HISTORY OF PRESENT ILLNESS:
•Site , intensity , type , aggrevating factor and relieving factor (SITAR)
•Onset - sudden or gradual
•Location - radiating
•Duration - frequency or chronology ( seasonal or daily variations )
•Characteristics - quality or severity
•Current situation - improving or deteriorating
•Effect on activity of daily living (ADL)
•Previous diagnosis of similar episodes
•Previous treatment and efficacy
Cardinal signs and symptoms :-
1.Cough : onset - sudden or gradual
duration - Acute < 3 weeks
Chronic - >3 weeks
Nature - Dry : irritation
Wet : signs of infection
Type - Mucoid
Mucopurulent : TB
Froathy : pulmonary oedema
Rusty ( blood ) : TB , lobar pneumonia
Odour - foul : infection
2) sputum : Amount (tea spoon , table spoon , cup )
Normal - 100 ml of tracheobronchial secretions are produced daily and cleared subconsciously
• Blood streaked sputum : inflammation of throat ( larynx , trachea ) or bronchi , lung cancer , ulcers
•Pink sputum : sputum and blood formed from alveoli and small peripheral bronchi
•Massive blood : cavitary TB , lung abscess ,bronchieactasis , lung infarction , pulmonary embolism
•Green or greenish coloured infection : pneumonia , cystic fibrosis ( green from degenerative changes in cell debris )
•Rust colored - pneumococcal bacteria , pulmonary TB
•Brownish - chronic bronchitis ( greenish / yellowish / brown ) , chronic pneumonia ( whitish - brown )
•Yellowish purulent - pus - haemophilus
Yellowish - green ( mucopurulent ) - treatment with antibiotics that reduce symptoms - bronchiectasis , cystic fibrosis , pneumonia
• Whitish grey - chronic allergic bronchitis ( no. of eosinophilis )
•White , milky or opaque (mucoid) - viral infection or allergy ( asthma )
•Foamy white - earlier phase - pulmonary edema
•Froathy pink - severe pulmonary edema
•Black - black specks in mucoid secretions - smoke inhalation ( fires , tobacco , heroine ) , coaldust
The physiotherapist should always relate breathlessness to the level of function that the patient can achieve
- Exercise tolerance ( no. of stairs client can climb or can walk )
- Shortness of breath at rest
- Association of paraoxysmal nocturnal dyspnea (PND)
- Associated swelling of ankles or recent weight gain
- Activities : Sudden ( pneumothorax , pulmonary embolism , DVT )
Always ( fibrosis , fluid )
A.NYHA ( New York Heart Association )
Grade 1 - no symptoms and limitation in ordinary physical activity
Grade 2 - mild symptoms , angina and slight limitation in ordinary activities
Grade 3 - marked limitation in activity due to symptom , even during less than ordinary activity .
Grade 4 - severe limitation , experience symptoms even at rest mostly bed bound patient .
B. MMRC ( Modified Medical Research Council )
Grade 0 - no dyspnea except with strenous exercise
Grade 1- dyspnea when walking up on the hill or hurrying on the level
Grade 2 - walks slower than most on the level or stops after 15 minutes of walking on the level.
Grade 3 - stops after few minutes of walking on the level.
Grade 4- dyspnea with minimal activity such as getting dressed or too dyspneic to leave the house.
C. ATS (AMERICAN THORACIC SOCIETY)
Grade 0- none - no trouble of dyspnea on level / uphill
Grade 1 - mild - dyspnea on at level / uphill.
Grade 2 - moderate - walks slower than person of same age
Grade 3 - severe - stops after 100 yards
Grade 4 - very severe - breathlessness
4. CHEST PAIN -
Chest pain in respiratory patients usually originate from musculoskeletal , pleural or tracheal inflammation as lung parenchyma and small airways contain no pain fibres.
Example : Pleuritic chest pain
Musculoskeletal (chest wall) pain
Efforts to treat - Heat , Splinting , Pain medication
INCONTINENCE - Coughing and huffing increases intra - abdominal pressure which may precipitate urinary leakage
5. OTHER SYMPTOMS:
Fever (pyrexia) - TB
Headache - morning headache - nocturnal CO2 retention
Peripheral oedema - right heart failure
Vomiting and nausea
Gastro intestinal reflex
Past medical history- •Thoracic , nasal , pharyngeotracheal , trauma or surgery , hospitalisation for pulmonary disorders.
