Respiratory System PDF

THE RESPIRATORY HISTORY AND PHYSICAL EXAMINATION DR. KADRIA FAIRCLOUGH BACKGROUND u Demonstrate an understanding of the surface anatomy of the lungs and their relation to closely adjacent structures u Correctly label the location of the right and left lung during inspiration and ex...

THE RESPIRATORY HISTORY AND PHYSICAL EXAMINATION DR. KADRIA FAIRCLOUGH BACKGROUND u Demonstrate an understanding of the surface anatomy of the lungs and their relation to closely adjacent structures u Correctly label the location of the right and left lung during inspiration and expiration, posteriorly and anteriorly in relation to the diaphragm, ribs, liver, stomach, spleen, and the chest wall u Identify the innervation: brachial plexus, and upper thoracic sympathetic outflow. How/why they can be compromised in specific lung conditions u Describe the location of the lungs in respect to the brachial plexus u Detail the location of Pleural Markings, Lung markings, Cardiac notch, Oblique fissure, horizontal fissure, and trachea u Locate on a lateral view the upper lobes, the middle lobe, the lower lobes and the Liver u Locate from a frontal view the upper lobes, lower lobes and middle lobe of the lungs THE RESPIRATORY HISTORY u Presenting complaint u History of Presenting Complaint u Past Medical History u Past Surgical History u Drug and Allergy History u Family and Social History u Review of Systems HPC u Clarify symptoms u Breathlessness u Wheeze u Cough u Sputum/Hemoptysis u Chest pain u Fever/rigors/night sweats u Weight Loss u Sleepiness Breathlesness u Dyspnoea u Resp vs Cardiac vs Psychological u Psychological: “I feel like I can’t get enough air into my chest” u Subjective u Mechanisms: u Stimulation of afferent nerves u Mechanical loading of resp muscles u Stimulation of chemoreceptors from hypoxia Macleod’s Clinical Examination Breathlessness u History: u Onset- sudden, gradual u How is breathing at rest and overnight-asthma, COPD, heart failure u Is breathing normal on some days u Exacerbating factors u How far can you walk; disease impact, restrictions Macleod’s Clinical Examination Wheeze u High pitched musical or “whistling” sounds u Produced by turbulent airflow through small airways u History: u Worse during exercise? u Does pt awake with wheezing? u Fever, allergies (think atopy)? u Worse on waking and clearing sputum? u Does pt smoke? u Green or yellow sputum? Cough u Cough reflex u Dislodge foreign material and secretions from central airways Expiratory effort Sudden opening Inspiration against closed of glottis with glottis rapid expiration  Cough u History u Duration u Present everyday? u Intrusive u Triggers u Smoking u Assoc clinical Features: wheeze, heartburn, altered voice u Drug Hx- ACE inhibitors *** Bovine cough-assoc with malignancy at left hilum➡left recurrent laryngeal nerve damage➡left vocal cord paralysis➡unable to close glottis Chest Pain u MSK vs Cardiac vs Respiratory u History u Site u Severity u Character u Exacerbating vs relieving factors u Assoc symptoms Chest Pain u Pleuritic u Sharp, knife-like, worse on inspiration and coughing u Costochondritis u Tietze’s syndrome u Idiopathic inflammation of the costochondral cartilages adjoining the sternum u Acute localized pain and tenderness u Herpes zoster (shingles) Other symptoms u Sputum u Stridor- Inspiratory vs expiratory u In infections: accumulation of neutrophils, mucus and proteinaceous secretions in u Fevers/Night sweats/Rigors the airway results in cough with expectoration u Weight Loss u Volume u Colour u Sleepiness u Consistency u Sleep related breathing disorder u Hemoptysis u OSA-Obstructive sleep apnea u Coughing up blood from resp tract u Confirm whether coughed up u Recurrent u Volume – large >20mL in malignancy, bronchiectasis, pulmonary vasculitis, AV malformation u Duration  Past Medical History Macleod’s Clinical Examination Remainder of History u Drug and Allergy History u Inhalers, Oxygen, NSAIDs, β-blockers, ACE inhibitors, Opioids u Family History and Social History u Asthma, Cystic fibrosis u Normal baseline u Home circumstance u Smoking and occupation u Review of Symptoms Macleod’s Clinical Examination PHYSICAL EXAMINATION INSPECTION PALPATION PERCUSSION AUSCULTATION  INSPECTION-GENERAL u Inspect from foot of bed, pt at 450 with head supported by a pillow u Note presence of nebulizers, O2, etc u Chest asymmetry u Deformities, scars, chest drains u Observe and time RR u 12-15 (up to 20 normal, >20 tachypnoea) u Cheyne-Stoke respiration- alternating deep and shallow breathing (high altitude in elderly and those with heart failure) u Use of accessory muscles u Subcutaneous mets, erythema nodosum Macleod’s Clinical Examination Tachypnoea u Rapid and shallow Increased CO2 Trigger chemoreceptor centre Increased respiratory rate  INSPECTION u Hands/Arms u Clubbing, tar staining, cyanosis u Coarse tremor (CO2 retention) u Note: bronchodilators cause fine tremor u Pulse u Distal forearm tenderness u Face and Neck u Conjunctiva-anaemia u Tongue- cyanosis vs hypoxia, 5g/dL deoxygenated Hb in capillaries u Ptosis and pupillary asymmetry-tumour at root of neck u SVC obstruction-dusky appearance and swelling INSPECTION u Neck u JVP u Tracheal deviation- tension pneumothorax u Cricosternal distance u Cervical LN u Thorax u Inspect again for anything missed Macleod’s Clinical Examination PALPATION u Apex beat u Chest expansion u Up and out with inspiration u ?asymmetry u Check upper and lower anterior chest wall u Chest asymmetry PERCUSSION u Air vs fluid u Tap anteriorly and posteriorly comparing sides u Posterior percussion- position pt sitting with arms folded across the chest u Cardiac dullness- dullness over left ventricle just lateral to lower left sternal edge Macleod’s Clinical Examination AUSCULTATION u Vital capacity 5L u Pneumothorax u Listen with diaphragm of u Absent breath sounds stethoscope (except hairy chest) u Hyper resonant on percussion u Vesicular- normal sounds u Pleural effusion u Bronchial- consolidation, improved u Accumulation of fluid between sound quality pleura lining lungs and chest cavity u Collapse- diminished breath u Absent breath sounds sounds u Dullness to percussion  MESOTHELIOMA.COM Freepick.com AUSCULTATION u Breath sounds u Examine in sequence and compare mirror image positions u Soft vs muffled; loud , harsh u Added sounds u Wheeze, crackles, rubs u Wheeze usually expiratory but may be inspiratory u Crackles usually assoc with secretions, pathological vs benign u Pleural rub from inflammation u Vocal resonance u Loud over consolidation or fibrosis u Whispering Pectoriloquy