Respiratory System Hist Exam

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Respiratory System

History & Examination


Prof Hari
rharinarayan@aimst.edu.my
Yr 3 2021
History Examination Investigations

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

Two main patterns - occur


independently/together

Acute onset - Br asthma, LVF, Massive


PE, Spontaneous
pneumothorax
Breathlessness
Exertional breathlessness -Heart failure,
Chronic lung
disease,
Obesity,
Anaemia,
Hyperthyroidism
Breathlessness
History
 Duration, mode of onset
 Sudden: PE, pneumothorax, acute asthma,
foreign body inhalation, acute pulmonary
oedema, hyperventilation syndrome
 Rapid (hours-days): pneumonia, acute asthma,
haemothorax, pleural effusion, ac. bronchitis
 Gradual-Slow (Weeks-months-yrs): COPD,
asthma, interstitial lung disease, pleural
effusion / fibrosis, ca bronchus / trachea
Breathlessness
History
 Exercise tolerance
 How far can you walk – flat surface / stairs
 Has it deteriorated ?
 PND, Orthopnoea
 Diurnal / Seasonal variation?*
 Occupation ?*
 A/w wheeze ?
Breathlessness

Onset, associated symptoms – extremely useful


in differential diagnosis
Sudden onset uncommon, indicates severe
disease
Pulmonary oedema associated with wheeze –
“cardiac asthma”
Wheeze
Aggravating factors - exertion, change
in temp., aerosols, smoke, dust, cat
and dog dander, pollen, chest
infections
Must be differentiated from stridor –
partial obstruction of a major airway at
the level of the supraglottis, glottis,
subglottis, and/or trachea – usually
more urgent *
Chest pain
Types related to respiratory disease
1. Upper retrosternal pain – ac. tracheitis
2. Retrosternal pain – lesions of the mediastinum –
tumours, ac mediastinitis, mediastinal emphysema.
3. Pleural pain – stretching of the parietal pleura*
 Duration
 Mode of onset
 Site, character, relationship to breathing & coughing
 Aggravating / relieving factors
Chest pain
Differentiate from non-respiratory causes.
 Pericarditis - central / left of sternum or in the
left or right shoulder, relieved by sitting up
leaning forwards, worse on lying down.
 MI – Severe, prolonged, other assoc. symptoms
 Dissecting aneurysm of aorta – sudden onset,
severe, sharp, stabbing, tearing pain radiating to
the back.
 Reflux oesophagitis – Heartburn, lying down,
odynophagia, other symptoms.
Other symptoms of Respiratory Disease
Weight loss, lethargy – malignancy,
tuberculosis, respiratory failure
Night sweats – tuberculosis,
lymphoma
Headache worse on waking,
drowsiness, confusion – hypercapnia
Hoarse voice laryngitis, recurrent
laryngeal nerve palsy, malignancy
Also ask about
Childhood - asthma, whooping cough,
pneumonia, measles
Previous history of DVT/ PE, TB etc
Smoking*
duration, “pack years” (20/day for 1 yr =1 PY)
Occupation
Past and present
Coal mining
Shipyards, construction industry (asbestos)
Paint sprayer, baker, farmer
Hobbies – avian exposure
Also ask about

Medication history – don’t


forget the
inhalers
Allergies
Other drugs – β blockers,
ACE-i
Source: Forbes & Jackson-A Colour Atlas of Clinical Medicine
Lastly

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

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