4-history taking & chest examination

7/24/2019 4-History Taking & Chest Examination

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History Taking & Chest

Examination

Dr. Waseem HAJJAR, MD. FRCS.

Assistant professor &Consultant Thoracic Surgeon


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A good history should be both:

Concise.

Coer the important points.


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Rules:

!. "atient shoul# $e allo%e# to tell his histor

in his o%n %or#s.

'. (ea#ing )uestions must $e aoi#e# unlessthe information can*t $e o$taine# $ other

means


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Questions:

!. Complete the imme#iate #escription.

'. +luci#ate the ague points.

. Fill in the gaps the histor not mentione# $

patient.

-. +mphasie the important points.


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Types of questions:

!. /eutral )uestions.

'. Simple #irect )uestions 0es1/o2.

. (ea#ing )uestions.


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WHAT SH34(D W+ 5/3W A634T

TH+ +7AM8/AT83/ 3F TH+ CH+ST9

HISTORY

SYMPTOMS

(A/DMAR5S

"+RT8/+/T :3CA64(AR;

S8


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Personal data:

/ame.

Age.

Se=.

3ccupation. Resi#ence.

The patients complaint>

A simple statement in the patients o%n %or#s an# its

#uration.


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HISTORY


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Present History:

This means #etaile# histor of the patients present

illness %hich must proi#e ans%er for the follo%ing

)uestions>

!. Duration

'. Mo#e of onset 0acute, su$ acute, chronic2.

. Se)uence of eents>

8. Course 0progressie, regressie or recurrent2.

88. Appearance of ne% a##itional smptoms or

#isappearance of others.

888. Treatment receie# #uring the course & response.

-. Analsis of each particular smptom.


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History

Acute1chronic #isor#er

"rece#ing sstemic #istur$ance

"ast me#ical histor

Drug histor

Social histor

Famil histor

3ccupational histor


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Past History:

Chil#hoo# #iseases.

Trauma.

Resi#ences or trael a$roa#.

Drug therap.

3perations.


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THE HIT!R"

FAM8(; H8ST3R; EMPHYSEMA AT AN EARLY AGE ? C3/S8D+R

A("HA @ ! A/T8TR;"S8/

RECURRENT RESPIRATORY INECTIONS AN!STERILITY IN A YOUNG A!ULT MALE@

C3/S8D+R C;ST8C F86R3S8S, 8MM3T8(+ C8(8A

3R ;34/


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#amily History:

Here#itar factor.

+=posure to same etiological circumstances.


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THE HIT!R"

OCCUPATIONAL # CHR3/3(3


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Ha$its:

SmoBing.

"hsical efforts.

A##iction.


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SYMPTOMS


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History

Dspnoea

Wheee Cough

Sputum

Haemoptsis

Chest pain


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MAIN SYMPTOMS OF

PULMONARY DISEASE

C34


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LUNG

58D/+;

S"(++/(8:+R

S58/

6RA8/

H+ART


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%ECRIE THE C!'(H

"R3D4CT8:+ @ /3/"R3D4CT8:+

AC4T+ @ CHR3/8C

T8M+ 3F DA;

"R+C8"8TA/TS @ R+(8+F

6(33D; @ /3/ 6(33D;

6AR58/< @ HAC5;


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C!'(H

SYMPTOM

M3R/8/AC4T+ @ 0"4(M3/AR; +M63(8SM, "/T7, ASTHMA2

CHR3/8C @ 0C3"D, CHF, 8(D2 TACH;"/+A @ RR'E 6R1M8/ 6RAD;"/+A ? RR G 6R1M8/ 0DR4


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%"P)E*

M; CH+ST F++(S T8


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THE NUMEROUS ETIOLOGIES

OF CHEST PAIN

"(+4R8T8C @ "AR8+TA( "(+4RA @ SHAR"

STA668/< @ 8/S"8RAT83/

+S3"HA


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SPUTUM - WHAT ARE ITS

CHARACTERISTICS ?

