Positional Dyspnea

Questions to ask

Dispnoea

•Is the breathless recent or has it been present for some time?

•Is it constant or does it come and go?

•What can’t you do because of the breathless?

•What makes the breathing worse?

•Does anything make it better?

WHEEZING

•Ask wherther the patient hears any noises coming from the chest

•Sometimes stridor may be mistaken for wheezing.

•Stridor indicates narrowing of the larynx, trachea or main bronchi

Points to note in general assessment.

•Physique

•Voice

•Breathlessness

•Clubbing

•Cyanosis or pallor

•Intercostal recession

•Use of accessory respiratory muscles

•Venous pulses

•Lymph nodes

Review

Framework for the routine examination of respiratory system

1.While taking the history, watch for respiratory distress, particularly while talking. Note any clues from the patient’s surroundings

2.Look at the hands for clubbing, cyanosis and evidence of carbon dioxide retention

3.Look at the mucous membranes for central cyanosis

4.Check the jugular venous pulse for evidence of cor pulmonale

5.Palpate for supraclavicular lymph nodes

6.Inspect the chest wall for deformities and inequalities

7.Note the pattern of breathing

8.Palpate the trachea for any displacement

9.Palpate the front of the chest for vocal fremitus and for right ventricular hyperthrophy

10.Assess expansion of the chest from the front and note any inequalities

11.Percuss the front of the chest comparing one side with the other and noting any areas of dullness; include the axillae

12.Auscultate the chest similarly and decide on the presence and nature of the brath sounds

13.Test for vocal resonance and, where appropriate, whispering pectoriloquy

14.Note any added sounds

15.Repeat last 6 steps on the back of the chest

16.If appropriate, measure the peak flow rate

An examination of the chest: summary (1)

•Observe the patient generally, and the surroundings

•Ask the patient’s permission for the examination, and ensure lying back comfortably at 45 degrees

•Examine the hands

•Check the face for anaemia or cyanosis

•Observe the respiratory rate

•Inspect the chest movements and the anterior chest wall

•Feel the position of trachea, and check for lymphadenopathy

•Feel the position of the apex beat

•Check the symmetry of the chest movements by palpation

•Percuss the anterior chest and axillae.

Sit the patient forward;

•Inspect the posterior chest wall

•Percuss the back of the chest

•Listen to the breath sounds

•Check the vocal resonance

•Check the tactile vocal fremitus.

Listen to the breath sounds on the front of the chest

•Check the vocal resonance

•Check the tactile vocal fremitus.

•Thank the patient and ensure they are dressed or appropriately covered.

Points to note on palpation of the chest.

•Swelling

•Pain and tenderness

•Tracheal position

•Cardiac impulse

•Asymmetry

•Tactile vocal fremitus

Points to note on percussion of the chest.

•Resonance

•Dullness

•Pain and tenderness