle finger with the top of the right middle finger o 2 or 3 sharp taps o moved your hand down several inter-spaces and repeat manoeuvre o percussion in 5 or so different locations should cover one hemi-thorax • Hyper-resonance may suggest a collapsed lung • Hypo-resonance or dullness suggests consolidation such as in infection, effusion or a tumour.  11. Check for tactile vocal fremitus. • Place the medial edge of your hand on the chest and ask the patient to say “99” or “blue balloon”. • Do this with your hand in the upper, middle and lower areas of both lungs. • Gives a suggestion of the constitution of the tissue deep to your hand.  o Lung consolidation: air filed lung parenchyma becomes engorged with fluid or tissue (usually in pneumonia) o Pleural fluid: pleural effusion can collect in space that exist between the lung and chest wall, displacing the lung upwards, fremitus will decreased 12. Finally, auscultate. • Do this in all areas of both lungs and on front and back comparing the sides to each other. o Start with upper aspect of the posterior fields o Listen over one spot then move stethoscope to same position on the other side and repeat o Listening in 4 places on each side o Lingual and right middle lobes can be examined while you are still standing behind the patient o Then move around to the front and listen to the anterior field in the same fashion o • Listen for any reduced breathe sounds, or added sounds such as crackles, wheeze, pleural rub or rhonchi.  • https://www.youtube.com/watch?v=MzTcy6M3poM

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13. Whilst using the stethoscope, ask the patient to again say “99” or “blue balloon” whilst listening in all areas – this is a more reliable test than the one described earlier.  14. Finish by examining the lymph nodes in the head and neck. • Start under the chin with the submental nodes • Move along to the submandibular then to the back of the head at the occipital nodes. • Next palpate the pre- and post- auricular nodes. • Move down the cervical chain and onto the supraclavicular nodes. 

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15. Thank your patient and allow them to dress. Wash your hands and report your findings to your examiner. 

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