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Phase 2b OSCEs > Respiratory System History and Examination > Flashcards

Respiratory System History and Examination Flashcards

1
Q

What topics should you ask about when completing a respiratory history?

A

● Breathlessness
● Cough
● Sputum
● Haemoptysis
● Pain
● Previous history
● Recent surgery
● Drug history and allergies
● Social history
● Family history

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2
Q

What are some questions that can be asked about breathlessness in a respiratory history?

A

● How is the patient normally? (Is this acute / chronic / acute on chronic?)
● Onset, timing, duration, variability, diurnal variation
● Exacerbating factors e.g. allergic triggers, exertion, cold air
● Relieving factors e.g. rest, medication
● Associated symptoms e.g. cough, sputum, haemoptysis, pain, wheeze, night sweats,
weight loss, oedema
● Severity e.g. at rest? Only on exertion? Limiting ADLs?

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3
Q

What are some questions that can be asked about a cough during a respiratory history?

A

● Onset, timing, duration (less than 2 months = acute, more than 2 months = chronic),
variation (e.g. recent change in a chronic cough), diurnal variation.
● Productive / unproductive?

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4
Q

What are some questions that can be asked about sputum during a respiratory history?

A

● Onset, timing, duration, variation, diurnal variation?
● Colour (e.g. rusty sputum suggests pneumococcal pneumonia; frothy pink may
indicate pulmonary oedema). Any haemoptysis?
● Consistency (viscous (fluid), mucous, purulent, frothy)
● Quantity (teaspoon, cupful etc.)
● Odour (fetid suggests bronchiectasis or a lung abscess)

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5
Q

What are some questions that can be asked about haemoptysis during a respiratory history?

A

● Origin (differentiate haemoptysis from haematemesis, was it coughed up?)
● Onset, timing, duration, variation
● Quantity
● Colour (fresh blood or dark altered blood)
● Consistency (liquid, clots, mixed with sputum)
● Sputum
● Chest pain
● Recent trauma to the chest or elsewhere?
● Recent / current DVT?
● Weight loss, fever, night sweats?
● Breathlessness?
● Bleeding or bruising elsewhere?

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6
Q

What is the mnemonic that can be used for pain in a respiratory history?

A

● SOCRATES
● Site
● Onset
● Character
● Radiation
● Associated symptoms
● Timing
● Exacerbating and relieving factors
● Severity

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7
Q

What questions can be asked about previous respiratory problems during a respiratory history?

A

● Pneumonia can lead to bronchiectasis or pulmonary fibrosis
● Tuberculosis can reactivate
● Severe measles or whooping cough can lead to bronchiectasis
● Asthma

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8
Q

What questions can be asked about previous surgery during a respiratory history?

A

● Dental surgery can lead to aspiration of purulent material or fragments of tooth
● Abdominal, pelvic or orthopaedic surgery are risk factors for DVT and possible
pulmonary embolism

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9
Q

What other systems can also be involved in respiratory disease and should therefore be considered for history taking during a respiratory history?

A

● Cardiac disease - pulmonary oedema -> angina, orthopnoea, paroxysmal nocturnal dyspnoea.
● Immunocompromised patients - HIV, Immunosuppression, and post-transplant surgery may indicate predisposition to atypical infections.

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10
Q

What questions can be asked about drug history and allergies during a respiratory history?

A

● Inhalers
● Steroids
● Antibiotics
● ACE inhibitors - may cause a cough
● Amiodarone - pulmonary fibrosis
● Beta-blockers - may worsen airway obstruction
● NSAIDS
● Oxygen therapy

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11
Q

What questions about social history can be asked during a respiratory history?

A

● Occupation (industrial hazards e.g. dusts, asbestos)
● Smoking (pack years e.g. 10/day for 30 years = half a pack x 30 = 15 pack years)
● Pets (can transmit infection or cause hypersensitivity reactions)
● Overseas travel
● Living conditions e.g. damp
● Alcohol
● Exercise, activities of daily living, independence

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12
Q

What questions can be asked about family history during a respiratory history?

A

● Infections may be transmitted between family members
● There is a genetic predisposition to allergic conditions (e.g. asthma)
● Alpha1-antitrypsin deficiency is a genetic cause of emphysema

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13
Q

What is the protocol for introduction during a respiratory exam?

