respiratory examination year 2 study guide · 9/2/2020 · shortness of breath – dyspnoea chest...

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Respiratory Examination

Year 2 Study Guide

Clinical Skills Teaching & Learning Centre

Written by: Clinical Skills Lecturing Team

Reviewed by: Dr Lisa Davies - Consultant in Chest Medicine

Dr A Clark – GP

Dr V Taylor-Jones – Consultant Anaesthetist

2

April 2020

Contents

Glossary ....................................................................................................................................... 3

Learning Objectives ..................................................................................................................... 4

Year 1 ....................................................................................................................................... 4

Year 2 ....................................................................................................................................... 4

Introduction .................................................................................................................................. 5

Anatomy ....................................................................................................................................... 5

History .......................................................................................................................................... 7

Preparation .................................................................................................................................. 9

Patient safety ............................................................................................................................... 9

Inspection ................................................................................................................................... 10

General Inspection .................................................................................................................. 11

Specific inspection .................................................................................................................. 11

Palpation .................................................................................................................................... 14

Percussion ................................................................................................................................ 16

Auscultation ............................................................................................................................... 16

Documentation ........................................................................................................................... 22

Bibliography, Further Reading & Information ............................................................................. 23

Tables ........................................................................................................................................ 23

References ................................................................................................................................. 23

Pictures ........................................................................................ Error! Bookmark not defined.

Further reading .......................................................................................................................... 24

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Glossary

Oropharynx – the back of the mouth

Pharynx – an area superior to the trachea

Trachea – the structure which contains the vocal cords

Brochus – large airway which derive from the trachea

Bronchi and Bronchioles – smaller airways which reduce in size the further into the lungs the go

Alveolar – terminal part of the airway where the exchange of gases takes place.

Attenuate – to filter or soften sound

Asthma – a lung disease which results in acute narrowing of the airways

Bronchitis – a chronic inflammatory lung disease which is characterised by inflammation and narrowing

of the airways and the production of secretions

Emphysema – an obstructive airway disease which is characterised by the destruction of the alveolar

sacs

Pulmonary fibrosis

Inspiration - inhalation

Expiration - exhalation

Pleural effusion – collection of fluid within the pleural space

Pneumothorax – air in pleural space due to lobe or lung collapse

Tension pneumothorax – pneumothorax which develops a positive pressure (medical emergency)

Angle of Louis – sternomanubrial joint

Lobe – right lung is divided into 3 lobes, left lung into 2lobes.

Fissure – the division between the lobes of the lungs, oblique fissure on left and right, horizontal of right

side only

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Learning Objectives

Year 1

1. To revise anatomy and physiology of lungs

2. To underpin anatomy and physiology to practical skill

3. To be able to percuss & auscultate lung fields

4. To understand reasons for undertaking a respiratory rate and oxygen saturation

Year 2

1. To be able to carry out a complete respiratory examination

2. To be able to recognise common abnormalities on percussion and auscultation

3. To be able to carry out an appropriate lymph node examination

5

Introduction

A respiratory examination may be performed alone or as part of a cardiorespiratory examination

due to the relationship between the cardiovascular and respiratory systems.

Anatomy

The upper airway consists of all structures from the nose to the vocal cords, including sinuses

and the larynx, whereas the lower airway consists of the trachea, airways, and alveoli. (see

figure 1)

The upper airways “condition” inspired air so that by the time air reaches the trachea, inspired

air is at body temperature and fully humidified.

The lower airway transports airflow to the lungs where oxygen is taken up and carbon dioxide is

expelled.

Figure 1 – The complete airway

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In order to ensure you perform a comprehensive examination of the chest, you need to know

the surface anatomy of the lungs. (see figure 2)

Remember “A, 2, 4, 6, 8, 10” in relation to the surface anatomy of the lung fields.

A - Apices of the lungs, remember to percuss and auscultate this area during the examination.

