Respiratory System Hist Exam
Respiratory System Hist Exam
Respiratory System Hist Exam
DIAGNOSIS
DD ?
Treatment
The Basics
• Be polite !
• Introduce yourself
• Make sure the patient is comfortable,
dignity preserved
• Explain what you would like to do
History
Presenting complaint
History of PC
Past medical history
Drugs and allergies
Family history
Social history
Systemic enquiry
Symptoms of Respiratory Disease
Cough
Sputum
Haemoptysis
Breathlessness
Wheeze
Chest pain
Symptoms of Respiratory Disease
Cough
1. Duration
2. Dry / productive
3. Postural variation*
4. Diurnal variation*
5. Seasonal variation*
Symptoms of Respiratory Disease
Cough
6. Nasal / Sinus symptoms
7. Heartburn
8. Medication
9. Aggravating factors
10. Cough on swallowing*
11. Character*
Symptoms of Respiratory Disease
Sputum
1. Duration
SCANTY
2. Quantity COPIOUS
3. Character / type
Serous, mucoid, purulent, mucopurulent,
blood stained, pink frothy, rusty, redcurrant
jelly, black, foul smelling
Cough & Sputum
• Chronic productive cough – COPD,
bronchiectasis
• Persistent dry cough – cancer, ACE-inhibitor,
pulmonary fibrosis (occasionally productive)
• Nocturnal cough – asthma, gastro-
oesophageal reflux, postnasal drip
• Large volume watery sputum –broncho-
alveolar cell carcinoma
• Sputum plugs – asthma, bronchopulmonary
asperigillosis
Source: Forbes & Jackson-A
Colour Atlas of Clinical Medicine
Haemoptysis
• Duration
• Quantity per day
• Fresh ? Blood clots ?
• Mixed with sputum ?
• Differentiate haematemesis, epistaxis,
bleeding from mouth or throat
• ≥ 600ml / day – Massive haemoptysis
- carcinoma of bronchus, PE, PTB, pneumonia,
bronchiectasis, trauma, pulmonary oedema,
vasculitis, mycetoma (aspergilloma), arterio-
venous malformations
Source: Forbes & Jackson-A Colour Atlas of Clinical Medicine
Breathlessness
Family history
Social history
Systemic enquiry
Examination
As always
Inspection
Palpation
Percussion
Auscultation
Examination
Introduce self
Ask for consent
Wash hands
Expose & position patient appropriately
Examination
5. Inspection
Inspect the patient from the end of the bed
Ask the patient to take a deep breath
Observe the pattern of breathing - depth,
symmetry
Wheeze, stridor, lip pursing, accessory
muscles, intercostal recession. Hoover’s
sign*,
Cheyne Stokes respiration*
Oxygen, nebuliser, inhaler, sputum pot
Source: Forbes & Jackson-A Colour Atlas of Clinical Medicine
Examination
Hands:
Cyanosis
Clubbing
‘Nicotine’ staining
Connective Tissue Disorder
CO2 retention-(Warm hands & dilated
veins, bounding pulse, flap)*
Fine tremor*
Wasting of small muscles*
Source: Forbes & Jackson-A Colour Atlas of Clinical Medicine
Examination
Chest Inspection:
Shape - pectus excavatum, pectus
carinatum, Harrison’s sulcus,
kyphoscoliosis. Barrel chest- best assessed
from side*
Scars (sternotomy, thoracotomy, drains)
Swelling, plethora and distended veins -
head, neck, arms, upper chest - SVCO
Asymmetry
Intercostal/ subcostal indrawing
Source: Forbes & Jackson-A Colour Atlas of Clinical Medicine
Source: Forbes & Jackson-A Colour Atlas of Clinical Medicine
Examination
Abdominal paradox*
Ankle oedema
Examination
6.Palpation
Position of trachea
Subcutaneous emphysema*
Neck nodes – examine from behind when
examining back of chest – inform patient (!)
Apex beat
Expansion - upper and lower chest (Hoover’s sign)
Tactile (vocal) fremitus *
Ask pt to say “99” whilst whilst holding ulnar border
of hand against the chest
Examination
7.Percussion
Compare right to left
2 taps
Don’t forget apices & axillae
Examination
8.Auscultation
Deep breath in and out through open mouth
Intensity of breath sounds- normal or reduced?
Breath sounds - vesicular or bronchial?
Added sounds present?
Rhonchi - monophonic, polyphonic, localized
Crepitations
Pleural rub grating, rubbing, crunching, foot steps
in snow
Esoteric - Vocal resonance, Bronchophony,
Aegophony, Whispering pectoriloquy *
Investigations
Chest pain
Breathlessness
Fever
Investigations
Pneumonia
Pulmonary embolus
Anxiety
COPD
Lung cancer (any manifestation)
Pneumothorax
Investigations
Blood count (FBC), ESR • D-dimer
Blood culture and sensitivity • CT scan
Oxygen saturation (sPO2) • Bronchoscopy
CXR • CTPA
PEFR • Pleural
Sputum aspirate
Spirometry
ECG
ABG