A

● Wash hands
● Introduction, identification and consent.
● General inspection of the bed area
● General observation of the bed area

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14
Q

What information can be ascertained from the general inspection of a patients bed area during a respiratory exam?

A

● Inhalers
● Nebuliser
● Oxygen mask
● Sputum pot

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15
Q

What information can be ascertained from the general inspection of a patient during a respiratory exam?

A

● Colour of the patient
● Breathing of the patient
● Comfort of the patient
● Purse lipped breathing -> COPD
● Nutritional state -> Obesity (obstructive sleep apnoea, pickwickian syndrome)

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16
Q

What are the four steps of a respiratory exam?

A

● Inspection
● Palpation
● Percussion
● Auscultation

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17
Q

What are some general observations of the hands during a respiratory exam?

A

● Colour
● Tar staining
● Skin changes
● Joint swelling or deformity

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18
Q

What would a colour change of the hands indicate during a respiratory examination?

A

● Cyanosis of the hands may suggest underlying hypoxia.

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19
Q

What would tar staining of the hands indicate during a respiratory examination?

A

● Caused by smoking, a significant risk factor for respiratory disease e.g. COPD and Lung cancer.

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20
Q

What would skin changes of the hands indicate during a respiratory exam?

A

● Bruising or thinning of the skin can be associated with long-term steroid use e.g. asthma, COPD, interstitial lung disease

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21
Q

What can joint swelling or deformity of the hands indicate during a respiratory exam?

A

● May be associated with rheumatoid arthritis which has many extra-articular manifestations that affect the respiratory system e.g. effusion and fibrosis.

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22
Q

What is finger clubbing?

A

● Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed.

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23
Q

In which diseases would finger clubbing be present?

A

● Finger clubbing is associated with several underlying disease processes.
● Most likely to be due to lung cancer, interstitial lung disease and cystic fibrosis.

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24
Q

How would you assess finger clubbing during a respiratory exam?

A

● Ask the patient to put their nails of their index fingers back to back.
● Healthy individual = small diamond shaped window called Schamroth’s window can be seen
● When clubbing develops this window is lost

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25
Q

How would you assess a fine tremor during a respiratory exam?

A

● Ask the patient to hold out their hands in an outstretched position and observe for a fine tremor which is typically associated with beta-2-agonist use (e.g. salbutamol)

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26
Q

What is asterixis?

A

● A type of negative myoclonus characterised by irregular lapses of posture causing a flapping motion of the hands.

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27
Q

What are the most likely causes of asterixis?

A

● Most likely - underlying CO2 retention in conditions that cause type 2 respiratory failure.
● Other causes - uraemia and hepatic encephalopathy.

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28
Q

How would you assess for asterixis during a respiratory exam?

A

● Ask patients to outstretch their hands and ask them to cock their hands back at the wrist joint and hold the position for 30 seconds.
● Observe during this time period.

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29
Q

Overall, what changes can be observed from the hands during a respiratory exam?

A

● Colour of patient
● Tar staining
● Skin changes
● Joint swelling / deformity
● Finger clubbing
● Fine tremor
●Asterixis

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30
Q

What actions would you perform during palpation of a patient during a respiratory exam?

A

● Temperature check
● Heart rate
● Respiratory rate

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31
Q

How would you assess the temperature of a patient during a respiratory exam?

A

● Place the dorsal aspect of the hand upon the patient.
● Healthy patient should be symmetrically warm

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32
Q

What would cool hands indicate during a respiratory exam?

A

● May suggest poor peripheral circulation.

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33
Q

What would excessively warm hands indicate during a respiratory examination?

A

● Can be associated with CO2 retention

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34
Q

How would you assess the patients heart rate during a respiratory exam?

A

● Palpate the patients radial pulse, located on the radial side of the wrist
● The tips of your index and middle finger aligned longitudinally over the course of the artery.
● Once you have located the pulse, assess the rate and rhythm.

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35
Q

How would you calculate the heart rate of a patient during a respiratory exam?

A

● Can either measure over 15, 30 or 60 seconds and scaling up respectively.
● The shorter the interval used the more inaccurate the result.
● For irregular rhythms you should use the full 60 seconds.