2 - 2nd costal cartilage, Angle of Louis (found on the sternum level with either the second rib or

second intercostal space), and T2/3 – the posterior oblique fissure (marking to the superior

surface of the posterior aspect of the lungs).

4 - 4th costal cartilage and the horizontal fissure of the right lung (separating the upper and

middle lobes).

6 - 6th rib which is where the inferior border of the lungs on the anterior aspect is located.

8 - 8th rib and the inferior border of the lungs on the lateral aspect.

10 - 10th rib where the inferior border of the lungs are found on the posterior aspect. The inferior

end of the oblique fissure is found on the anterior aspect of the chest in the mid clavicular line

level with the 6th rib. It curves upwards towards the 2nd / 3rd thoracic vertebrae

Figure 2 – Lung borders and fissure

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History

Prior to any clinical examination you should have taken a detailed history from the patient to

enable you to tailor the examination to the patient’s presenting complaint and current clinical

condition.

Indications

The decision to undertake a respiratory examination will be based on the patient’s presenting

complaint, history and current clinical picture (see table 1). There are many indications for

performing this examination and they include:

From the patient’s history:

Shortness of breath – dyspnoea

Chest pain on breathing

Chest trauma

Coughing

A presenting history suggesting lung pathology

Coughing blood – haemoptysis

General examination

Table 1. Considerations in History (with associated examination findings)

Condition Possible symptoms Possible examination findings

Asthma

Shortness of breath

Can’t catch breath (tight chest)

Cough

Fatigue

Dry

Can’t talk properly

(broken sentences)

High respiratory rate

Low peak flow rate

SaO2 < 90%

Cyanosis

Poor chest expansion due to air trapping

Diffuse wheeze

Tachycardia

Bradycardia (late worrying sign)

Accessory muscle use

Bronchitis Shortness of breath High respiratory rate

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Cough with sputum SaO2 < 90%

Cyanosis

Barrel chest

Emphysema

Shortness of breath

Cough

Fatigue

Can’t talk properly

(broken sentences)


SaO2 < 90%

Pale

Pursed lip breathing


Pulmonary

fibrosis

Shortness of breath



Fatigue

Cyanosis


SaO2 < 90%

Pale



Chest

infection

Shortness of breath

Fatigue

Cough with purulent sputum


SaO2 < 90%

Possible accessory muscle use

Lung cancer

Shortness of breath



Fatigue

Cyanosis

Cough with blood / sputum or both


SaO2 < 90%



Weight loss or cachexia


Pulmonary

emboli

Shortness of breath

Chest pain

Cyanosis

Cough with blood stained watery

secretions


SaO2 < 90%

Cyanosis

Poor chest expansion due to air trapping

Diffuse wheeze

Tachycardia



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Pneumothorax

Shortness of breath


Cyanosis


SaO2 < 90%

Cyanosis

Possible tracheal deviation (tension)

Poor chest expansion due to collapsed

lung

Tachycardia



Respiratory examination should include:

Inspection (general and specific)

Palpation (chest wall, chest expansion, apex beat)

Percussion (chest wall)

Auscultation (chest wall)

Preparation

Patient safety

• Introduce yourself

On first meeting a patient introduce yourself and explain your role.

• Check the patient’s identity and allergies

Confirm that you have the correct patient with the name and date of birth, if available

please check this with the name band, written documentation and the NHS number/

hospital number/ first line of address.

• Explain what you want to do

Ensure the procedure is explained to the patient in terms that they understand.

• Gain informed consent

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For the examination, ensure that the patient fully understands what the procedure

involves before seeking consent. Some patients may require the presence of a

supportive friend, family member, carer or translator to support understanding.

• Consider an appropriate chaperone

This procedure may require the presence of a chaperone. A chaperone is someone who

is familiar with the examination and can ensure that nothing inappropriate occurs by

either party. The chaperone can be a useful resource, not just being present to ensure

the patient is treated appropriately, but to help and support the patient.

