Respiratory Examination & History - Canvas | Sunderland

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OSPAP Programme

Respiratory Examination & History

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The Beginning!

• Environment! • Introduce yourself • Ask permission to take the history • Have you got the correct person!! • Patients Demographics

– Name – Age – Occupation – Background

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Kurtz S, Silverman J, Benson J, Draper J (2003) Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides. Academic Medicine;78(8):802-809

Providing Structure:

• Making organisation overt

• Attending to flow

Building the relation ship:

• Using

appropriate non-verbal behaviour

• Developing rapport

• Involving the patient

Explanation and planning: • Providing the correct amount and type of information • Aiding accurate recall and understanding • Achieving a shared understanding: incorporating the

patient’s illness framework • Planning, shared decision making

Closing the session:

• Ensuring appropriate point of closure • Forward planning

Physical Examination

Gathering Information: • Exploration of the patient’s problem to discover the:

• Biomedical perspective • Patient perspective • Background information (context)

Initiating the Session: • Preparation • Establishing initial rapport • Identifying reason for the consultation

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Structure

• Presenting Complaint

• History of Presenting Complaint

• Past medical history

• Drugs (medications/allergies)

• Family history

• Social history

• System enquiry

Polly (Peter)

Has

Pretty

Damn

Fine

Sexy (smelly)

Stockings (socks)

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OPQRSTU

Onset Pain, precipitating factors Quality, quantity Radiation, relieving factors Severity/score, symptoms Timing You (ICE)

• O

• P

• Q

• R

• S

• T

• U

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I.C.E.

• Ideas – “Do you have any particular worries about this symptom?”

• Concerns – “What is concerning you?”

• Expectations – “What are you hoping for me to do for you today?”

(Moulton 2007)

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Past Medical History

Open questions

What illnesses have you had?

(include psychiatric conditions if appropriate)

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History Taking

Drug History

• Not just prescribed drugs - include over the counter remedies

and alternative medicine

• Name each substance, dose and duration

• Compliance

• Drug allergies & sensitivities

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Medication and Allergies

• Medication – Generic name if possible

– Dose

– Route of administration

– Recent change

– Include OTC and homeopathic / herbal

– Recreational drugs

• Allergies & Sensitivities – When? Diagnosed?

– How presented, symptoms

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History Taking

Family history • Open question - ‘tell me about any illness(es) which run in the

family

• Ask specifically about immediate family including parents

• Diagnosis and age

• Cause of death

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Social History

• Family situation

• Relationships incl. Marital status

• Occupation

– Past and present

– Exposure

• Community Involvement & Network

• Hobbies

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Social History

Alcohol history

Quantity and type

Place of drinking

Alone or accompanied

Money spent

Purpose

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Social History

Tobacco

Duration

Type - pipe, cigarettes, cigars

Amount

If stopped when

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Systematic Inquiry

General

Well being

Appetite

Sleep

Energy

Weight change

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Systemic Enquiry

• Direct questioning

• Organise symptoms by system

• Explore any positives with open ended questions and then clarify as per presenting complaint

• Use lay terms

• Summarise

• Anything else?

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Systemic Enquiry

C.V.S. • Chest pain

• Breathlessness – On exertion

– Lying flat

– Wake up at night

– Orthopnoea

• Palpitations

• Ankle swelling

• Exercise Tolerance

• Pain in legs when walking

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Systemic Enquiry

R.S.

• Shortness of breath

• Chest pain – On inspiration

• Cough

• Sputum – Blood

• Wheeze

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Systemic Enquiry

GI System • Dental / Gum Problems

• Reduced appetite/weight loss

• Swallowing – painful

– difficult

• Indigestion, heartburn

• Abdominal pain

• Vomiting

• Altered bowel habit

• Blood loss

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Systemic Enquiry

Urogenital Pain on passing urine

Frequency - day, night

Colour of urine

Males: (age), difficulty starting, poor stream, dribbling, discharge, libido

Females: menarche, menopause, frequency, regularity, urge or stress, incontinence, discharge, abnormal bleeding, libido

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Systemic Enquiry

CNS • Weakness

• Disturbance of sensation

• Headaches

• Visual disturbance

• Dizziness, blackouts (clarify these)

• Fits

• Confusion

• Disturbance of speech

• Hearing

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Systemic Enquiry

Locomotor • Joint Pain

• Joint Stiffness

• Swelling

• Mobility

• Gait

• Falls

• Redness and warmth

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Systemic Enquiry

Endocrine • Heat intolerance (change)

• Cold intolerance (change)

• Change in sweating

• Thirst and Polyuria

• Prominence of eyes (change)

• Swelling in neck

• Energy

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Systemic Enquiry

The Skin • Rash

• Spots

• Itching

• Ulcers

• Lumps/growths

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Summary

• Salient features of

– Presenting history

– Relevant past history

– Background

• Differential diagnosis

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History Taking

Explanation

• Most important from the patients point of view

• Communication skills are vital

• Speak clearly and audibly

• Avoid jargon

• Avoid emotive words

• Most important information first

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Examination

Includes:

General inspection

Specific inspection (hands, face, chest)

Palpation

Percussion

Auscultation

Additional checks

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Inspection

• General inspection

• Hands

• Face

• Eyes

• Mouth

• Anterior chest

• Posterior chest

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Palpation

• Lymph nodes

• Trachea

• Anterior chest

• Posterior chest

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Percussion

• Explain purpose of percussion

– Identifying areas of tympany & dullness

• Identify appropriate percussion points

• Use correct percussion technique

– Compare side to side, identifying percussion note

• Posterior chest

–As per anterior chest

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Auscultation

• Explain purpose of auscultation- asks pt to breathe through mouth • Identify normal /abnormal breath sounds and causes

– bronchial, vesicular, crepitations, wheeze, pleural rub

• Identify appropriate auscultation points

– Takes time to Listen thru full respiratory cycle at identified auscultation points

• Demonstrate correct auscultation technique with diaphragm placed firmly on

chest wall • Demonstrate vocal resonance

– Correct vocal resonance technique

• Posterior chest:

– As per anterior chest

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Additional checks

• Sacral oedema (as in heart failure)

• Inspect both legs: – Calf pain

– Leg swelling

– Palpate calves for tenderness DVT

– Increased temp of leg

– Inflammation

• Thank the pt

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Recap

Examination:

General inspection

Specific inspection (hands, face, chest)

Palpation

Percussion

Auscultation

Additional checks

History:

Presenting Complain

Hx PC (OPQRSTU)

Prev Med Hx

Drug Hx

Family Hx

Social Hx

Systems Review

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