Respiratory System

History & Physical examination

Mohan Kumar
MBBS,MD
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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 youre 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 uid 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 in
the respiratory tract.
Although cough typically signals a problem in the
respiratory tract, it may also be cardiovascular in origin.
Stimuli-
Mechanical: Foreign body, pus, mucus, blood etc
Inflammation: of the respiratory mucosa
Chemical : 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 as
in 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 of
Pulmonary edema.

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Investigations
History & Physical examination
Chest radiography: Mass lesion, parenchymal
opacification, interstitial disease, honey combing,
lymphadenopathy
Pulmonary function testing (PFTs): 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 or
hematemesis- 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 suggests
heartburn.

Anxiety is the most frequent cause of chest pain
in 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 thoraco
abdominal 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- Biliary
colic, Stomach-Gastritis.

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Wheezing:
Wheezes are musical respiratory
sounds that may be audible
both to the patient and to
others.
suggests partial airway
obstruction 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
NSAIDs: 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 and
any 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 As
1. ASK-about smoking at each visit
2. 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 educational
materials 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 of
smoking.
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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