rs history

8/11/2019 RS History

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Respiratory System –

History & Physical examination

Mohan Kumar MBBS,MD

10/4/2014 1:26 PM



Essentials Of Diagnosis

• Goals of the history are to develop a probable diagnosis or limited

differential diagnosis and to assess severity of illness.

• Important features of symptoms include severity, chronicity,

moderating and aggravating factors, and associated systemic

symptoms.• Risk factors for lung disease are identified in past medical, family,

social, occupational, environmental, and drug histories.

• Physical examination should be directed to narrow the differential

diagnosis or confirm a specific diagnosis.• Pulmonary examination emphasizes assessing the quality of

normal breath sounds as well as the presence and nature of

adventitious sounds.

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Common complaints

Dyspnea

Cough & Sputum

Hemoptysis Chest Pain

Wheezing

Associated symptoms

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Dyspnea: Shortness of breathing (SOB), a non painful but

uncomfortable awareness of breathing I.e. inappropriate

to the level of exertion.

Synonyms: Breathlessness, suffocating, heavy breathing

commonly results from cardiac or pulmonary disease: – increased ventilatory demand (exercise, dead space

ventilation)

– increased work of breathing from abnormal airway resistance

(Asthma)

– heightened awareness of breathing (anxiety, hyperventilation

syndrome)

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Dyspnea: commonly results from cardiac or pulmonary disease:

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Description Patho-physiology

Chest tightness Bronchoconstriction , Interstitial edema

(Asthma, MI)

Increased work of breathing Airway obstruction (COPD, severe asthma)

Neuromuscular disease (Myopathy, kyphoscoliosis)

Air hunger, need to breathe Increased drive (CHF, Pulmonary embolism)

Unsatisfying breath Hyperinflation (COPD, asthma)

Restricted tidal volume (Pulmonary fibrosis)

Heavy, rapid breathing De-conditioning



SOB- questions to ask

•“Do you get short of breath?”

• “When do you feel short of breath?”

• “How far do you walk on level ground before you have shortness of breath?”

• “Do you get short of breath when you’re climbing stairs?”

•

“How many steps can you climb before you get short of breath?” • “When did it start?”

• “What makes it worse?”

• “What makes it better?”

•

“Do you wake up at night short of breath?” • “Do you have to prop yourself up on pillows in order to sleep at night? How

many?”

• “Have you been wheezing?”

• “Have you noticed any fluid retention around your ankles?”

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Types of Dyspnea

Dyspnea on exertion

Paroxysmal nocturnal dyspnea (PND): dyspnea that awakens a

patient from sleep. Patients typically describe a sensation of

suffocation or air hunger one or more hours after falling

asleep that is relieved within minutes of sitting up

Orthopnea: dyspnea that develops within minutes of lying

down- Heart failure, obesity, diaphramatic paralysis, COPD etc

Dyspnea at rest

Platypnea: dyspnea that develops or worsens in the upright

position. Non-specific, associated with Chronic Liver disease

or pulmonary AV malformations

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Causes of Dyspnea

• Acute dyspnea: is mostly due to viral or bacterial pneumonia,

asthma, pulmonary embolism, pneumothorax, pulmonary edema,

aspiration, or mucous plugging of airways.

• Chronic, slowly progressive dyspnea: caused by COPD, Ch.

Bronchitis, severe asthma refractory to bronchodilators, interstitial

lung disease, or pulmonary vascular disease.

• Dyspnea on occupational exposure: that progresses during the work

week with improvement during periods away from work. Ex:

Silicosis, asbestosis etc

• Reactive airways disease: Seasonal variation or worsening of

symptoms after exercise, exposure to cold dry air, pets, or

nonspecific irritants. Ex: Asthma

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Diagnostic Approach to Dyspnea

• History & Physical examination

• Chest Xray: lung volumes, parenchyma, vasculature,

pleural effusion

• CT scan: ILD, Pulmonary embolism

• EKG: Ventricular hypertrophy, prior MI

• Echocardiography: Valvular heart disease, HF

• Cardiopulmonary Exercise test

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Cough:

• Protects lungs from injury and infection

• It is a reflex response to stimuli that irritate receptors inthe respiratory tract.

• Although cough typically signals a problem in therespiratory tract, it may also be cardiovascular in origin.

• Stimuli-

Mechanical: Foreign body, pus, mucus, blood etc

Inflammation: of the respiratory mucosaChemical : Aspiration of food etc

Thermal: hot or cold air

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Cough

“Do you have a cough?”

“When did it start?”

“How often do you cough?”

“Do you bring up any phlegm/sputum with your cough, or is it dry?”

“What color is it?”

“Is there any blood in it?”

“Can you estimate the amount of the phlegm? Teaspoon? Tablespoon?

Cupful?”

“Does anything make it better?”

“Does anything make it worse?”