;+((3W @


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HEMOPTYSIS - REQUIRES

CAREFUL QUESTIONING

TH8S S;M"T3M 4S4A((; D+/3T+S A

S+R834S 8((/+SS. T6, T4M3R,

6R3/CH8+CSTAS8S, "+, CARD8AC

D8S+AS+ TH+ "AT8+/T SH34(D 6+ 4+ST83/+D

CAR+F4((; R+


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CLUES TO DIFFERENTIATING

HEMOPTYSIS FROM HEMATEMESIS

HEMOPTYSIS

C34


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THE PULMONARY

E"AMINATIONSIGNS


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,H*T H!'-% ,E .)!, *!'T THE

E/*0I)*TI!) !# THE CHET1

H8ST3R;

S;M"T3MS

LAN!MAR&S

PERTINENT $OCA%ULARY

SIGNS

HO' TO PERORM AN E"AM

HO' TO ORMULATE A !IERENTIAL !IAGNOSIS

H3W T3 "R+S+/T TH+ 8/F3RMAT83/


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T3"3


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T3"3


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The Chest

8nspection

"alpation

"ercussion

Auscultation


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Inspection o t!e c!est

I()ort*+t:

# SHAPE

# MO$EMENT

# $ISI%LE PULSATIONS,

SHAPE o- the .hest:!e-or(ities: # /y)hosis

# s.oliosis

# de)ressed ster+u( 0)e.tus e1.*2*tu(3

# bulges i+ le-t )*r*ster+*l *re*0.o+ge+it*l (*l-or(*tio+3

e4g4 $S!

o- the thor*1


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Chest 2all

"ectus carinatum "ectus e=caatum


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Pe3tus Ex3a4atum


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Inspe3tion

Shape Scars (esions Resp rate Resp #epth Mo#e of $reathing A$normal inspirator moements A$normal e=pirator moements

Asmmetr of moement


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Ni.oti+e st*i+i+g


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5 liters o-O5


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6ARR+( CH+ST


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arrel Chest

AP Di"#ete$ % T$"ns&e$se

Di"#ete$


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P*-P*TI!)

F++(8/< W8TH TH+ HA/D @ F8/


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Palpation

Chest e=pansion

Tactile ocal fremitus


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Chest Expansion


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Chest Expansion


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Chest Expansion


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Tr*.he* e1*(


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Per3ussion

8llustrate resonance

Compare $oth si#es

Map out a$normal area


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0ETH!% !# PERC'I!)

D8R+CT 8/D8R+CT

D8S+AS+ A M3/TH -!I-?I'>!K


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0ETH!% !# PERC'I!)


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0ETH!% !# PERC'I!)


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Per3ussion

8mpaire#0dull2resonance o$taine# @

Aerate# lung tissue is separate# from the

chest %all e.g. flui#, pleural thicBening

(ung tissue is airless e.g. consoli#ation,collapse, fi$rosis

Lsto+y dull+ess? pleural effusion

Hperresonance ? pneumothora=


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Per3ussion te3hnique

"lace left han# on chest %all, palm

#o%n%ar#s %ith fingers separate#

'n#phalan= oer area of intercostal space

Right mi##le finger striBes the 'n# phalan=pro#ucing hammer effect

+ntire moement comes from %rist


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PERC'I!) !')%

T;M"A/; @ H+ARD 3:+R TH+ A6D3M+/

R+S3/A/C+ @ H+ARD 3:+R /3RMA(

(4/ "rimar orsecon#ar 0lung, pleural, me#iastinal2

Suppuratie lung #isease> 0lung a$scess,

$ronchiectasis, empema2 Diffuse interstitial fi$rosis> Aleolar capillar

$locB sn#rome

8n association %ith other sstemic #isor#ers

C-'I)(


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C-'I)(

"A8/(+SS @ F8/


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LO$I%ON!6S ANGLE@ TH+ A/'GO?'G,!GO