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36
Q

What would a bounding pulse indicate during a respiratory exam?

A

● Can be associated with underlying CO2 retention (e.g. type 2 respiratory failure).

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37
Q

What would pulsus paradoxus indicate during a respiratory exam?

A

● This is a late sign of cardiac tamponade, severe acute asthma and severe exacerbations of COPD (unlikely to come up during OCSE station)

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38
Q

What is pulsus paradoxus?

A

● Pulse wave volume decreases significantly during the inspiratory phase.

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39
Q

How would you assess respiratory rate during a respiratory exam?

A

● While still palpating the patients radial pulse, assess the respiratory rate.
● Do not make the patient aware you are doing this as it can alter consciousness of breathing in the patient.

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40
Q

What would differences in the respiratory rate indicate during a respiratory exam?

A

● Asymmetries in the expiratory and inspiratory phases of respiration (e.g. the expiratory phase is often prolonged in asthma exacerbations and in patients with COPD).

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41
Q

How would you calculate respiratory rate during a respiratory exam?

A

● Assess the patient’s respiratory rate for 60 seconds to calculate the number of breaths per minute.

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42
Q

What would a healthy respiratory rate be in adults?

A

● Should be between 12-20 breaths per minute.

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43
Q

What is bradypnoea and what would this potentially indicate?

A

● A respiratory rate of less than 12 breaths per minute.
● Opiate overdose

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44
Q

What is tachypnoea and what would this potentially indicate?

A

● A respiratory rate of more than 20 breaths per minute.
● Acute asthma

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45
Q

What does jugular venous pressure indicate during a respiratory exam?

A

● Provides an indirect measure of central venous pressure.

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46
Q

Why can the JVP provide an indirect measurement of the central venous pressure?

A

● Internal jugular vein connects to the right atrium without any intervening valves, resulting in a continuous column of blood.
● The changes in the right atrial pressure are reflected in the internal jugular vein

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47
Q

How would you measure the jugular venous pressure in a patient during a respiratory exam?

A
  1. Position the patient in a semi-recumbent position at 45º.
  2. Ask the patient to turn their head to the left slightly.
  3. Inspect between the medial end of the clavicle and the ear lobe - it has a double double waveform pulsation
  4. Measure the JVP by measuring the vertical distance between sternal angle and the top of the pulsation point.
48
Q

What would a raised JVP indicate during a respiratory exam?

A

● Venous hypertension which can be caused by
● Pulmonary hypertension -> RSHF (COPD / interstitial lung disease)
● Other heart related causes such as congestive heart failure, tricuspid regurgitation and constrictive pericarditis)

49
Q

What areas of the face should be inspected during a respiratory exam?

A

● General inspection
● Eyes
● Mouth

50
Q

What would a plethoric completion suggest during a respiratory exam?

A

● A congested red-faced appearance is associated with polycythaemia (e.g. COPD) and CO2 retention (e.g. type 2 respiratory failure)

51
Q

What signs can be seen in/around the eyes during a respiratory exam?

A

● Conjunctival pallor
● Ptosis, Miosis and Enophthalamos.

52
Q

What would conjunctival pallor indicate during an eye inspection of a respiratory exam?

A

● Suggestive of underlying anaemia.
● Ask the patient to gently pull down their lower eyelid to allow you to inspect the conjunctiva.

53
Q

What would ptosis, miosis, and enophthalmos indicate during an eye inspection of a respiratory exam?

A

● All features of Horner’s syndrome (anhydrosis is another important sign associated with the syndrome).

54
Q

Explain the pathology of Horner’s syndrome and how it can be linked to respiratoey disease?

A

● Horner’s syndrome occurs when the sympathetic trunk is damaged by pathology such as lung cancer affecting the apex of the lung (e.g. Pancoast tumour).

55
Q

What features can be observed in/around the mouth during a respiratory exam?

A

● Central cyanosis.
● Oral candidiasis.

56
Q

What are the signs of central hypoxia in the mouth during a respiatory exam?

A

● Bluish discolouration of the lips and/or the tongue associated with hypoxaemia.

57
Q

What are the signs of oral candidiasis of the mouth during a respiratory exam?

A

● A fungal infection commonly associated with steroid inhaler use (due to local immunosuppression). It is characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa.