Associated symptoms: seasonal, wheeze, nasal discharge, heart burn, fever

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Duration of Cough

Acute (<3 weeks): common cold, Acute bronchitis,

pertusis, pneumonia, Left heart failure, Asthma, foreign

body.

Subacute (3-8 weeks): post infectious cough, asthma,

bacterial sinusitis.

Chronic (>8 weeks): COPD, GE reflux, chronic

bronchitis, bronchiectasis, post nasal drip, drugs (ACE

Inhibitors), bronchogenic carcinoma

Nocturnal cough: asthma, heart failure, GERD etc

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Causes of Cough

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Cough (Cont.)

Dry/ Unproductivecough: Without secretions. Dry hacking cough asin Mycoplasmal pneumonia, ACE inhibitor use etc

Productive cough: Sputum/phlegm is raised.

–Productive cough in bronchitis, bacterial pneumonia

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Charecter of Sputum:

• Mucoid sputum:

It is translucent, white or grey e.g. Asthma

• Purulent sputum:

yellowish or greenish, seen in bacterial bronchitis/pneumonia.

• Foul smelling or putrid sputum:bronchiectasis, lung abscess, necrotizing pneumonia

• Rusty sputum: (Prune-Juice sputum):

Purulent sputum containing changed blood pigment.

Pneumococcal or streptococcal pneumonia.• Frothy sputum:

A thin secretion containing air bubbles, typical ofPulmonary edema.

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Investigations

• History & Physical examination

• Chest radiography: Mass lesion, parenchymal

opacification, interstitial disease, honey combing,

lymphadenopathy• Pulmonary function testing (PFT’s): Obstructive or

restrictive, methacoline challenge

• Sputum: gross & Microscopic exam, culture, gram stain etc

• Bronchoscopy

• High resolution CT

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Hemoptysis:

• coughing up of blood from the lower respiratory tract.

• vary from blood-streaked sputum to frank blood.

• assess the volume of blood produced as well as the

other sputum attributes, and associated symptoms(weight loss, fever or anorexia). >600ml/day- Massive

hemoptysis

•

Distinguish among hemoptysis, epistaxis orhematemesis- source of blood

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Hemoptysis:• Before using the term “hemoptysis,” try to confirm the source of

the bleeding by both history and physical examination.• Blood or blood-streaked material may originate in the mouth,

pharynx, nose or gastrointestinal tract and is easily mislabeled.

• When vomited, it probably originates in the gastrointestinal tract

(Blood originating in the stomach is usually darker (Acidic pH)than blood from the respiratory tract (Alkaline pH) and may be

mixed with food particles)

• Factors helping in differential diagnosis:

–

Amount – Duration of bleeding

– Patients age

– Smoking history

– Accompanying findings: weight loss, fever, chest pain

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Hemoptysis: causes based on site of origin

Tracheobronchial tree:

Bronchitis : Blood streaking of purulent sputum

bronchiectasis (Cystic fibrosis): chronic copious sputum prodn

Bronchogenic carcinoma: Smoking, Asbestos exposure

Lung Parenchyma:

Pneumonia: Fever chills with Blood streaking of purulent sputum

Cavitatory tuberculosis

Lung abscess: Putrid smell of sputum

Pulmonary Vasculature:

Pulmonary embolism: Chest pain, dyspnea with hemoptysis

Pulmonary AV malformations

Trauma

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Chest Pain- way of presentation

A clenched fist over the sternum suggests angina pectoris

A finger pointing to a tender area on the chest

wall suggests musculoskeletal pain

A hand moving from neck to epigastrium suggestsheartburn.

Anxiety is the most frequent cause of chest painin children, along with costochondritis.

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Chest Pain

•

May arise from thoracic organs, pleura, diaphragm,chest wall & overlying skin

• Quality and location of pain are related to sensory

innervation of lesion: visceral cardiac & somatic

pleuritic pain

• Chest pain attributable to lungs results from pleural

involvement (Chest wall and parietal pleura

supplied by intercostal and phrenic nerves).• No pain receptors in the lung parenchyma.

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Anatomy of Pleuritic pain

• Costal & Peripheral

diaphragmatic pleura

supplied by Intercostal

nerves. Pain is felt in thoracoabdominal wall

• Mediastinal & Central

diaphragmatic pleura

supplied by Phrenic nerve.Referred to root of neck and

shoulder (C3-5 dermatome)

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Pleuritic Chest Pain- attributes

Onset: Instantaneous If trauma, MSK. Hours to days If inflammation of pleura

Location : anywhere in chest wall but well localized. Pain due to pericarditis is

retrosternal

Duration: constant

Character: sharp pain

Aggravating/Alleviating : on inspiration, movement of chest wall. Pericardial

pain worsens on lying and improves on sitting forward

Associated manifestations: dyspnoea, cough, leg pain, swelling etc

Radiation: may radiate to neck or shoulder. Pericardial pain radiates to back

Timing: How often did (does) it come? What circumstance and time of the

day does pain comes?

