HISTORY TAKING AND GENERAL EXAMINATION OF RESPIRATORY SYSTEM

Seminar Presented by: Dr Himanshu Rana (JR-3)

Scheme of history taking• Initial enquiry• Chief complaint• History of present illness• Past medical history• Systemic enquiry• Family history• Occupational history• Drug history• Social history• Personal history

• Symptoms• Cough• Sputum production• breathlessness• Chest Pain• Hemoptysis• Wheeze / Stridor

Cough• Reflex act of forceful expiration against a

closed glottis generating positive intrathoracic pressure as high as 300 mm Hg.

• Aim is to clear the airways.

Acute cough (<3 wks)• Upper respiratory tract infections• Pneumonia• Pulmonary embolism • Congestive Cardiac Failure

Subacute cough (3- 8 weeks)• Viral infections• Post infective • Post nasal drip• GERD

Chronic cough >8 wks• Pulmonary Tuberculosis• Bronchial Asthma• COPD• Bronchogenic carcinoma• Eosinophilic bronchitis• Post nasal drip• GERD• Drugs like ACE inhibitors• Congestive cardiac failure

Nocturnal cough• Post nasal drip.• GERD• Chronic brochitis.• Bronchial asthma.• Obstructive sleep apnea• Left Ventricular Failure• Aspiration

Sputum• Consistency• Amount• Color• Postural variation• Smell

Consistency• Serous - Upper Respiratory tract Infection,

Bronchoalvelolar carcinoma • Mucoid - Chronic bronchitis, Bronchial Asthma • Mucopurulent - Bacterial infection

Amount

Copious Amount– Bronchiectasis– Lung Abscess– Necrotizing pneumonia– Alveolar cell carcinoma– Empyema rupturing into bronchus

(Bronchorrhoea - >100ml sptum/day)

Color of sputum– Yellow / Green — Bacterial infection– Black — coal worker pneumoconiosis– Pink frothy sputum — Pulmonary edema– Rusty sputum- pneumococcal pneumonia– Red currant jelly sputum- klebsiella – Blood tinged / streaking of sputum- tuberculosis– Anchovy sauce — Ruptured amoebic liver abscess.

Postural variation– Lung Abscess– Bronchiectasis

Foul Smell– Lung abscess– Bronchiectasis – Anaerobic bacterial infection

Dyspnea“Subjective experience of breathing discomfort

that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors that may induce secondary physiological and behavioural responses.”

(The American Thoracic Society)

• Onset • Duration• Severity • Aggravating and relieving factors• Postural variation• Diurnal variation

Onset

Within minutes– Pneumothorax – Pulmonary embolism– Inhalation of foreign body– Larygeal edema– Left heart failure

Hours to Days– Acute Respiratory Distress Syndrome– Bronchial Asthma– Pneumonia– Left heart failure

Weeks to Months– COPD– ILD– Pleural effusion– Anemia– Thyrotoxicosis – Left ventricular failure

Grading of Dysponea (MMRC scale)Grade Description of Breathlessness

0 I only get breathless with strenuous exercise.

1 I get short of breath when hurrying on level ground or walking up a slight hill.

2 On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace.

3 I stop for breath after walking about 100 yards or after a few minutes on level ground.

4 I am too breathless to leave the house or I am breathless when dressing.

• Aggravating factors– Exposure to allergen– Exercise– Drugs– Cold whether

• Relieving factors– Medication– Rest– Removal of allergen

Diurnal and postural variation– Bronchial asthma– Lung abscess– Bronchiectasis

Haemoptysis

Types• Frank- expectoration of blood only• Spurious- secondary to upper respiratory tract

infection above the level of larynx• Pseudo hemoptysis- due to pigment produced

by gram negative bacteria, Serratia marcescens

Severity • Mild <100ml /day• Moderate 100-150ml/day• Severe upto 200 ml/day• Massive > 600ml /day or 100ml/day for more

than 3 days or 150 ml/hr.

