39 - Physical Diagnosis of the Respiratory System

Question 1

Objectives

Answer 1

• Know what questions to ask for SOB, cough, chest pain
• Know the common exam to do for respiratory system
• Know the common exam findings

Question 2

What questions will you ask your patient with shortness of breath?

Answer 2

• When did it start?
• Were you doing anything when it started?
• Sudden or gradual?
• Are you taking anything to treat it?
• Describe it
• What makes it better? Worse?
• Do you have wheezing, coughing or sputum production?
• Do you smoke?
• What is your occupation?
• Do you have allergies?

Question 3

Why do you ask about treatments for SOB?

Answer 3

• COPD and asthmatics are already on medications – keep that in mind
• How are you using your inhaler? How often are you using it? (SHOW)

Question 4

What else should you ask if a SOB patient is having sputum production?

Answer 4

• Color

- Yellow/green doesn’t necessarily mean that they have bacteria, but could be viral

Question 5

What else should you ask if your patient is a smoker?

Answer 5

• How long have you been smoking? How many packs/day? Need to think cancer
• Usually have a cough first thing in the morning

Question 6

What questions will you ask your patient with a cough?

Answer 6

• When did it start?
• Have you had this before?
• How often?
• Describe it
• Do you cough anything up?
• What does it look like?
• SOB?
• Tired?
• Fever?
• Weight loss?
• Night sweats?
• Does anything make it better or worse?
• Tobacco use?
• Occupation?
• Sick contacts?
• Medications?
• Allergies?

Question 7

What should you remember if they are coughing something up?

Answer 7

Remember that they could be coughing from sinusitis – need to remember to check this

Question 8

What do you need to know about SOB with a cough?

Answer 8

• If coughing is accompanied is by shortness of breath, it is more concerning
• Airway compromise is present

Question 9

What is important to remember about a fever?

Answer 9

Harder to tell if an elderly patient has a fever, not as easy to detect

Question 10

What should you think about if your patient with a cough has weight loss?

Answer 10

TB

Question 11

What should you think about if your patient with a cough has night sweats?

Answer 11

If they are elderly, it is usually the first sign of COPD

Question 12

What should you ask your patient who comes in with chest pain?

Answer 12

• Onset
• What were you doing?
• Have you had it before?
• Describe it
• Where?
• Radiation?
• Sudden or gradual?
• Continuous?
• Scale of 1-10?
• Nausea or vomiting?
• Tobacco use?
• Medications?
• Better or worse?
• History of heart probs?
• BP probs?
• Family history?

Question 13

What are vesicular breath sounds?

Answer 13

• Breath sounds that are normally heart best over the posterior chest (back)
• Inspiration will sound a little bit longer than expiration

Question 14

What are bronchial breath sounds?

Answer 14

• Breath sounds that are normally heard over the trachea and right apex better
• Expiratinon will be a little longer than inspiration

Question 15

What are crackles?

Answer 15

Discontinuous sounds that resemble the sound produced by rubbing strands of hair together in front of your ear or pulling apart strips of velcro

Question 16

What are coarse crackles?

Answer 16

Louder, low pitched crackles that are fewer in number

Question 17

What are fine crackles?

Answer 17

Soft, higher pitched crackles that are greater in number

Question 18

What are wheezes?

Answer 18

• High pitched continuous musical sounds heard mostly on expiration
• They will either be pacing or sitting on the edge of the table pushing their chest up to lengthen the airway
• This is a sign of a serious breathing problem

Question 19

What is stridor?

Answer 19

• Loud. musical sound of definite and constant pitch that indicates upper airway obstruction which is confined to inspiration over the neck

Question 20

What is a pleural rub?

Answer 20

• Loud, grating or rubbing sound predominately heard during expiration

Question 21

When would you hear crackles?

Answer 21

MOST COMMON = Pneumonia

• Sometimes it is faint, but majority of the time it will be there
• 90-95% sure on pneumonia diagnosis without any workup

Other conditions

• Pulmonary fibrosis
• Elevation in left atrial pressure
• MI

Question 22

Describe the steps to a respiratory system exam

Answer 22

• Inspect and palpate the chest
• Compare side to side
• Observe chest shape and AP diameter (barrel chest?)
• Observe respiration (rate, rhythm, effort)
• Respiratory expansion anteriorly (how well is the chest moving?)
• Assess for tactile fremitus
• Percussion of the chest
• Auscultation

Question 23

What are general rules of thumb that can help you determine what the problem is?

Answer 23

• Tall and thin = PE

- Short and stout = COPD

Question 24

Why is it dangerous to assess the respiratory system by respiratory rate alone?

Answer 24

If it looks normal (15-16), an elderly patient might still be in distress

Question 25

What vital signs will you need to take?

Answer 25

• Blood pressure
• Pulse rate and rhythm
• Respiration rate and depth
• Temperature
• Pulse ox
• General appearance

Question 26

Describe the use of a pulse ox

Answer 26

Oxygenation will start to go down and will eventually effect the cardiovascular system

When you see a heart problem. always assess respiration