Severity/ Quantity: on a scale of 1 to 10. mild to severe pain

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Chest pain: Respiratory Causes

• Sudden acute pain: pneumothorax, rib #, pulmonary

embolism

• Rapid onset, progressive over days with

inflammatory signs of fever, sweats,chills, myalgia:acute infectious pneumonia

• Chronic pain: TB, cancer, ILD

•

Point tenderness over rib: rib fracture • Point tenderness over costochondral junction:

costochondritis

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Chest Pain:Cardiac, Pulmonary, gastrointestinal, musculoskeletal,

psychosomatic etc

Organ Conditions

Heart Angina, Myocardial infarction (MI),

Pericardium Pericarditis

Aorta Aortic dissection.

Trachea & large bronchi Tracheobronchitis

Parietal pleura Pneumonia, pleuritis, Pericarditis etc

Esophagus Reflux, Esophagitis

Chest wall Costochondritis, Herpes zoster

Extra thoracic structures Neck-Cervical arthritis, Gallbladder- Biliarycolic, Stomach-Gastritis.

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Wheezing:

Wheezes are musical respiratorysounds that may be audible

both to the patient and to

others.

suggests partial airwayobstruction from secretions,

tissue inflammation, or a

foreign body.

Do not confuse with inspiratory

stridor (harsh, loud sound) seen

in laryngitis (croup).

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Associated Symptoms

• Fever

• Hoarseness

•

Appetite & Weight loss• Weakness/fatigue

• Night sweats

•Anxiety

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Drug history

• NSAID’s: Asthma

• ACE inhibitors: Cough

•

Antineoplastic agents like busulfan,bleomycin: Pulmonary fibrosis

• Use of inhalers (assess compliance and technique).

• Use of steroids (some measure of severity in

asthma).

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History of Allergy

• Food

• Inhaled allergens

•

Particular drugs• Cold air

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Past history:

previous consultation for similar problem, a previous diagnosis andany previous treatment .

often the past history that gives the clue to the aetiology

• Childhood asthma, wheezing or 'bronchitis'.

• Malignant disease (pulmonary metastases).• Infections including pneumonia, tuberculosis & whooping cough.

• Chest trauma and operations.

• Thromboembolic disease, specifically deep vein thromboses and

pulmonary embolus.

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Family history:

• Cystic fibrosis• Alpha 1 AT deficiency- emphysema

• Atopic diseases such as hay fever and eczema.

•

Asthma• Infectious diseases such as tuberculosis, pneumonia

(remember high risk groups).

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Personal & social History

•Tobacco use: No. of pack years, age at onset, passive smoking

• Occupational history- asbestos, silica, coal dust etc

• Toxic and environmental Exposures

• Presence of household pets- dog, cat, birds etc

• Sexual history may be relevant to risk of HIV and AIDS.

• Travel history: clues to diagnosis of atypical infections

– TB in developing countries,

– histoplasmosis in Ohio & Mississippi river valleys,

– coccidiomycosis in desert southwest etc.

– Long duration flight travel- DVT, Pulmonary embolism

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Tobacco cessation

• Smoking is the leading preventable cause of death,

accounts for 1 in 5 deaths each year in united states

• Assessment of readiness to quit smoking- 5 A’s

1. ASK-about smoking at each visit2. ADVISE patients regularly to stop smoking using

a clear, personalized message

3. ASSESS patient readiness to quit

4. ASSIST patients to set stop dates and provide educationalmaterials for self-help

5. ARRANGE for follow-up visits to monitor and

support patient progress

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Immunizations (adults)

• ‘Flu shot’- influenza (every year) and pneumococcal

vaccines. All those who wishes to reduce risk of

infection especially

•Adults with chronic illness

• Residents of nursing home and care facilities

• Health care personnel

•

Immunosuppressed adults.. etc

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Common Clinical Conditions

• Pneumonia – Acute illness with productive cough. Sputum mucoid or purulent, may

be blood streaked or rusty. May be associated with chills, high fever,dyspnea, and chest pain.

• Chronic Bronchitis – chronic productive cough for 3 months in each two successive years;

sputum mucoid or purulent may be blood streaked even bloody.Dyspnea and wheezing may develop. Long standing history ofsmoking.

• Asthma – Episodic dyspnea and wheezing. Cough with thick mucoid sputum.

History of allergy

•

Pulmonary embolism – Acute onset of dyspnea, pleuritic chest pain, cough, hemoptysis etc.

H/O Prolonged bed rest, surgery, CHF, trauma, air travel etc

• Cancer of Lungs – Cough dry to productive; sputum may be blood streaked or bloody.

Long history of smoking. Anorexia, weight loss etc

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