•Use of ventilation - assisting devices
•COPD- TB , bronchitis , emphysema , etc
•Other chronic disorders - cardiac , cancer , blood clotting disorders
•Immunization (pneumococcal , influenza )
•DM / TB / BP / asthma
Surgical history -
Endoscopy , tracheostomy , lobectomy
Personal and social history -
Appetite / bowel , bladder / nutrition
Economic condition - poor / fair / good
Vital sign :
General appearance- Ectomorph
Body weight - BMI - weight in kg
Height in meter square
Nails - Clubbing
Eyes - pallor (anaemia)
Plethora (high haemoglobin)
Jaundice (yellow color due to liver or blood disturbance)
Tongue and mouth - Cyanosis - hypoxemia
Jugular venous pressure - increased in right heart failure , chronic lung disease , dehydrated patient
Peripheral oedema - seen in decreased albumin level , impaired venous or lymphatic function , increased steroids
In bedbound patients , check the sacrum.
Observation of chest-
Transverse diameter > A P Diameter
Abnormalities - •Kyphosis
•Kyphoscoliosis - restrictive lung defect
•Pectus carinatum - pigeon chest
•Hyperinflation or barrel chest - AP = transverse - ribs horizontal
Breathing pattern -
12 to 16 breath per minute
Inspiratory : expiratory = 1:1.5 to 1:2
Check for bradypnea , tachypnea , hyperventilation
Prolonged expiration - 1:3 to 1:4
•Pursed lip breathing
•Kaussamaul ‘s respiration - metabolic acidosis
•Cheyne strokes respiration - drugs ( narcotics) , heart failure , neurological disturbances
•Ataxic breathing - cerebellar disease
•Apneutic breathing - brain damage
•Thoracoabdominal - female ; abdominothoracic
• ICU Patients - mode of ventilation ( supplemental oxygen , intermitent positive pressure ventilation)
•Route of ventilation (mask , endotracheal tube , tracheostomy )
•Level of consciousness (glasgow coma scale)
•Central venous pressure (CVP) , pulmonary artery pressure (PAP)
TRACHEA - tracheal deviation indicates underlying mediasternal shift . trachea may be pulled towards in collapsed or fibrosed upper lobe or pushed away from pneumothorax or large pleural effusion .
CHEST EXPANSION - BY TAPE :
Supramammary - 1.5cm
Mammary - 1.5 cm
Inframammary - 1cm
Technique : at residual volume , the examiner ‘s hands are placed spanning the posterolateral segment of both bases , with the thumbs touching in the midline posteriorly . both the sides should move equally with 3 - 5 cm being the normal displacement.
Hoover’s sign :
Paradoxical movement of the lower chest can occur in patients with severe chronic airflow limitation who are extremely hyperinflated . as the dome of the diaphragm cannot descend any further diaphragm contraction during inspiration pulls the lower ribs inwards. This is called hoover’ s sign.
Vocal fremitus -
It is the measure of speech vibrations transmitted through the chest wall to the examiner’ s hands .It is the measure by asking the patient to repeatedly say ‘ggg’ or 111 whilst the examiner`s hands are placed flat on both sides of the chest .
Increase in patient whose lung underneath is relatively solid ( consolidated)
Decrease in patient - pneumothorax or pleural effusion.
It is performed by placing the left hand firmly on the chest wall so that the finger have good contact with the skin . the middle finger of the left hand is struck over the DIP joint with the middle finger of the right hand . for all the positions , percuss at 4 to 5 cm intervals over the intercostal spaces , moving systematically from superior to inferior and medial to lateral .
Resonance - the expected sound can usually be heard over all areas of the lungs.
Hyper resonance - associated with hyperinflation may indicate emphysema , pneumothorax or asthma.
Dullness or flatness - pneumonia , atelactasis , pleural effusion , pneumothorax or asthma.
Tympany - sound usually associated with percussion over the abdomen .
Auscultation with the stethscope provides important clues to the condition of the lungs and pleura . all sounds can be characterized in the same manner as the percussion notes , intensity , pitch , quality and duration.
1.Breath sound : normal - bronchial , vesicular
Abnormal - crackels, rhonchi ,wheeze , pleural friction rub.
2. Vocal resonance :
Transmission of voice through the airway and lung tissue to the chest wall where it is heard through a stethscope . it is usually tested by instructing the patient to say ‘99’ repeatedly .
Decrease in resonance - emphysema , pneumothorax , pleural thickening or pleural effusion .
3. Heart sound :
1st - closure of mitral and tricuspid valve.
2nd - closure of pulmonary and aortic valves.
3rd - cardiac failure
4th - heart failure , hypertension , aortic valve disease
TEST RESULTS : 1.SPIROMETRY - The forced expiratory volume in 1 second (FEV) , the forced vital capacity ( FVC ) and peak expiratory flow rate (PEFR) are important measures of ventilatory function.
2.ARTERIAL BLOOD GASES - ABG provide an accurate measure of O2 uptake and CO2 removal by the respiratory system as a whole
Normal values :
pH : 7.35 TO 7.45
PaO2: 10.7 to 13.3 kPa ( 80 - 100 mmHg)
PaCO2: 4.7 TO 6.0 KPa (35 to 45 mm hg)
HCO3: 22 - 26 MMOL / L
Base excess : -2 to +2
3. Chest radiograph