58
Q

What areas/features should be inspected on the chest when performing a respiratory exam?

A

● Scars
● Chest wall deformities
● Assess tracheal position
● Assess cricosternal distance

59
Q

What is a median sternotomy scar and what may it suggest during a respiratory exam?

A

● Located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG).

60
Q

What is a axillary thoracotomy scar and what may it suggest during a respiratory exam?

A

● Located between the posterior border of the pectoralis major and anterior border of latissimus dorsi muscles, through the 4th or 5th intercostal space. This surgical approach is used for the insertion of chest drains.

61
Q

What is a postolateral thoracotomy scar and what may it suggest during a respiratory exam?

A

● Located between the scapula and mid-spinal line, extending laterally to the anterior axillary line. This surgical approach is used for lobectomy, pneumonectomy and oesophageal surgery.

62
Q

What is a infraclavicular scar and what may it suggest during a respiratory exam?

A

● Located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion.

63
Q

What do radiotherapy-associated skin changes during inspection of the chest of a respiratory exam indicate?

A

● May be present in patients who have been treated for lung cancer. Clinical features can include xerosis (dry skin), scale, hyperkeratosis (thickened skin), depigmentation and telangiectasia.

64
Q

What are the types of chest wall deformities that can be seen during inspection in a respiratory exam?

A

● Asymmetry
● Pectus excavatum
● Pectus carinatum
● Hyperexpansion aka. barrel chest

65
Q

What is asymmetry of the chest and what can it indicate during a respiratory exam?

A

● Typically associated with pneumonectomy e.g. lung cancer, and thoracoplasty e.g. tuberculosis

66
Q

What is pectus excavatum?

A

● A caved-in or sunken appearance of the chest

67
Q

What is pectus carinatum?

A

● Protrusion of the sternum and ribs

68
Q

What is hyperexpansion aka. barrel chest and what can it indicate?

A

● Chest wall appears wider and taller than normal. Associated with chronic lung diseases such as asthma and COPD

69
Q

How would you assess the tracheal position during a respiratory exam?

A
  1. Ensure patient’s neck musculature is relaxed by asking them to position their chin slightly downwards.
  2. Dip your index finger into the thorax beside the trachea.
  3. Gently apply side pressure to locate the border of the trachea.
  4. Compare this space to the other side of the trachea using the same process.
  5. A difference in the amount of space between the sides suggests the presence of tracheal deviation.
70
Q

What should you do before you assess the tracheal position during a respiratory exam?

A

● It can be a little uncomfortable for patients, so warn them regarding this in advance.

71
Q

In what conditions would you get tracheal deviation AWAY from underlying pathology during a respiratory exam?

A

● Tension pneumothorax
● Large pleural effusions

72
Q

In what conditions would you get deviation TOWARDS the underlying pathology during a respiratory exam?

A

● Lobular collapse
● Pneumonectomy

73
Q

What is the cricosternal distance?

A

● The distance between the inferior border of the cricoid cartilage and the suprasternal notch.

74
Q

How would you assess the cricosternal distance during a respiratory exam?

A
  1. Measure the distance between the suprasternal notch and cricoid cartilage using your fingers.
  2. In healthy individuals, the distance should be 3-4 fingers.
75
Q

What is special about the finger measurement when measuring the cricosternal distance?

A

● Cricosternal distance is actually based on the size of the patient’s fingers so if their fingers are significantly different in size from your own, it may be worth using their fingers for the assessment.

76
Q

What would be a pathological finding when measuring the cricosternal distance and what would the indication be, during a respiratory exam?

A

● A distance of fewer than 3 fingers suggests underlying lung hyperinflation (e.g. asthma, COPD).

77
Q

What are the steps involved in palpation of the chest during a respiratory exam?

A

● Palpate the apex beat.
● Assess chest expansion

78
Q

How would you palpate the apex beat during a respiratory exam?

A
  1. Palpate the apex beat with your fingers placed horizontally across the chest.
  2. In healthy individuals, it is typically located in the 5th intercostal space in the midclavicular line.
79
Q

What would a displaced apex beat be suggestive of during a respiratry exam?

A

● Right ventricular hypertrophy e.g. pulmonary hypertension, COPD, interstitial lung disease
● Large pleural effusion
● Tension pneumothorax

80
Q

How would you assess chest expansion during a respiratory exam?