• Adequate exposure maintaining dignity

This examination will require the patient to undress from the waist up. Ensure you

provide a gown or some form of covering to the patient irrespective of gender,

• Position the patient appropriately – consider moving and handling

For this examination, the patient should be asked to either sit upright in a chair or lay

semi-recumbent on an examination couch / bed. Some patients may need to stay upright

due to their respiratory condition to assist their breathing.

• Wear Personal Protective Equipment as required

The donning of PPE follows your risk assessment. If your patient presents with signs and

symptoms of a respiratory infection you may wish to wear a mask and face shield or full

PPE should it be deemed appropriate.

• Wash your hands before and after you touch the patient (as per WHO guidelines)

(1)

Equipment

For this examination you will need;

• Hand cleanser

• Stethoscope

• Hard surface wipe to clean the stethoscope

• Appropriate PPE

Inspection

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General Inspection

• Observe the patient’s environment and their general appearance.

• Also check vital signs (RR, SPO2, HR, BP, CRT, Temperature, Urine, ACVPU/GCS and BM

as appropriate). Respiratory rate must be counted for a full minute (1 respiration is a

complete breath in and out).

In the environment there may be many indicators of possible conditions including:

• Oxygen (see figure 2)

• Medications related to respiratory conditions such as inhalers.

• Oxygen saturation monitor

• Sputum carton

• Smoking paraphernalia

Figure 3 – oxygen masks

Specific inspection

A systematic inspection should be undertaking to look closely for possible signs of perianal,

anal, rectal and urinary (male) conditions.

• Check the patient’s hands, fingers, eyes, mouth, teeth, tongue and breath.

Hands (see hand and nail study guide)

Look for nail signs which may develop over a period of time and indicate a chronic disease

process. These signs may include:

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• Clubbing – in chronic disease the finger tips take on a bulbous (swollen) appearance.

• Koilonychia – another sign of chronic disease. Koilonychia is commonly termed as spooning.

It occurs secondary to a chronic iron deficiency anaemia.

• Pale nail beds - may indicate acute / chronic anaemia.

• Tremor – may be associated with the use of bronchodilators.

• Asterixis – CO2 retentive flap (unable to keep wrists in a dorsiflexed position) due to

hypoventilation or diffusion problems.

Face and mouth

Are the tarsal conjunctiva (lining of the eye lids) pink or pale? Which may indicate chronic or

acute anaemia.

Do the nostrils flair as the patient inhales which may suggest a respiratory insufficiency?

Any tar staining to the nose?

Is there inflammation evident at the corners of the mouth (angular cheilitis / angular stomatitis)

which can be associated with cancer, oral thrush and certain medications?

Look at the mouth, ensuring you look under the tongue:

• Is the mouth well hydrated? Dehydration may be a sign of poor oral intake.

• Oral thrush which may occur secondary to steroid use.

• Pursing of the lips during exhalation to maintain a positive pressure in the lungs (may be

observable in chronic respiratory conditions).

Neck

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Look at the trachea for possible deviation. The trachea would normally lay in the midline of the

neck, but may be pushed or pulled to the side by a number of conditions including tension

pneumothorax or a fibrosing tumour.

Figure 4 – Tracheal position

Look at the neck muscles (accessory muscles) do they tense as the patient inhales? This may

be seen in chronic respiratory conditions and aids inhalation by increasing the distance between

the clavicles and diaphragm (further reducing intrathoracic pressure).

Chest

Look at the shape of the chest. Does it appear normal? Is there any deformity such as:

Pectus carinatum (pigeon chest) – patients with pectus carinatum usually develop normal hearts

and lungs, but the malformation may prevent these from functioning optimally.

Figure 5 – Pectus carinatum

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Pectus excavatum (funnel chest) – The most common form is a cup-shaped concavity, involving the lower end of the sternum; also, a broader concavity involving the upper costal cartilages is possible. Pectus excavatum defects may be symmetric or asymmetric (see figure 5).

Figure 6 – Pectus excavatum

Barrel chest - refers to an increase in the anterior posterior diameter of the chest wall

resembling the shape of a barrel, most often associated with emphysema.