CLU%%ING


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DO NOT FORGET THE TRACHEA

TRACH+A( D+:8AT83/

A4SC4(TAT+ ? STR8D3R

TRACH+A( T4< 03(8:+RS S8


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A%NORMAL %REATHING PATTERNS

A"/+A ? CARD8AC ARR+ST

683TS @ 8/CR+AS+D 8/TRACRA/8A( "R+SS4R+ @ DR4


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6

RE*THI)(7

TH8S /38S+ CA/ 6+ H+ARD AT TH+ 6+DS8D+W8TH34T TH+ ST+TH3SC3"+

(AC5S A M4S8CA( "8TCH

A8R T4R64(+/C+ CA4S+D 6; /ARR3W+D

A8RWA;S CHR3/8C 6R3/CH8T8S


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LUNG SOUNDS

BREATH SOUNDS ADVENTITIOUS

TRACHEAL

BRONCHIAL

VESICULAR

WHEEZE

RHONCHI

CRACKLEPLEURAL RUB

STRIDOR

SQUEAK

RE*TH !')%


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RE*TH !')%

:+S8C4(AR @ /3RMA( 6R+ATH S34/DS ? S8T+ 3F "R3D4CT83/ TH+A(:+3(8

TRACH+A( @ T464(AR @ (85+ 6(3W8/< A8R THR34


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%REATH SOUN!S

TIMING

CHARACTERISTIC

TRACHEAL %RONCHIAL %$ $ESICULAR

INTENSITY $ERY LOU! LOU! MO!ERATE LO'

I:E RATIO 7:7 7:8 7:7 8:7

th d


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reath sounds

5 i l $ th d


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5esi3ular $reath sounds

:i$rations of the ocal cor#s cause# $tur$ulent flo% through the larn=

Transmitte# along trachea, $ronchi to chest

%all Rustling )ualit

8nspiration continuous %ith e=piration

8ntensit increases #uring inspiration & fa#es

#uring first !1r#e=piration

%iminished $reath so nds


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%iminished $reath sounds

Con#uction limite# $Airflo% limitation

e.g. #iffusel @ asthma, emphsema

localise# @ tumour, collapse

Something separating chest %all from lung

e.g. effusion, fi$rosis

ron3hial $reathing


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ron3hial $reathing

L$lo%ing inspirator & e=pirator soun#s +=pirator phase as long as inspiration

Distinct pause $et%een phases

High?pitche# e.g. consoli#ation (o%?pitche# e.g. fi$rosis

*dded sounds


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*dded sounds

Rhonchi 0%heee2 Crepitations 0cracBles2

"leural soun#s

Rhon3hi


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Rhon3hi

Due to passage of air through narro%e#$ronchus e.g. $ronchospasm, mucosal

oe#ema

Musical )ualit High or lo% pitche#

4suall e=pirator

+=piration prolonge#


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*%5E)TITI!' !')%


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*%5E)TITI!' !')%

TH+S+ AR+ S34/DS H+ARD D4R8/

Rhythm or for3e = palpitation


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Rhythm> or for3e = palpitation

0 time, mo#e of onset & offset, relation to

e=ertion, #uration, irregularit2.

A ymptoms due to pressure on

surrounding stru3tures


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surrounding stru3tures

0 esophagus, $ronchi , neres, spine2

(eneral Examination


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!.


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-o3al Examination

9 Com$ined Inspe3tion and palpation:


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!. Shape.'. Car#iac impulses 0ape= $eat, parasternal

pulsations, epigastric, to the right of

sternum, suprasternal notch, 'n#left space2

. Thrills.-. "alpa$le heart soun#s.K. "osition of the me#iastinum

I. Tactile ocal fremitusO. Chest moementsG. (ocal ten#erness,pulsations,%heees.


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*pex $eat


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; Per3ussion


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Tpes of percussion notesApices of the lungs

Anterior chest %all

(ateral chest %all "osterior chest %all

Car#iac an# hepatic #ullness


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6reath soun#s.A#entitious soun#s.

:ocal resonance .


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4-history taking & chest examination

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