A
  1. Place your hands on the patient’s chest, inferior to the nipples.
  2. Wrap your fingers around either side of the chest.
  3. Bring your thumbs together in the midline, so that they touch.
  4. Ask the patient to take a deep breath in.
  5. Observe the movement of your thumbs (in healthy individuals they should move symmetrically upwards/outwards during inspiration and symmetrically downwards/inwards during expiration ).
  6. Reduced movement of one of your thumbs indicates reduced chest expansion on that side.
81
Q

What pathology would be indicated for symmetrically reduced chest expansion during a respiratory exam?

A

● Pulmonary fibrosis reduces lung elasticity, restricting overall chest expansion.

82
Q

What pathology would be indicated for asymmetrically reduced chest expansion during a respiratory exam?

A

● Pneumothorax, pneumonia and pleural effusion would all cause ipsilateral reduced chest expansion.

83
Q

What is percussion of the chest used for during a respiratory exam?

A

● Percussion of the chest involves listening to the volume and pitch of percussion notes across the chest to identify underlying pathology. Correct technique is essential to generating effective percussion notes.

84
Q

Describe correct technique for chest percussion during a respiratory exam?

A
  1. Place your non-dominant hand on the patient’s chest wall.
  2. Position your middle finger over the area you want to percuss, firmly pressed against the chest wall.
  3. With your dominant hand’s middle finger, strike the middle phalanx of your non-dominant hand’s middle finger using a swinging movement of the wrist.
  4. The striking finger should be removed quickly, otherwise, you may muffle the resulting percussion note.
85
Q

What areas should be percussed during a respiratory exam?

A

● Supraclavicular region: lung apices
● Infraclavicular region
● Chest wall: percuss over 3-4 locations bilaterally
● Axilla

86
Q

What are the 4 types of percussion note that can be heard during a respiratory exam?

A

● Resonant
● Dullness
● Stony dullness
● Hyper-resonance

87
Q

What would a resonant percussion note indicate during a respiratory exam?

A

● A normal finding

88
Q

What would a dull percussion note indicate during a respiratory exam?

A

● Suggests increased tissue density (e.g. cardiac dullness, consolidation, tumour, lobular collapse)

89
Q

What would a stony dull percussion note indicate during a respiratory exam?

A

● Typically caused by an underlying pleural effusion

90
Q

What would a hyper-resonant percussion note indicate during a respiratory exam?

A

● The opposite of dullness, suggestive of decreased tissue density e.g. pneumothorax

91
Q

Describe the correct technique for auscultation of the chest during a respiratory exam?

A
  1. Ask the patient to relax and breathe deeply in and out through their mouth (prolonged deep breathing should, however, be avoided).
  2. Position the diaphragm of the stethoscope over each of the relevant locations on the chest wall to ensure all lung regions have been assessed and listen to the breathing sounds during inspiration and expiration. Assess the quality and volume of breath sounds and note any added sounds.
  3. Auscultate each side of the chest at each location to allow for direct comparison and increased sensitivity at detecting local abnormalities.
92
Q

What are vesicular breath sounds?

A

● Normal quality breath sounds in healthy individuals.

93
Q

What are bronchial breath sounds and what would it indicate during a respiratory exam?

A

● Harsh-sounding (similar to auscultating over the trachea), inspiration and expiration are equal and there is a pause between.
● This type of breath sound is associated with consolidation.

94
Q

What would quiet breath sounds indicate during a respiratory exam?

A

● Suggest reduced air entry into that region of the lung (e.g pleural effusion, pneumothorax).

95
Q

What is a wheeze?

A

● A continuous, coarse, whistling sound produced in the respiratory airways during breathing.

96
Q

What is stridor?

A

● A high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways.

97
Q

What is coarse crackles?

A

● Discontinuous, brief, popping lung sounds

98
Q

What is fine end-inspiratory crackles?

A

● Often described as sounding similar to the noise generated when separating velcro.

99
Q

What would a wheeze indicate during a respiratory exam?

A

● Wheeze is often associated with asthma, COPD and bronchiectasis.

100
Q

What would stridor indicate during a respiratory exam?