Flail segment – if there are rib fractures which result in a free segment of rib / ribs., A flail

segment may be seen. This would be an area which is drawn inwards as the patient breathes

in.

Unequal chest expansion – if a condition affects just 1 lung (pneumothorax, tumour) it may be

possible to see a difference in the expansion of the chest during inhalation (with the expansion

being less on the affected side).

Additional

Listen for sounds, is the patient breathing normally or are they struggling? They may have a

wheeze, stridor or cough. When they talk note if they are talking in full sentences or do they

have to pause between words and is there any hoarseness when they speak.

Palpation

Palpate across chest wall (including clavicles) assessing for pain, continuity of ribs / clavicles.

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Assess for presence or absence of subcutaneous emphysema - Subcutaneous refers to the

tissue beneath the skin, and emphysema refers to trapped air. This may be evident in patients

with fractured ribs.

Expansion can be assessed by, when the patient breaths out, placing thumbs together and

laying outstretched hands across the posterior and anterior chest wall. On inspiration the

thumbs should move apart. This should be repeated on the posterior chest wall. Chest

expansion may be affected by a number of conditions including Chronic Obstructed Pulmonary

Disease COPD, asthma, pneumonia, chest trauma, pneumothorax, and pulmonary fibrosis (see

figure 6).

Figure 7 – Chest expansion

Apex Beat

In the teaching session you will be taught two postures that you may place your patient in.

These positions assume that the patient is on a couch or bed.

1. Supine at a 45° angle

2. Lying on their left-hand side in the Decubitis position. Asking the patient to adopt this

position makes it easier to find the apex beat.

Starting with the fingertips in the mid axillary line approximating the 3rd, 4th and 5th intercostal

spaces, slowly draw the examining hand towards the midline in small increments.

Continue to move medially until a tapping sensation can be felt below the fingertips.

Identify the position of the apex beat using landmarks (Angle of Louis, 2nd, 3rd, 4th, 5th and 6th

intercostal spaces and the mid clavicular, anterior axillary and mid axillary lines).

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Percussion

It is essential that you take tour time and are systematic when percussion the chest wall. As the

lungs are air filled in normal health we would expect a resonant sound to be produced when

percussion over healthy lung tissue, if fluid or tumour have occupied a space where lung tissue

should be then when we percuss over it we would hear a dull sound which is abnormal.

Percussing areas overlying air without lung tissue present (pneumothorax) can produce a

hyper-resonant sound. NB. The more pressure in the thoracic cavity the higher the note

produced (tension pneumothorax).

To percuss place your middle finger firmly in the intercostal spaces (lay finger along intercostal

space) and tap with the middle finger of the other hand. When percussing the clavicles, tap your

finger directly on to bone (see figure 7).

Figure 8- Percussion

Remember to compare sides by alternating from similar areas on the right and left side. Percuss

on the anterior, lateral and posterior chest walls. Ensure you adequately cover all of the lobes of

the lungs percussing a minimum of 4 – 6 sites anteriorly, 2 – 3 sites laterally and 6 – 8 sites

posteriorly.

Auscultation

When performing auscultation, we may hear normal or abnormal breath sounds. We may also

hear additional sounds. The site where you are listening will affect what is normally heard.

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Use the diaphragm of the stethoscope (or bell if patient has hairy chest).

When performing auscultation think about:

• The position where the sounds are heard and how does this relate to lung structure

(lobes)

• The sounds heard, thinking about the duration (how long), intensity (how loud), pitch

(high or low) and timing (within the respiratory cycle).

• Additional sounds heard.

Patient breathes with open mouth, slightly deeper and ask the patient to turn their head slightly

to the left to prevent them breathing directly onto you.

Directly compare left and right lung fields. Auscultate an appropriate number of sites to ensure

all lobes examined. Auscultate anterior, lateral and posterior chest walls.

Listen for: presence of normal / abnormal breath sounds dependant on area being listened to

and the presence of additional sounds e.g. wheeze, crackles or pleural rub.

