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History taking and examination of Respiratory Sysetm
The respiratory system can be examined quickly in practice or in exam in the format given in the article. Hope its helpful to the various clinicians on ISC.
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Salient features of Respiratory system clinical Case.
Introduce yourself to the patient.
History taking (Points to be noted):
1.Cough.
2.Sputum.
3.Haemoptysis (acute infection including in COPD, pulmonary infarction, bronchogenic carcinoma, bronchiectasis, TB,Goodpasture's syndrome, puhnonary haemosiderosis, mitral stenosis).
4.Dyspnoea
-Intermittent (asthma, recurrent pulmonary oedema, exacerbations of COAD).
-Over days (pleural fluid, carcinoma of bronchus, heart failure).
-Over months to years (COAD, fibrosing alveolitis, anaemia, fibrotic lung disease).
-Over a few hours (pulmonary oedema, bronchial asthma, pneumonia).
- Acute or sudden (pneumothorax, pulmonary oedema, inhaled foreign body).
5.Wheezing (airways limitation including asthma, COAD).
6.Chest pain (pleurisy, tracheitis).
7.Smoking.
8.Family history.
EXAMINATION (Points to be noted)
1. Place the patient in a sitting position and ask whether he or she is comfortable.
2. Examine the sputum cup and comment on the sputum.
3. Examine the patient from the foot end of the bed and comment as follows:
- Whether the patient is breathless at rest.
-On wasting, if any, in the infraclavicular region.
-On diminished movement on the right or left side.
-Count the respiratory rate.
4.Examine the hands:
-Clubbing.
-Cyanosis.
-Tar staining (the yellow 'nicotine' staining is actually due to tar).
-Examine the pulse for bounding pulse and asterixis (signs of carbon monoxide narcosis).
5.Examine the face:
-Comment on the tongue, looking for central cyanosis.
-Comment on the eyes, looking for pallor and evidence of Horner's syndrome.
6.Examine the neck:
-Comment on neck veins.
-Check for cervical lymphadenopathy.
*Comment on the trachea:
-Whether or not it is deviated.
-The distance between the cricoid cartilage and suprasternal notch.
7.Palpate:
-Apex beat.
-Movements on both sides with the fingers symmetrically placed in the intercostal spaces on both sides.
-Vocal fremitus (tell the examiner that you would prefer to do vocal resonance because it gives the same information and is more reliable).
8.Percussion: percuss over supraclavicular areas, clavicles, upper, middle and lower chest on both sides.
9.Auscultation:
-Over supraclavicular areas, upper, middle and lower chest on both sides -comment on breath sounds (whether vesicular or bronchial) and on adventitious sounds (wheeze, crackles or pleural rub). If crackles are heard, ask the patient to cough and then repeat auscultation. It is important to time the crackles to ascertain whether they occur in early, mid or late inspiration.
-While auscultating the front of the chest, seize the opportunity to listen to the second pulmonary sound.
-Check for vocal resonance by asking the patient to repeat 'one, one, one'.
-Check for forced expiratory time (FET) if your diagnosis is chronic obstructive airways disease (COAD) by asking the patient to exhale forcefully alter full inspiration while you are listening over the trachea: if the patient takes more than 6 seconds, airway disease is indicated.
10. Ask the patient to sit forward:
-Palpate - assess expansion posteriorly.
-Percuss - on both sides including axillae.
- Auscultate - posteriorly including the axillae.
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