Clinical assessment chest symptoms

1. 3- Respiratory system
History taking
Dr Doha Rasheedy
Lecturer of Geriatric Medicine
Department of Geriatric and Gerontology
Ain Shams University

2. Symptoms of chest case
1- Cough.
2- Expectoration.
3- Chest pain.
4- Haemoptysis.
5- Dyspnea.
6- Toxic symptoms.
7- wheeze.
8- Oedema of lower limb.
9- Mediastinal compression.
10- Cyanosis.
11- Pain in the right hypochondrium.
12- Any other positive symptoms of other systems.

3. COUGH.

4. Analysis of cough
• Timing
• duration
• Posture
• Character
• Severity
• Expectoration or dry
• Associated symptoms

5. a- Time of cough:
• Early morning, e.g.: In chronic bronchitis
• Night, e.g.: in P.N.D (P.V.C)
• All over the day, e.g.: in chest infection

6. Duration of cough
• acute, defined as lasting less than three
weeks
• subacute, lasting three to eight weeks
• chronic, lasting more than eight weeks

7. • Acute: common cold, pertussis, allergic
rhinitis, acute bacterial sinusitis, exacerbation
of COPD, hypersensitivity pneumonitis,
aspiration, infectious pneumonia
• Subacute: Postinfectious cough, rhinitis,
tracheobronchitis, Asthma, subacute bacterial
sinusitis
• Chronic: COPD, TB, Bronchiectasis,
Bronchogenic carcinoma, Asthma, GERD,
ACEis

9. Cough of suppurative lung diseases or cavitary
syndrome:
– Cough with huge amount of yellow-greenish
fetid sputum.
– Cough and expectoration are related to
posture.
Cavitary or Suppurative Lung Disease
Includes:
1- Bronchiectasis.
2- Lung abscess.
3- Empyema with broncho - pleural fistula.

10. Some characteristic coughs
– Laryngitis: Cough with a hoarse voice.
– Tracheitis: Dry and very painful.
– Pleurisy: Sharp pain (chest wall)
– Post-nasal drip: Tickly
– Asthma: Chronic, paroxysmal, worse after exercise and at night
– Oesophageal reflux Dry and nauseating. Often first thing in the
morning.
– Tracheo-oesophageal fistula (rare) Nauseating and worse after eating
– Epiglottitis: Barking
– Laryngeal nerve palsy: hollow, brassy
– Left heart failure:Productive and worse on lying flat

11. Associated
• Fever
• Wheeze
• Toxic manifestation
• expectoration

12. EXPECTORATION

13. Expectoration
• Comment on :
– Amount
– Colour
– Odour
– Consistency
– Relation to time
– What ↑, ↓
– Relation to posture
– hemoptysis

14. Amount
• Regular coughing up of large volumes of purulent
sputum influenced by posture is characteristic of
bronchiectasis.
• The sudden production of large amounts of purulent
sputum on a single occasion suggests the rupture of a
lung abscess or empyema into the bronchial tree.
• Large volumes of watery sputum with a pink tinge in an
acutely breathless patient suggests pulmonary oedema,
• whereas large volumes of watery sputum for weeks
(bronchorrhoea) is a symptom of alveolar cell cancer.

15. colour
• Clear or 'mucoid' sputum is produced by patients with COPD without
active infection.
• Yellowish sputum is found in acute lower respiratory tract infection
(live neutrophils) and also in asthma (eosinophils).
• Green sputum (dead neutrophils) indicates chronic infection as in
exacerbations of COPD, bronchiectasis, etc. Purulent sputum is
usually green because of the presence of lysed neutrophils and their
breakdown products, specifically the green-pigmented enzyme
verdoperoxidase. The first sputum produced in the morning by a
patient with COPD may be green because of nocturnal stagnation of
neutrophils.
• In the early stages of pneumococcal pneumonia sputum may be a
characteristic rusty red colour as pneumonic inflammation passes
through the red hepatization phase.
• In coal miners with pneumoconiosis the rupture of necrotic areas of
pulmonary fibrosis can result in the expectoration of black sputum
(melanoptysis).

17. • Mucoid Asthma, tumors, tuberculosis, emphysema, pneumonia
• Mucopurulent Asthma, tumors, tuberculosis, emphysema, pneumonia
• Yellow-green, purulent Bronchiectasis, chronic bronchitis
• Rust-colored, purulent Pneumococcal pneumonia
• Red currant jelly Klebsiella pneumoniae infection
• Foul odor Lung abscess
• Pink, blood-tinged Streptococcal or staphylococcal pneumonia Gravel
Broncholithiasis
• Pink, frothy Pulmonary edema
• Profuse, colorless (also known as bronchorrhea) Alveolar cell carcinoma
• Bloody Pulmonary emboli, bronchiectasis, abscess, tuberculosis, tumor,
cardiac causes, bleeding disorders

18. Taste or smell
• 'Foul' or 'vile' tasting or smelling sputum
suggests anaerobic bacterial infection and
can occur in bronchiectasis, lung abscess
and empyema.
• In some patients with bronchiectasis a
change of sputum taste indicates an
infective exacerbation

19. HAEMOPTYSIS

20. Haemoptysis
• It is important to determine whether the blood has been
coughed up from the respiratory tract, been vomited from
the upper gastrointestinal tract or has suddenly
appeared in the mouth without coughing, suggesting a
nasopharyngeal origin.

