Respiratory Assessment

CHEST ASSESSMENT

NAME:

AGE/GENDER:

OCCUPATION:

ADDRESS:

CHIEF COMPLAINT:

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

SUBJECTIVE ASSESSMENT

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

               Severity - tired patient, disrupts sleep or conversation ,causes chest pain

       Color :

• 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

3) Breathlessness-

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 ) 

SCALES -

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.

eg : pleuritic chest pain

     Tracheitis

      Musculoskeletal (chest wall) pain 

      Angina pectoris

      Pericarditis

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

Shivering

Weight loss

Palpitations

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

•Allergy

•Immunization (pneumococcal , influenza )

•DM / TB / BP / asthma

Surgical history -

Endoscopy , tracheostomy , lobectomy

Personal and social history -

Sleep

Appetite / bowel , bladder / nutrition

Smoking

Exercise tolerance

Home environment

Economic condition - poor / fair / good

OBJECTIVE ASSESSMENT

General examination

Vital sign :

Temperature

Pulse

Respiratory rate

Blood pressure

Spo2

General appearance- Ectomorph

                                  Mesomorph

                                  Endomorph

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

•Apnoea

•Hypopnea

•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)

PALPATION :

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.

PERCUSSION -

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 :

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