History taking and general examination of respiratory system

1. HISTORY TAKING AND GENERAL
EXAMINATION OF RESPIRATORY
SYSTEM
Seminar Presented by: Dr Himanshu
Rana (JR-3)

2. 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

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

4. 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.

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

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

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

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

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

11. Consistency
• Serous - Upper Respiratory tract Infection,
Bronchoalvelolar carcinoma
• Mucoid - Chronic bronchitis, Bronchial Asthma
• Mucopurulent - Bacterial infection

12. Amount
Copious Amount
– Bronchiectasis
– Lung Abscess
– Necrotizing pneumonia
– Alveolar cell carcinoma
– Empyema rupturing into bronchus
(Bronchorrhoea - >100ml sptum/day)

13. 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.

14. Postural variation
– Lung Abscess
– Bronchiectasis

15. Foul Smell
– Lung abscess
– Bronchiectasis
– Anaerobic bacterial infection

16. 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)

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

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

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

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

21. 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.

22. • Aggravating factors
– Exposure to allergen
– Exercise
– Drugs
– Cold whether
• Relieving factors
– Medication
– Rest
– Removal of allergen

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

24. 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

25. 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.

26. 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

27. Causes of hemoptysis
Infection-
– TB
– Lung Abscess
– Bronchiectasis
– Pneumonia
– Fungal infection (aspergillosis blastomycosis)

28. Neoplasm-
– Bronchogenic ca
– Bronchial adenoma
– Metastatic tumour

29. CVS
– MS
– PHT
– Pulmonary embolism
– AV malfromation

30. • Collagen vascular disorder
– Vasculitis
– Wegener’ s granulomatosis
– Microscopic polyangitis
– Churgstrasuss syndrome
– Goodpastures’s syndrome
• Traumatic
• Iatrogenic.
• Bleeding disorder

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

32. causes
• Upper
– Tracheatis
• Mid and Lower
– Mediastinitis
– Mediastinal tumor
– GERD
– Achalasia cardia
• Diffuse esophageal spasm

33. • 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”

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

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

36. Pulse
• Bradycardia - Hypoxia.
• Tachycardia - Pneumonia, Pulmonary
Embolism, ARDS
• Unequal - Pancost Tumour , Mediastinal
syndrome.
• Pulsus Paradoxus – Acute severe asthma,
COPD.

37. 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

38. Examination of EYE
Finding on Examination Likely Etiology
Horner’s syndrome Pancost tumour
Phlycten, Choroid tubercule Tuberculosis
Conjunctival chemosis SVC Syndrome, CO2 narcosis
Papilloedema SVC obstruction, CO2 narcosis

39. Pallor
• Chronic Infections – TB
• Chronic inflammatory disorders – interstitial
lung disease, connective tissue disease.
• Malignancies.

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

41. Cyanosis
Respiratory disorders
– Acute severe Asthma
– Tension Pneumothorax
– Pulmonary AV malformations
– Acute laryngeal oedema
– ARDS

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

43. 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.

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

45. Clubbing
Causes
• Bronchogenic carcinoma
• Bronchiectasis
• Lung abscess
• Empyema
• Cystic fibrosis
• Interstitial lung disease
• Congenital
• Unilateral clubbing — Pancoast tumour

46. 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

47. Pedal Edema
• Cor Pulmonale
• Chronic infections / inflammations –
secondary to hypoalbuminemia.
• A/w renal involvement –
– Wegener’s granuomatosis
– Polyarteritis nodosa
– Microscopic polyangitis
– Goodpasture syndrome

48. Miscellaneous
• Scleroderma - nail bed telengectasias,
raynod’s phenomenon, calcinosis cutis
• Sarcoidosis – lupus pernio