22. Comment on
• Amount
• Duration
• Frequency
• Character
• Associated symptoms

23. • Ccc: a small or large amount of pure blood. Streaking of clear sputum
with blood or the presence of blood clots in the sputum.
• Haemoptysis with purulent sputum suggests an infective cause such
as bronchiectasis.
• Diffuse staining of sputum with blood (pink froth) can occur in acute
pulmonary oedema.
• Coughing up large amounts of pure blood is fortunately rare but
potentially life-threatening; the most frequent causes are
bronchiectasis, tuberculosis, and lung cancer.
• Haemoptysis occurring intermittently for a few years, usually in
association with a respiratory tract infection occurs in bronchiectasis.
• Daily haemoptysis for a week or more is a common symptom of lung
cancer, other causes include tuberculosis and lung abscess.
• Single episodes of haemoptysis may need immediate investigation if
they are very large or associated with symptoms, e.g. pleuritic chest
pain and breathlessness suggesting pulmonary thromboembolism
and infarction.

24. Causes of haemoptysis
Tumour: Lung cancer, endobronchial metastasis,
carcinoid
Infection bronchiectasis, tuberculosis, and lung abscess
Vascular pulmonary infarction, arteriovenous malformation
Vasculitis Wegener's granulomatosis, Goodpasture's
syndrome
Trauma Inhaled foreign body,
Iatrogenic: bronchoscopic biopsy
transthoracic lung biopsy
bronchoscopic diathermy
cardiac Mitral valve disease. Acute left ventricular failure
heamatological Blood dyscrasias, Anticoagulation

25. CHEST PAIN

26. Chest pain
• Chest pain related to pulmonary disease
usually results from involvement of the
chest wall , mediastinal structures or
parietal pleura.
• Comment on:
– Site, radiation
– Character
– What ↑,↓
– Duration
– Associated symptoms

27. • Pleuritic pain is typically sharp, stabbing and always intensified by inspiration or
coughing.
– parietal pleura of the upper six ribs is perceived as a localized pain
– irritation of the parietal pleura overlying the central diaphragm is referred to the neck or shoulder tip.
– The lower six intercostal nerves innervate the parietal pleura of the lower ribs and the outer diaphragm,
pain referred to the upper abdomen.
• Mediastinal pain Mediastinal pain is typically central, retrosternal and unrelated to
respiration or cough.
– pain originating from the tracheobronchial tree due to infection or inhalation of irritant dusts is typically
retrosternal, with a raw burning character, and is greatly worsened by cough
– . A dull aching retrosternal pain that progresses to disturb sleep can be a feature of malignancy
invading mediastinal lymph nodes or enlarging thymoma.
– Massive pulmonary thromboembolism sufficient to induce an acute increase in right ventricular
pressure may produce central chest pain identical to myocardial ischaemia.
• Chest wall pain: may indicate respiratory or musculoskeletal disease. patients with
chronic cough or breathlessness develop a generalized feeling of chest tightness or
diffuse pain.

28. Causes of chest pain

30. DYSPNEA

31. Dyspnea
• Dyspnea occurs whenever the work of
breathing is increased
• Dyspnea may be due to diseases of
bronchi, lungs, pleura or thoracic cage,
cardiac failure, increased demand for
oxygen, neurological diseases and
psychogenic causes.

32. Comment on
• Onset
• Progression
• Frequency (Pulmonary embolism, asthma)
• Severity
• Exertional, positional
• Associated symptoms

34. Variability, aggravating/relieving factors
• Left ventricular failure and respiratory muscle weakness commonly present
with breathlessness when lying flat (orthopnoea). This is due to inability of
the left ventricle to compensate for the normal increased venous return to
the heart on lying down or to embarrassment of the diaphragm in respiratory
muscle weakness. However, orthopnoea can be a feature of any severe
lung disease.
• Breathlessness that wakes the patient from sleep is typical of asthma and
left ventricular failure (paroxysmal nocturnal dyspnoea). Patients with
asthma are typically awoken between 3 and 5 a.m. and have associated
wheezing.
• Breathlessness that is worst first thing on waking in the morning is more
typical of COPD and may settle after coughing up sputum.
• Patients with exercise-induced asthma may notice that their breathlessness
continues to worsen for 5-10 minutes after stopping activity.
• If asthma is suspected ask directly whether exposure to allergens (e.g.
animals, shaking bedding, mowing the lawn), irritants with smoke,
perfumes, fumes, cold air or drugs (e.g. aspirin) or non-steroidal anti-
inflammatory drugs is associated with breathlessness.
• Breathlessness that improves at the weekend or on holiday is suggestive of
occupational asthma or extrinsic allergic alveolitis.