In some areas of the chest we are listening to the airflow in the major airways; i.e. Trachea

(tracheal sounds) and sternal edges (bronchial sounds).

In all other areas of the thorax we listen to the way airflow in the major airways is transmitted

(attenuated). It is this transmission (attenuation) of the sound which changes if an abnormality is

present.

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Normal sounds heard during auscultation:

https://www.youtube.com/watch?v=KRtAqeEGq2Q

Tracheal breath

Loud, high pitched, hollow (sound like air is being blown through a pipe) and are heard when

auscultating over the neck and trachea. There is a distinct pause between the inspiratory and

expiratory phases of respiration.

Bronchial breath

Tubular, hollow sounds which are heard when auscultating over the large airways around the

sternum at the 2nd / 3rd intercostal spaces (hilum). Considered abnormal if heard over the

peripheral lung fields away from the hilum. There is a distinct pause between the inspiratory

and expiratory phases of respiration.

Vesicular Sounds

Attenuated (filtered) sounds which conduct through normal lung tissue from the left and right

main bronchus. These sounds are heard on areas away from the sternum on the anterior,

lateral chest wall and lower back. There is no pause between the inspiratory and expiratory

phases of respiration. The inspiratory sounds are longer than the expiratory.

Bronchovesicular sounds

Tubular, are softer bronchial sounds which are heard when auscultating over the upper back

near to the spinal column. They are a mixture of the the bronchial breath sounds heard near the

sternum and the vesicular sound heard over the rest of the lung fields.

Additional sounds

Auscultation of normal lungs should reveal vesicular breath sounds and no added sounds,

dependant on area being listened to.

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Possible added sounds are: Wheeze, Stridor, Crackles – fine or coarse and Pleural rub

Wheeze

A whistling sound caused by turbulence in the airflow. A sign of localised narrowing within the

bronchial tree. They sound like prolonged musical sounds and are usually heard in expiration in

conditions such as asthma. Inspiratory wheeze is more common when a singular narrowing of

the brachial tree is present such as a tumour. If a wheeze is evident you may ask the patient to

‘cough’ see if the wheeze disappears or changes. This may be suggestive of a plug of sputum.

Stridor

A sign of large airway narrowing / obstruction. A harsh sound which is usually high pitched and

increasing in intensity during inhalation although may be evident in exhalation also.

Coarse crackles

Harsh snaps, crackles and pops heard as films of fluid burst as the patient breathes. A sign of

thick fluid or secretions in the large bronchi which can usually be cleared or altered by coughing.

Fine crackles

Inspiratory, high pitched, explosive, involve popping open of fluid menisci in the small airways

(can be mimicked by rubbing hair between finger and thumb over ear). Early inspiratory causes

include: Chronic bronchitis and Bronchiectasis. Late inspiratory causes include: Left ventricular

failure, Fibrosis and Pneumonia

Pleural rub

Occurs when inflamed pleural surfaces rub together due to the normal lubricating fluid being

lost.

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A creaking noise (can be reproduced by rubbing on the dorsum of a cupped hand placed over

the ear). Usually heard in both inspiration and expiration.

Has 2 phases corresponding to the inspiratory and expiratory phases of respiration.

Absent breath sounds

Breath sounds may become absent due to collapse of the lung underlying the area being

auscultated (no lung tissue to transmit the sound) and hypoventilation / poor respiratory effort

when the amount of air flowing is inadequate to produce sound.

Additional examination techniques

If an abnormality is found on percussion or auscultation then the following 2 techniques may

help to determine if air, fluid or a solid mass lies in the area of abnormality

Tactile fremitus

The ulnar borders of the hands are placed on either side of the chest in the intercostal spaces

overlying the perceived abnormality.

The patient is asked to say “99”.

If the abnormality is a solid mass (tumour or consolidation) then the vibration generated will be

felt more on the abnormal side.

If there is a collapse of the lung then reduced or no vibration may be felt on the abnormal side.

