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Skill Laboratory Module

BLOCK : Respiratory system


TOPIC : Respiratory history taking and physial e!amination in
adults
I" #$%$R&L OB'$CTI($
After completing skill practice, the student will be able to perform respiratory
history taking and physical examination.
II" SP$CI)IC OB'$CTI($
At the end of skill practice, the student will be able to perform the procedure
of respiratory physical examination systematically including:
History taking
Systematic physical examination of respiratory system by performing
inspection, palpation, percussion and auscultation
III" S*LL&B+S ,$SCRIPTIO%
-". Sub Module Ob/eti0e
After finishing skill practice of clinical examination, the student will be able
to perform history taking and physical examination of respiratory disorders
-"1 $!peted ompetenies
Student will be able to demonstrate the procedure of history taking of
respiratory disorders
-"-" Method
a. Presentation
b. Demonstration
c. oaching
d. Self practice : role!play
-"2 Laboratory 3ailities
a. Skills laboratory: table, chairs, and examination couch
b. "rainers
c. Patient : real patient and model
d. Student learning guide
e. "rainer#s guide
f. $eferences
-"4 (enue
Skills laboratory
-"5 $0aluation
a% Point nodal e&aluation
b% 'S(
-"6" Sub Model Ob/eti0e
After finishing skill practice of clinical examination, the student will be
able to perform respiratory system physical examination.
-"7" $!peted Competenies
Student will be able to demonstrate the procedure of physical
examination of:
)ocating er&ical lymph node
"racheal position
)ocating chest abnormalities &ertically and circumferentially
Shape and mo&ement of the chest
"actile fremitus
hest Percussion
*ormal breath sounds
Presence and absent of ad&entitious sounds
Presence and absent of transmitted &oice sounds +bronchophony,
egophony and whispered pectorilo,uy%
I(" L$&R%I%# #+I,$ )OR P8*SIC&L $9&MI%&TIO% O) &,+LT
R$SPIR&TOR* P&TI$%T
Proedure 3or linial e!amination
%o Steps: Task . 1 - 2 4
&" CLI$%T &SS$SSM$%T
-. .reet client respectfully and with kindness
/. "he patient should be gi&en ade,uate explanation about
history taking and the goal or expected result of history taking
0. 1dentifying patient#s data + described elsewhere%
B" 8ISTOR* T&KI%#" Take a medial history onsidering :
- hief complaint
! Dyspnea
! 2e&er
! ough +expectoration%
! hest pain
/. Present illness +depends on the chief complaint%
hronology of chief complaint
! )ocation
! 3uality
! Se&erity
! "iming +onset, duration, fre,uency%
! Setting in which the symptoms occur
! 2actors that precipitate, aggra&ate or alle&iate
! Any associated manifestation+s%
0 .eneral medical history
! Past history
! 2amily history
+Asthma and other atopic disease Alpha - antitrypsin%
! 'ccupational history
! "uberculosis contact
! Smoking history
C P8*SIC&L $9&MI%&TIO%
I PR$P&R&TIO%
- "ell the patient what is going to be done
/ Help the patient on to the examination table
0 4ash hands thoroughly with soap and water and dry with a
clean dry cloth or air drier
5 "he examiner should stand at the patient#s right side
II $9&MI%&TIO% T$C8%I;+$
A
6
C
.eneral Physical (xamination +described elsewhere%
)ocating er&ical )ymph *odes
-. 7ake the patient comfortable and relax
/. 2lexed the neck slightly forward and if needed slightly
toward the examination
0. Palpate using the pads of your index and middle fingers
5. 7o&e the skin o&er the underling tissue in each area
8. Describe location, ,uantity, si9e +diameter%, consistency,
mo&ability, presence specific formation +package%.
2indings :
- Preauricular : in front of the ear
2 Posterior auricular : superficial to mastoid process
3 'ccipital : at the base of the skull posteriorly
4 "onsilar : at the angle of mandible
5 Submandibular : midway between the angle and the
tip of the mandible. "hese nodes are usually smaller
and smoother than lobulated submandibular gland
against which they lie
6 Submental : in the midline a few cm behind the tip of
mandible
7 Superficial cer&ical : superficial to sternomastoid
8 Posterior cer&ical : along the anterior edge of
trape9ius
9 Deep cer&ical chain : deep to the sternomastoid and
often inaccessible to examination. Hook your thumb
and fingers around either side of the sternomastoid
muscle to find them
10 Supracla&icular : deep in the angle formed by the
cla&icle and the sternomastoid
TR&C8$&
-. 1nspect trachea for any de&iation from its midline position.
/. Place the finger along one side of the trachea and note
the space between trachea and the sternomastoid.
0. ompare it with the other side. *ormally the space
should be symmetrical.
, Loating Chest abnormalities To loate 0ertially
&nterior hest
-. 1dentify the suprasternal notch
/. 7o&e your down about 8 cm
0. 2ind the hori9ontal bony ridge that ;oin the
manubrium to the body of sternum.
5. 7o&e your finger laterally and find the ad;acent /
nd
rib
and costal cartilage
8. 2rom here you can walk down the interspaces.
<. "he first intercostals space below the /
nd
rib is the
second intercostals space.
Posterior chest
-. 2laxed the patients neck forward
/. 2ind the most prominent process
0. "he most prominent is the =
5. 4hen two process appear e,ually prominent they are
= and "-
8. "hen you can felt and counted the process below them
<. >ou can also estimating location from location of
inferior angle of scapula is usually leis at the le&el of
the =
th
rib of interspace.
"o locate findings around the circumference of the chest
-. midsternal and &ertebral are lines drops &ertically mid
sternal and mid&ertebral
/. identify both end of the cla&icle and the midcla&icular
line drops &ertically from the mid point of cla&icle.