HAEMOPTYSIS HAEMATEMESIS

Cough precedes Nausea & vomiting precedes

Frothy, may be mixed with sputum No air, mixed with food particles

pH alkaline pH acidic

Bright red Dark brown

H/o respiratory disease h/o peptic ulcer or chronic liver disease

No h/o malena h/o malena present

Investigation: bronchoscopy Investigation: endoscopy

Causes of hemoptysis

Infection-– TB– Lung Abscess– Bronchiectasis – Pneumonia– Fungal infection (aspergillosis blastomycosis)

Neoplasm-– Bronchogenic ca– Bronchial adenoma– Metastatic tumour

CVS– MS– PHT– Pulmonary embolism– AV malfromation

• Collagen vascular disorder– Vasculitis – Wegener’ s granulomatosis – Microscopic polyangitis – Churgstrasuss syndrome– Goodpastures’s syndrome

• Traumatic• Iatrogenic.• Bleeding disorder

Chest Pain• Site• Onset • Duration• Severity• Character• Radiation • Associated symptoms• Aggravating/Relieving factor• Diurnal /seasonal variation• Retrosternal Pain :-

causes• Upper– Tracheatis

• Mid and Lower– Mediastinitis – Mediastinal tumor– GERD– Achalasia cardia

• Diffuse esophageal spasm

• Pleural Inflammation – Catchy pain, increases on deep inspiration and on pressure is stabbing in chararcter.

• Pancoast tumor– shoulder and arm pain due to compression of C8, T1-2 roots is sharp shooting pain along the course of nerve.

• Erosion of ribs – constant dull aching chest pain.• Tietze’s syndrome – costochondritis(usually 2nd

costochondral junction), unknown etiology.

“Always keep ‘Angina’ in mind”

• General Examination• General condition• Vitals– Temperature– Pulse– Respiratory Rate & Breathing pattern.– Blood pressure

• Pallor • Icterus • Cyanosis• Clubbing• Lymphadenopathy • Pedal oedema• Built• Nourishment• Tripod position• Purse lip breathing• Paraneoplastic syndrome– Cushing’s syndrome– Gynecomastia – Carcinoid syndrome

Pulse• Bradycardia - Hypoxia. • Tachycardia - Pneumonia, Pulmonary

Embolism, ARDS• Unequal - Pancost Tumour , Mediastinal

syndrome.• Pulsus Paradoxus – Acute severe asthma,

COPD.

Respiratory Rate & Breathing Pattern-TACHYPONEA > 20 Causes• Pneumonia • Acute pulmonary odema • Pulmonary embolism • Acute Respiratory Distress Syndrome • Metabolic acidosis • Others causes - Fever, hypoxia, excitation,

nervousness

Examination of EYEFinding on Examination Likely Etiology

Horner’s syndrome Pancost tumour

Phlycten, Choroid tubercule Tuberculosis

Conjunctival chemosis SVC Syndrome, CO2 narcosis

Papilloedema SVC obstruction, CO2 narcosis

Pallor• Chronic Infections – TB• Chronic inflammatory disorders – interstitial

lung disease, connective tissue disease.• Malignancies.

Icterus– Cor pulmonale – Iatrogenic – Anti Tubercular Medications– Metastasis to Liver– Pulmonary infarction.– Sepsis – secondary to chest infection.

CyanosisRespiratory disorders – Acute severe Asthma– Tension Pneumothorax – Pulmonary AV malformations– Acute laryngeal oedema – ARDS

Lymphadenopathy• Sites• Number• Tender/Non-tender• Discrete/matted• Consistency• Fixed/Mobile• Overlying skin• Sinus

Lymphatic drainage :• Parietal Pleura – Multiple nodes• Rt lung + Lt lower lobe — Rt supraclavicular

LN• Left upper lobe — Lt supraclavicular LN

(Troisier’s sign).• Apical portion drains directly in scalene LN.

Causes-• URI• Tuberculosis• HIV• Sarcoidosis • Lung Carcinoma• Lymphoma• Secondaries

ClubbingCauses• Bronchogenic carcinoma• Bronchiectasis • Lung abscess• Empyema• Cystic fibrosis• Interstitial lung disease• Congenital • Unilateral clubbing — Pancoast tumour

Grade Description

Grade 1 Obliteration of the angle between the nail and the nail bed and positive fluctuation test

Grade 2 Parrot beak appearance

Grade 3 Drumstick appearance

Grade 4 Hypertrophic osteoarthropathy

Pedal Edema• Cor Pulmonale • Chronic infections / inflammations – secondary

to hypoalbuminemia.• A/w renal involvement – – Wegener’s granuomatosis – Polyarteritis nodosa – Microscopic polyangitis – Goodpasture syndrome

Miscellaneous• Scleroderma - nail bed telengectasias,

raynod’s phenomenon, calcinosis cutis• Sarcoidosis – lupus pernio