Vocal resonance

The head of the stethoscope is place over the perceived abnormality

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The patient is asked to say “99”.

If the abnormality is a solid mass (tumour or consolidation) then the sound of “99” will be heard

clearly as opposed to the normal side in which the sound will be muffled.

If there is fluid on the abnormal side then the sound will be ‘more’ muflled.

Possible pathologies

Following the examination if we take all the findings together we may be able to determine the

cause of any problem. Table 2 shows the findings which may relate to certain respiratory

conditions.

Table 2 – Possible pathologies

Ch

est

mo

vem

ent

Tra

ch

ea

Pe

rcu

ssio

n

Au

sculta

tion

Vo

cal

reson

an

ce

Tactile

Fre

mitu

s

Normal Normal

excursion Central Resonant

Vesicular over peripheral lung

fields Nil Nil

Consolidation

? Reduced Central Dull Bronchial Increased Increased

Pleural Effusion ? Reduced

? deviated away from

the affected

side

Dull Reduced Reduced Reduced

Pneumothorax ? Reduced

? deviated toward the affected

side

Hyper-resonant

Reduced Reduced Reduced

Tension pneumothorax

? Reduced

? deviated away from

the affected

side

Hyper-resonant

Reduced Reduced Reduced

Pulmonary Fibrosis

Reduced Central Reduced Resonant

Reduced Crackles

VELCRO™ Nil Nil

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Lymph Nodes

The lymph node groups which are associated with the respiratory system include:

Sub mental – under the chin

Sub mandibular – under the body of the mandible

Tonsillar (jugulodigastric) – at the angle of the jaw

Preauricular – in front of the ear

Post auricular – behind the ear

Cervical nodes – superficial and deep along the line of the sternocleidomastoid

Clavicular nodes – supra (above) and infra (below) the clavicles

Axillary nodes – Anterior (against the anterior axillary fold), posterior (against the posterior

axillary fold), Medial (against the chest wall), Lateral (against the humerus) and apical (at the

apex of the axilla)

(See lymph examination study guide for further information)

Documentation

Recording your findings

Don’t forget when recording your findings to include the patient identifiers, date (and time), your

signature and printed name at the end.

Warning: it is easy to confuse left and right sided findings so ensure that you are

reporting correctly.

Be sure to report any abnormal findings to your supervisor even if you are unsure.

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Bibliography, Further Reading & Information

Tables

Table 1. Considerations in History (with associated examination findings)

Table 2. Possible pathologies

References

1 - WHO (2009) http://www.who.int/infection-prevention/tools/hand-hygiene/en/

Figures

Figure 1 - The complete

airway

LadyofHats / Public domain https://commons.wikimedia.org

Figure 2 - Lung borders and

fissures

Donaldson, Gavin, Medical Sciences, 13, 603-642

Figure 3 - Oxygen masks CSTLC

Figure 4 - Tracheal position

CSTLC

Figure 5 - Pectus carinatum By Tolson411 - Own work, CC BY-SA 3.0,

https://commons.wikimedia.org/w/index.php?curid=9473775

Figure 6 - Pectus

excavatum

CC BY-SA 3.0,


Figure 7 - Chest expansion CSTLC

Figure 8 - Percussion CSTLC

http://www.who.int/infection-prevention/tools/hand-hygiene/en/

https://commons.wikimedia.org/



24

Further reading

All British Thoracic Society guidance

https://www.brit-thoracic.org.uk/standards-of-care/guidelines/

NICE guidance (2018) on Chronic Obstructive Pulmonary Disease (2018)

https://www.nice.org.uk/guidance/conditions-and-diseases/respiratory-conditions/chronic-

obstructive-pulmonary-disease#panel-pathways

NCEPOD (2012) Time to Intervene

Importance of respiratory rate in relation to patient outcomes

https://www.ncepod.org.uk/2012report1/downloads/CAP_fullreport.pdf

respiratory examination year 2 study guide · 9/2/2020 · shortness of breath – dyspnoea chest...

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