Respiratory System Assessment

Dr Abdelhaleem Bella

The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course...but a life course, for which the work of a few years under teachers is but a preparation.

The Basic
Medicine is learned at the bedside and not in the classroom Practice makes perfect Rapport AND NURS ( Name + Understanding+ Respect+ Support) Start with open ended questions , frequent summary, clarify conclude . Anatomical , Physiological ,Aetiological and Impact

HISTORY

Introduction : General Info

Presenting Complaint HPI PH SH PMH PSH Drugs

FH SR Summary

Common Symptoms
1. 2. 3. 4. 5. 6. 7. 8. 9. Cough Sputum Dyspnea Wheeze Chest Pain Snoring and EDS Hoarseness Hemoptysis` General : Fever , Sweating, Wt Loss, Appetite

When the Patient Has Cough .

1 How long have you had the cough? 2 Do you cough up anything? What? How much? 3 Have you had sinus problems? 4 Is the sputum clear or discoloured? Is there any blood in the sputum? 5 Have you had high temperatures? 6 Does coughing occur particularly at night (acid reflux)? 7 Have you become short of breath? 8 Have you had lung problems in the past? 9 Have you been a smoker? Do you still smoke? 10 Have you noticed wheezing?-Asthma, chronic obstructive pulmonary disease (COPD)? 11 Do you take any tablets?-ACE inhibitors

Cough Duration

Cough Character

When the patient complains of Breathlessness

1 How long have you been short of breath? Has it come on quickly? 2 How much exercise can you do before your shortness of breath stops you or slows you down? Can you walk up a flight of stairs? 3 Have you been woken at night by breathlessness or had to sleep sitting up?-Paroxysmal nocturnal dyspnoea (PND), orthopnoea 4 Have you had heart or lung problems in the past? 5 Have you had a temperature? 6 Do you smoke? 7 Is there a feeling of tightness in the chest when you feel breathless?Angina 8 Do you get wheezy in the chest? Cough? 9 Is the feeling really one of difficulty getting a satisfying breath?-Anxiety 10 Is it painful to take a big breath?-Pleurisy or pericarditis 11 Did the shortness of breath come on very quickly or instantaneously?-Pulmonary embolus (very quick onset) or pneumothorax (instantaneous onset)

Dyspnea And Onset+ Duration

Dyspnea Extra

EXAMINATION

General Appearance: Blue Bloaters and Pink Puffers

Sputum

Pattern of Breathing

Hand Examination: Cyanosis

Nail :Staining

Nails : Yellow Nails

Diabetes mellitus Amyloidosis Median/ulnar nerve injury; Thermal injury; and Jaundice. Consider yellow nail syndrome if a patient has lymphedema and bronchiectasis.

Nails : Clubbing
A, Schamroth sign. In the absence of clubbing, opposition of the index fingers nail to nail creates a diamond-shaped window (arrowhead). In clubbed fingers, the loss of the profile angle because of the increase in tissue at the nail bed causes obliteration of this space (arrowhead). B, Distal phalangeal finger depth (DPD)/interphalangeal finger depth (IPD) represents the phalangeal depth ratio. In normal fingers, the IPD is greater than the DPD. In clubbing, this relationship is reversed

Nails : Clubbing and possible disease

Nails: Clubbing

nail clubbing, drumstick fingers, Water-glass nails for the resemblance and Hippocratic fingers
1. Periungual erythema and softening of the nail bed (spongy feeling on palpation) 2. Increase in the normal 160-165o angle between the nail bed and proximal nail fold (Lovibonds angle) (Figure 2) 3. Increase nail curvature (secondary to the increase Lovibonds angle) 4. Enlargement giving the drumstick appearance

hypertrophic osteoarthropathy(HOA) characterised by periostitis of long bones and pain. It is also referred to as Pirre Mari-Bamberger syndrome.

Hand : Flapping Tremor

Central Cyanosis : Lips

Face : Congestion

Face: Horner Syndrome

Cervical Lymph Nodes

CHEST

Chest : Inspection ,distended Veins

Chest Inspection: Pectus Carinatum

Chest Inspection : Pectus Excavatum

Chest Inspection : Scars

Chest Inspection : Scars

Chest Inspection : Scars

Chest Inspection : Scars

Chest Inspection: Barrel

Chest Inspection : Kyphoscoliosis

Harrison Sulcus and asso signs

Palpating the Trachea

Inspection : chest expansion

Palpation: Chest Movement

Percussion

Sequence

Percussion Notes

Auscultation

Auscultation: Breath sounds

Auscultation : Breath Sounds

Bronchial :Heard over the trachea and mainstem bronchi (2nd4th intercostal spaces either side of the sternum anteriorly and 3rd-6th intercostal spaces along the vertebrae posteriorly). The sounds are described as tubular and harsh. Also known as tracheal breath sounds. Bronchovesicular :Heard over the major bronchi below the clavicles in the upper of the chest anteriorly. Bronchovesicular sounds heard over the peripheral lung denote pathology. The sounds are described as medium-pitched and continuous throughout inspiration and expiration. Vesicular :Heard over the peripheral lung. Described as soft and low- pitched. Best heard on inspiration. Diminished :Heard with shallow breathing; normal in obese patients with excessive adipose tissue and during pregnancy. Can also indicate an obstructed airway, partial or total lung collapse, or chronic lung disease.

Pathophysiology and Clinical Signs

FURTHER SYSTEM EXAMINATIONS

INVESTIGATIONS

Learn to love the freedom of the student life, only too quickly to pass away; the absence of the coarser cares of after days, the joy in comradeship, the delight in new work, the happiness in knowing that you are making progress. Once only can you enjoy these pleasures.

Osler W. The Master-Word in Medicine. In: Aequanimitas, With Other Addresses to Medical Students, Nurses and Practitioners of Medicine.3rd ed. New York: McGrawHill Book Company, 1932: 362.

INVESTIGATIONS

Normal Female CXR

Peak Flow Meter

Pulmonary Function Test

SUMMARY & CONCLUSION

http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/IMAGES/CDLungSounds/mac/cugell-07july11.swf

http://www.stethographics.com/main/physiology_ls_introduction.html