https://meded.ucsd.edu/clinicalmed/lung.

htm - Good site for general Physical Exam and other Clinical based needs

1. Read the note with your partner outside the room, note down and begin to think of your differential and what questions for
the history are going to be important (Do a more focused history and physical than you would for an SP encounter)

2. When you walk into the room take a look at the vitals – are they struggling to breath at this point? Ask them -> give nasal
cannula if yes

3. Know the treatments for each of the vitals that you can impact

a. Temp – do you need to treat?

i. If so 1 gram of Tylenol if LFTs normal

b. SaO2 – be conservative; what are your options

i. Start with NC, progress to NRB followed by BiPAP  ET tube

c. Nebulizer Meds: what are indications?

i. Acute exacerbations of Asthma or COPD

d. Other?

4. History

a. HPI

i. When did this start?

ii. Has this happened before?

iii. Are you having any pain? -> Scale /10 -> radiating?

iv. Relieving/Aggravating factors?

v. Do you feel like you are getting better, worse, the same?

vi. Any other symptoms you have noticed?

b. Past Medical history – Diagnosed medical conditions?

c. Family medical history  anything like this run in the family

d. Surgical History – recently?

e. Social history

i. Tobacco, illicit drugs, alcohol, occupation?

f. Medicines – what medications do you take

g. Allergies

h. ROS

i. Gen: Fever, nausea, vomiting, weight

ii. Skin: Rash, bruising

iii. MSK: Weakness, fatigue

iv. Neuro:

v. HEENT: PERRL, NC/AT

 vi. Cardio: SOB (at rest, during exercise, during normal walking etc..), edema, CP

vii. Pulm: Wheezing, cough

5. Physical Exam

a. Lungs Auscultation– do this bilaterally, 6 spots

i. Above clavicle (missing on picture)

ii. 1st Intercostal space

iii. 3rd intercostal space

iv. 5th intercostal space

v. Mid axillary line around 6th intercostal space

vi. Midaxillary line around 4th or 5th intercostal space

b. Heart - Auscultation

i. Aortic – Below 2nd Rib parasternal – Right Side

ii. Pulmonary – Below 2nd Rib parasternal – Left Side

iii. Tricuspid – 5th-6th rib on the left side just off the sternum on left side

iv. Mitral – below 5th rib at mid axillary line on left side

c. Lungs Percussion

d. Pulses – Radial, Dorsalis Pedis/Posterior Tibialis

5. Interpret the initial vital signs: Pulse, BP, RR, Temp, and SaO2
6. If the oximetry reading is low (<90%) have a FOCUSED PLAN to improve the SaO2.

How to give O2? Remember need to improve his oxygenation using one of the following items:
a. Nasal cannula Nasal Cannula  1-6L  22-44%
b. Simple face mask  6-10L  35-60%
c. Venturi-mask  6-10L  24-50% - IF CO2 RETAINER (COPD)
d. Non-rebreather mask  8-15L  80-90% - IF IN EXTREMIS
e. BVM  12-15L  100%  Tidal Volume breaths

7. At the same time as you are managing any and all abnormal vital signs, ASSESS your patient with a focused list of questions:
BRIEF HISTORY, PMH, ROS, SH, ALLERGIES, MEDICATIONS, AND FAMILY HISTORY
Ask family members if present. Be concise and to the point.

8. FOCUSED PHYSICAL EXAM

-Evaluate the patient's mentation, work of breathing, pulses, mucus membranes, eyes, chest, lungs, heart, abdomen (if needed) and
extremities (if appropriate)
9. DIAGNOSTIC TESTS
- determine if you need to order CMP, CBC, EKG, CXR, ABGs, or other tests
10. TREATMENTS
- determine if you need to administer medications, prepare for advanced airway procedures, or modify your treatment plan based
upon available information
11. DIAGNOSIS
- be able to formulate your diagnosis and treatment plan. Be able to present the patient's history, physical exam findings, diagnostic
tests, your initial assessment, treatment, and ultimate disposition of the patient.
EVERY ACTION THAT YOU TAKE MUST BE VERBALIZED IN ORDER TO RECEIVE CREDIT.

Remember these values:

1. PaO2 60 = Sat 90%
2. PaO2 40 = Sat 75%
3. PaO2 27 = Sat 50%

PAO2 = (760-47)*.21 – PaCO2/0.8

A-a = PAO2 – PaO2 (if 65+  AGE X 0.3= the A-a gradient)  R  L shunt, or a Diffusion abnormality

AIG  Na+ - (Cl + HCO3-)

NL values – PaO2 = 70-100, PaCO2 = 40, pH = 7.35-7.45, HCO3- = 24

NL values in emphysema – Pa02 65, PaC02 37, pH 7.39, HC03- 26, Sat. 92%
NL values in COPD – Pa02 55, PaC02 60, pH 7.34, HC03- 32, Sat. 85%

If COPD patient in acute exacerbation

 Moxifloxacin + Azithromycin

How to Read/Present an X-ray to an attending

 Rule 1: DO NOT GO STRAIGHT TO THE PATHOLOGY

 https://www.radiologymasterclass.co.uk/tutorials/chest/chest_system/chest_system_06
 http://www.lasvegasemr.com/foam-blog/systematic-approach-to-reading-chest-x-rays
 Technique:
o What direction is the X-ray in?
o Is it a good x-ray?
 All structures you want
 Good inspiratory effort (shows 8-10 posterior ribs)
 Proper penetration(see the thoracic vertebrae)
o Medical Devices or lines (Nasogastric tubes/Endotracheal tubes/central lines etc.)
 A – Airway/Apices
o Look at trachea, R/L Main stem bronchi
o Pneumothorax?
o Deviation -> Tension pneumothorax
 B – Bones
o Fractures
o Symmetrical (is it just posture or is their deformity?)
 C – Cardiac Shadow
o Does the heart look enlarged?
o Widened mediastinum?
o Cardiothoracic ratio
 Heart width/thorax width -> should be less than 50% or it is cardiomegaly
 D – Diaphragm
o Is it even?
o Abnormal here could mean phrenic nerve involved
 E – Edges of image/Everything else
o Edges – look around the outside and see if everything looks proper
 o Pneumonia -> remember anatomy to decide which lung field
 Lower lobes should be posterior looking
 Superior lobes should be anterior looking
 F – Lung Fields
o Even, symmetrical
o Pneumothorax
o Pleural effusion

PAO2 = (760-47)*.21 – PaCO2/0.8

A-a = PAO2 – PaO2 (if 65+  AGE X 0.3= the A-a gradient)  R  L shunt, or a Diffusion abnormality

AIG  Na+ - (Cl + HCO3-)

NL values – PaO2 = 70-100, PaCO2 = 40, pH = 7.35-7.45, HCO3- = 24