RESPIRATORY HISTORY AND EXAMINATION History 6 principle symptoms are, Cough Sputum Production Haemoptysis Chest Pain Breathlessness

ssness Wheeze

All can occur in the absence of respiratory disease. For eg, in AMI, breathlessness, wheeze and chest pain can occur due to pulmonary edema. Many respiratory conditions share the same combination of symptoms but the mode of onset, duration, progression and severity of each symptom differ. So need to explore each symptom in relevant detail. COUGH Most common symptom of respiratory disease Acute episodes are caused by infections and mainly viral. Cough >> an involuntary reflex to remove secretions or particles from the pharynx and airways. Sound of the cough and the circumstances in which it happens is important.

Sound of Cough Feeble, non explosive cough with hoarseness may occur with resp muscle weakness or with lung cancer invading the left recurrent laryngeal nerve (resulting paralysis) Asthma or COPD cough is usually prolonged and heard with a wheeze. May be associated with syncope due to the prolonged increase of intra-throacic pressure. Barking quality /Hoarse >> Laryngeal inflammation, infection and tumor. May be seen with stridor (inspiratory wheeze). Moist cough indicates secretions and occurs with bronchial infection and bronchiectasis. Persistent smokers moist cough in the morning is typical of chronic bronchitis. Any change in this pattern >> think abt possibility of Bronchiogenic carcinoma.

Circumastances of the cough Nocturnal Cough >> think Asthma. Daytime cough, after a meal >> think GORD Daytime cough >> Chronic sinus disease with post nasal drip. ACE Inhibitors >> dry cough (SE). Coughing after swallowing >> Neuromuscular disease of the oropharynx. Worse on weekdays and better on weekends >> think Occupational etiology >> Allergic cough due to ? Any sounds after cough ? Like Whooping >> Pertussis

SPUTUM White Yellow Green Rusty Red

Need to ask about Amount o Large amounts of purulent sputum influenced by posture is characteristic of Bronchiectasis o Large volumes of watery sputum with a pink tinge in a dyspnoeic patient indicates pulmonary edema. o Large volumes of watery sputum for weeks is a Sx of alveolar cancer. Color o Clear or Mucoid Usually by COPD patients without active infection. Yellow o Acute Lower Respiratory Tract Infection and in Asthma Green o Dead neutrophil, chronic infection as in exacerbation of COPD, bronchiectasis. Rusty Red o Pneumococcal Pneumonia o Why? o Pneumonic Inflammation passes thru the red hepatization phase.

Smell Foul suggest anaerobic infection. HAEMOPTYSIS Coughing up blood. Need to know whether its from the respiratory system or it has been vomited or been in the mouth without coughing. Impt and shd always be investigated.

Causes of Haemoptysis. Tumor Infection: Bronchiectasis, TB, Lung Abscess, CF Vascular Vasculitis Trauma: Inhaled foreign body, chest trauma, iatrogenic Cardiac: Mitral Valve Disease, Acute LVF Hematological: Anticoagulation Need to know Amount and appearance Duration and frequency

Amount and appearance Clear sputum with blood or blood clots in the sputum for more than a week is suggestive of lung cancer. Seen with purulent sputum, suggest an infective cause such as bronchiectasis. Diffuse staining of blood with froth suggest pulmonary edema. Just coughing up blood is life threatening >> Bronchiectasis, TB and Lung Cancer.

Duration and Frequency Intermittently for a few years, usually with infection >> bronchiectasis Daily for a week or more >> Sx of lung cancer, TB and Abscess.

CHEST PAIN Pleura, Chest wall or Mediastinal Structures.

Need to ask SOCRATES! Pleuritic Pain Typically sharp Stabbing Worse on inspiration and coughing. Can radiate to the shoulder tip, neck or abdomen. Chest Wall Pain Respiratory or Musculoskeletal Disease Mimics Pleuritic Pain. Sudden onset of localized pain after vigorous coughing or direct trauma is characteristic. Dull,aching, gnawing and unrelated to respiration might indicate malignant chest wall pain. Dermatomal pain might indicate herpes zoster.

Mediastinal Pain Central Retrosternal, unrelated to respiration or cough. Dull aching pain that disturbs sleep can be a malignancy, invading lymph nodes.

Common DDx of Chest Pain Non Central Pleural Infection o Pneumonia o Bronchiectasis o TB Malignancy o Lung Cancer o Mesothelioma o Metastatic Pneumothorax CT Disease o RA o SLE

Chest Wall Malignancy Persistent cough Musscle sprain/tears Rib fracture Thoracic Shingles

Central Chest Pain Tracheal: Infection Cardiac: PE or AMI Esophageal: Oesophagitis or Rupture Mediastinal: Lung Cancer, Lymph nodes, Metastases SHORTNESS OF BREATH Mode of onset Duration Progression Variation Aggravating and Relieving Factors Severity Associated Symptoms Acute or Chronic : Progressed Fast or slow (over days, months and years) o Minutes PE Pneumothorax Acute LVF Asthma Inhaled Foreign Body o Hrs to Days Pneumonia Asthma Exacerbation of COPD o Weeks to Months Anemia

Pleural Effusion Resp Neuromuscular disorders

o Months to Years COPD Pulmonary Fibrosis TB Aggravating and Relieving Factors. Lying flat >> orthopnoea >> think of LVF Wakes up from night gasping for air >> PND >> Asthma and LVF. Any associated wheezing >> asthma. Worst thing in the morning when woken up >> COPD, better after coughing. With exercise, SOB gets worse >> Intrinsic asthma. Weekends better >> occupational exposure. Severity On patients life. Affecting function? How far can one walk? Exertional? Associated Symptoms No chest pain Pleuritic Pain Central pain. Wheeze n cough.

No chest pain Pulmonary embolism Pneumothorax Metabolic acidosis Hypovolaemia/shock Acute left ventricular failure/pulmonary oedema Pleuritic chest pain Pneumonia Pneumothorax Pulmonary embolism Rib fracture

Central chest pain Myocardial infarction with left ventricular failure Massive pulmonary embolism/infarction Wheeze and cough Asthma

COPD

Wheeze High pitched Made by air passing thru small airways. Limited to and louder during expiration. Sx of Asthma and COPD. Wheeze with night cough and SOB is characteristic of asthma Wheeze with morning cough and excessive breathing is characteristic of COPD. Need to differentiate between this and stridor, its an insipiratory noise made due to obstruction in the large airways.