Respirology

You are seeing Mrs. Muller, a 45 year old female, in the ER for a new pneumonia. Please examine the patient and comment on his chest X-ray.

Physical Examination

Inspection

• Comments on presence of central/peripheral cyanosis (frenulum, lips, fingernails)
• Inspects for clubbing
• Comments on respiratory status – tachypnea /intercostal indrawing/accessory muscle use, etc.
• Examines for thoracic deformities

Percussion/Palpation

• Percusses in all anterior and posterior fields and comments on findings.
• Uses percussion to estimate diaphragmatic excursion on posterior.

Auscultation

• Instructs patient to breathe when auscultating
• States that they would auscultate both lung fields in at least 5 different locations
• Listens to at least one full breath at each location
• Auscultates posterior fields, asking patient to cross arms in order to shift scapulae out of lung fields.
• Comments on of breath sounds and presence of adventitious sounds

Chest X-Ray

• Comment on abnormality on X-Ray

You are about to see Mr. Singal in your outpatient clinic. He tells your nurse that he has recently noticed blood in his sputum. Take a focused history concerning his complaint.

History

• Onset, duration, frequency of hemoptysis
• Quality of hemoptysis
• Volume of hemoptysis
• Sputum production and volume
• Distinguishes from hematemesis
• Associated shortness of breath
• Fever
• Chest pain
• Associated B-Symptoms – weight loss, night sweats, chills
• Smoking history (quantity in pack-years)
• Drug use (prescription and other)
• Personal history of lung disease
• Infectious contacts
• Exposure to environmental airborne irritants
• Family history of cancer, especially lung
• TB exposure, including place of birth
• Addresses patient’s concerns as to what caused the bloody sputum

You are seeing Mrs. Clark, a 30 year old woman, in the Emergency Department today shortness of breath. Take a focused history of his complaint.

History

• Onset and duration of shortness of breath
• Alleviating factors, including any use of puffers
• Aggravating factors, including exercise, second hand smoke, allergens
• Progression or worsening of symptoms
• Presence of nighttime symptoms
• Frequency
• Sputum production, presence of blood in sputum
• Recent cough, sore throat, myalgias and other symptoms of URTI
• Chest tightness
• Presence of fever or chills
• Recent respiratory illness
• Smoking history (quantity in pack-years)
• alcohol/drug history
• Exposure to infectious contacts
• Vaccination history – especially seasonal flu
• Exposure to environmental allergens/irritants
• Recent travel
• Effect on daily activities, including work and home life
• Exercise intolerance
• Past occurrence of such symptoms
• Personal history of asthma
• Family history of atopy (asthma, eczema, etc.)

You are seeing Mr. Smith, a 60 year old man, in your outpatient clinic today for a worsening productive cough. Take a focused history of his complaint.

History

• Onset of cough
• Worsening cough
• Sputum production and volume
• Change in sputum color
• Presence of blood in sputum
• Associated shortness of breath
• Fever
• Chest pain
• Recent respiratory illnesses
• Smoking history (quantity in pack-years)
• Other drug use
• Personal history of lung disease
• Occupational history to airborne toxins/irritants
• Infectious contacts
• Exposure to environmental allergens
• Recent travel
• TB exposure history

Physical

Inspection

• Comments on presence of central/peripheral cyanosis (frenulum, lips, fingernails)
• Comments on respiratory status – tachypnea /intercostal indrawing/accessory muscle use, etc.
• Examines for thoracic deformities

Percussion/Palpation

• Percusses all anterior and posterior fields and comments on findings
• Uses percussion to estimate diaphragmatic excursion on the posterior chest
• Assesses fremitus in all anterior and posterior fields and comments on findings
• Evaluates chest expansion using palpation

Auscultation

• Instructs patient to breathe while auscultating; listens for at least one full breath at each location of auscultation
• Auscultates both lung fields in at least 5 different locations
• Auscultates posterior fields, and asks patient to cross arms in order to shift scapulae away from the lung fields
• Comments on of breath sounds and presence of adventitious sounds, e.g. crackles and wheezes