0. Anterior and posterior axillary lines drop &ertically from
the anterior and posterior axillary folds
5. "he midaxillary line drops from the apex of the axilla
T$C8%I;+$S O) C8$ST $9&MI%&TIO%
$!amine the posterior hest
Inspetion
-. place the patient in supine position
/. your position is in the midline position in front of the
patient
0. inspect the shape of the chest and the way in which it
mo&es
5. findings : deformities or asymmetry, abnormal retraction of
interspace during inspiration, impairment of respiratory
mo&ement on one or both side or a unilateral lag +delay%
in the mo&ement.
Palpation
Test respiratory e!pansion
-. place your thumb about at the le&el of and parallel to the
-?
th
ribs, your hands grasping the lateral rib cage.
/. Slide your hand medially a bit in order to raise loose skin
folds between your thumb and the spine.
0. ask the patient to inhale deeply
5. 4atch the di&ergence of your thumbs during inspiration
and feel for the range and symmetry of respiratory as the
thorax expands and feel for the extent and symmetry of
respiratory mo&ement.
Tatile 3remitus
a. use either the ball +the bony part of the palm at the base
of the fingers% or the ulnar surface of your hand and place
it in both side of the chest symmetrically
b. ask the patients to repeat the words @ninety nineA or @one
: one : oneA
c. repeat this examinations in other areas of the chest
symmetrically
Perussion
-. hyperextend the middle finger of your left hand +the
pleximeter finger%
/. press its distal interphalangeal ;oint firmly on the surface
to be percussed.
0. AB'1D contact by any other part of the hand
5. Position your right forearm ,uite close to the surface with
the hand cocked upward. "he right middle finger should
be partially flexed, relaxed, and poised to strike
8. Strike the pleximeter finger with the right middle finger
+the plexor%, with a ,uick, sharp but relaxed wrist motion
<. Aim the strike at your distal interphalangeal ;oint.
=. )earn to identify fi&e percussion notes which can be
distinguished by differences in their basic ,ualities of
sound : intensity, pitch and duration.
&usultation
1. instruct the patients to breath deeply through an open
mouth
2. listen to breath sound with the diaphragm of your
stethoscope
3. mo&e your stethoscope from one side to the other and
comparing symmetrical areas of the lung
4. pattern of breath sound identified by their intensity, pitch,
and relati&e duration of their inspiratory and expiratory
phases
5. the normal breath sounds are : &esicular,
broncho&esicular and bronchial
6. listen for any added or ad&entitious sound that are
superimposed on the usual breath sound. Ad&entitious
sounds are crackles +rales%, whee9es and rhonchi
7. if you hear crackles, listen for the following characteristics
a. loudness, pitch and duration +summari9ed as fine or
coarse crackles%
b. number +few to many%
c. timing in respiratory cycle
d. location on the chest wall
e. persistence of their pattern from breath to breath
f. any change after a cough or a change in the patients
position
C. if you hear whee9e or rhonchi , note their timing and
location and do they change with deep breathing or
coughing
D. if you hear abnormally located broncho&esicular or
bronchial breath sound, continue on to asses transmitted
&oice sound.
-?. 4ith stethoscope, listen in symmetrical areas o&er the
chest, as you :
g. ask the patient to say @ninety nineA. *ormally the
sound transmitted through the chest wall are muffled
and indistinct. )ouder and clearer &oice sounds are
called bronchophony
h. ask the patient to sal @eeA you will normally hear a
muffled long ( sound. 4hen @eeA is heard as @ayA. An
( to A change +egophony% is present.
i. Ask the patient to whisper @ninety nineA or @one : two :
three @. "he whispered &oice is normally heard faintly
and indistinctly. )ouder, clearer whispered sounds are
called whispered pectorilo,uy
8ISTOR* T&KI%#
,*SP%$&
TIMI%#
sine <hen =
ho< about the progression" Is it slo<ly progressi0e =>
aute in onset and separate <ith symptoms 3ree period =>
sudden onset o3 dyspnea => episodi and reurrent =
)&CTORS T8&T &##R$(&T$
is the dyspnea <orsen <ith position ?supine> lying do<n
to right:le3t@
is the dyspnea <orsen <ith e!ertion or <ith rest =
is the dyspnea <orsen <ith allergen> irritants> respiratory
in3etion> emotion"
)&CTOR T8&T R$LI$($
is the dyspnea relie0e <ith position ?rest> sitting up@ =
is the dyspnea relie0e <ith e!petoration =
is the dyspnea relie0e <ith separation 3rom aggra0ating
3ators =
&SSOCI&T$, S*MPTOMS
ough> ortopnea> paro!ysmal noturnal dyspnea
hroni produti0e ough> reurrent respiratory in3etion>
<heeAing
pleuriti pain> 3e0er
hemoptysis
palpitation> hest pain
S$TTI%#
history o3 heart disease or its risk 3ators =
history o3 smoking> air pollutants and reurrent
respiratory in3etion =
en0irontmental and emotional ondition
postpartum> postoperati0e period> prolong bed rest>
hip:leg> C8)> COP,
an!iety
C8$ST P&I%
." Bhere is it = Restrosternal> preordial> le3t or right side o3 hest <all
,oes it radiate = To the nek> bak"
1" Bhat is it like = shar3> kni3e like> pressing
-" 8o< bad is it> se0ere =
2" Bhen does this omplain start= 8o< long = 8o< o3ten does it ome=
4" Bhat 3ator that make is <orse= deep breathings oughing =
5" &nd <hat 3ator make it better> relie0e=
Rest> sitting up> lying on the in0ol0ed side ?le3t:right side@
6" Is there any symptom oumpanied it"
,yspnoe> oughing> 3e0er"