A

● Stridor has a wide range of causes, including foreign body inhalation (acute) and subglottic stenosis (chronic).

101
Q

What would coarse crackles indicate during a respiratory exam?

A

● Typically associated with pneumonia, bronchiectasis and pulmonary oedema.

102
Q

What would fine end-inspiratory crackles indicate during a respiratory exam?

A

● Fine end-inspiratory crackles are associated with pulmonary fibrosis.

103
Q

Describe the technique for assessing vocal resonance during a respiratory exam?

A
  1. Ask the patient to say “99” repeatedly at the same volume and in the same tone.
  2. Auscultate all major regions of the anterior chest wall, comparing each side at each location.
104
Q

What is the assessment of vocal resonance used for in a respiratory exam?

A

● The presence of increased tissue density or fluid affects the volume at which the patient’s speech is transmitted to the diaphragm of the stethoscope.

105
Q

What would increased volume indicate during a vocal resonance assessment in a respiratory exam?

A

● Increased volume over an area suggests increased tissue density (e.g. consolidation, tumour, lobar collapse).

106
Q

What would decreased volume indicate during a vocal resonance assessment in a respiratory exam?

A

● Decreased volume over an area suggests the presence of fluid or air outside of the lung (e.g. pleural effusion, pneumothorax).

107
Q

What is an alternative method for assessing conduction of sound through lung tissue rather than by a vocal resonance assessment?

A

● Tactile vocal fremitus

108
Q

What is an alternative method for assessing conduction of sound through lung tissue rather than by tactile vocal fremitus?

A

● Vocal resonance assessment

109
Q

Describe the method of tactile vocal fremitus during a respiratory exam?

A

● Involves feeling for sound vibrations on the chest wall with your hands as the patient speaks.

110
Q

Describe the method of palpating the lymph nodes during a respiratory exam?

A
  1. Position the patient sitting upright and examine from behind if possible. Ask the patient to tilt their chin slightly downwards to relax the muscles of the neck and aid palpation of lymph nodes. You should also ask them to relax their hands in their lap.
  2. Inspect for any evidence of lymphadenopathy or irregularity of the neck.
  3. Stand behind the patient and use both hands to start palpating the neck.
  4. Use the pads of the second, third and fourth fingers to press and roll the lymph nodes over the surrounding tissue to assess the various characteristics of the lymph nodes. By using both hands (one for each side) you can note any asymmetry in size, consistency and mobility of lymph nodes.
  5. Start in the submental area and progress through the various lymph node chains.
111
Q

Name some respiratory causes of lymphadenopathy?

A

● Lung cancer with metastases
● Tuberculosis
● Sarcoidosis

112
Q

Describe how you would perform a posterior chest assessment during a respiratory exam?

A

● With the patient still sitting forwards, ask them to fold their arms across their chest so that their hands are touching the opposite shoulder. This results in rotation of the scapulae to better expose the underlying chest wall for assessment.
● Assess the posterior chest including inspection, chest expansion, percussion, tactile vocal fremitus (or vocal resonance) and auscultation.

113
Q

What are the final steps to be perform during a respiratory exam?

A

● Assess for evidence of pitting sacral and pedal oedema (e.g. congestive heart failure).
● Assess the calves for signs of deep vein thrombosis (e.g. swelling, increased temperature, erythema, visible superficial veins) as the patient may have shortness of breath secondary to pulmonary embolism.
● Inspect for evidence of erythema nodosum, which can be associated with sarcoidosis.

114
Q

How would you complete a respiratory examination?

A

● Explain to the patient that the examination is now finished.
● Thank the patient for their time.
● Dispose of PPE appropriately and wash your hands.
● Summarise your findings.

115
Q

What further assessments and investigations could be performed, depending on your findings, during a respiratory exam?

A

● Check oxygen saturation (SpO2) and provide supplemental oxygen if indicated.
● Check other vital signs including temperature and blood pressure.
● Take a sputum sample.
● Perform peak flow assessment if relevant (e.g. asthma)
● Request a chest X-ray (if abnormalities were noted on examination)
● Take an arterial blood gas if indicated (also see ABG interpretation)
● Perform a full cardiovascular examination if indicated (e.g. cor pulmonale)

Phase 2b OSCEs (2 decks)

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