35. Types of Dyspnea in Various Respiratory Diseases
1. upper respiratory obstruction: dyspnea associted with the presence
of stridor and inspiratory retraction of supraclavicular fossae.
2. Pulmonary parenchymal diseases: (Pneumonia, extensive
tuberculosis, bronchogenic carcinoma and interstitial lung diseases
such as sarcoidosis and pneumoconiosis): There is tachypnea. The
respiratory movements may be shallow. Respiratory failure may
develop and this manifests as central cyanosis, mental confusion
and flapping tremors.
3. Bronchial asthma: Acute intermittent obstruction with expiratory
wheezing is typical of bronchial asthma. The attacks occur suddenly
in paroxysms, especially worsened in the early hours of the
morning. Several allergens like pollen or dust, environmental
factors, respiratory infection and anxiety precipitate the attacks.
Often the duration of dyspnea extends over several years. Family
history of asthma and other atopic disorders may be present in
many cases. Other allergic manifestations may coexist with asthma

37. 7. Diaphragmatic paralysis: Bilateral diaphragmatic paralysis
leads to dyspnea. Transverse myelitis and demyelinating diseases
such as Guillain-Barre syndrome may lead to diaphragmatic
paralysis. Pressure on the phrenic nerves by tumors gives rise to
uni-or bilateral paralysis. The patient is tachypneic. The abdominal
wall is sucked in during inspiration and this is termed paradoxical
respiration.
8. Diseases of the chest wall: Gross kyphoscoliosis and pectus
excavatum which reduce the intrathoracic volume and distort
intrathoracic structures give rise to dyspnea. The patient is
tachypneic. Expansion of the chest is asymmetrical and non-
uniform. Repeated respiratory infections and progressive changes
in the lungs lead to the development of cor-pulmonale and
respiratory failure.

40. TOXIC SYMPTOMS

41. Toxic symptoms
• Night fever
• Night sweating
• Loss of appetite
• Loss of weight
Occur with chronic inflammatory, infectious
conditions (TB, Bronchiectasis, Chronic
lung abscess).

42. WHEEZE

43. wheeze
Causes:
1. BA
2. COPD
3. airways obstruction by a foreign body,
secretion(or tumor.
4. cardiac asthma

44. Comment on
• At what age did the wheezing begin
• At rest / exercise
• Expiratory/ inspiratory
• Frequency
• Timing in the day season
• In between attacks free or not
• Allergen Are there any precipitating factors, such as
foods, odors, emotions, animals, etc.?"
• What usually stops the attack
• Family history of atopy
• Drugs: BB, NSAIDs

45. • Typically wheeze is limited to, and louder during,
expiration.
• A common mistake is failure to distinguish wheeze from
inspiratory stridor caused by the partial occlusion of a
large airway by tumour or foreign body
• It is most commonly seen in bronchial asthma and other
conditions where there is bronchial narrowing. In asthma
this symptom occurs paroxysmally. When the bronchial
obstruction is due to structural lesions, wheezing may be
constant.

46. MEDIASTINAL PRESSURE
SYMPTOMS

47. Mediastinal pressure symptoms
• Dyspnea
• Dysphagia
• Hoarsness of voice
• Cough
• Face and upper limbs edema

48. causes
• Mediastinal LN( TB, sarcoidosis,
Bronchogenic carcinoma) lymphoma
• Thymoma

49. CYANOSIS

50. cyanosis
• Central or peripheral
• Warm or cold hand
• Associated symptoms

51. SLEEP APNEA

52. Sleep Apnea
• disruptive snoring, episodes of upper airway
obstruction during sleep.(obstructive)
• Breathing pauses during sleep
• excessive daytime fatigue or sleepiness.
• chronic fatigue, morning headaches
• Unexplained Cor pulmonale
• These patients are often obese and
hypertensive
• History of neurological disorder(central)

53. LIPPER RESPIRATORY TRACT
SYMPTOMS.

55. COR PULMONALE

56. Cor pulmonale
• Manifestations:
1. Oedema L.L. usually before ascites
2. Hepatic congestion: Pain in right hypochondrium +
Jaundice.
3. G.I.T congestion = Dyspepsia.