Respiratory System

Presenting symptoms: (N.B. Very likely to be a resp history taking

station- asthma, COPD, TB)

1. Cough and Sputum

N.B. Duration is important
 Acute + fever= RTI (acute bronchitis/ pneumonia)
 Chronic (>8 Wks) + wheezing = asthma
*Table pg 108: ddx based on character and ddx based on duration
* remember to ask about sputum ( colour, quantity, smell, taste, blood)
2. Haemoptysis
N.B. DISTINGUISH FROM HAEMATEMESIS
 Mild: <20mL/24hours- blood streaked sputum
 Massive: >250mL/24hours- medical emergency
 Carcinoma, CF, Bronchiectasis, TB
*table pg 109: Ddx
3. Dyspnoea
N.B Resp/ Cardiac causes
NYHA functional Class:

Class1 Disease present w/o dyspnoea

Class 2 Dyspnea on moderate exertion
Class 3 Dyspnea on mild exertion
Class 4 Dyspnoea at rest

*Determine amount of steps/ distance patient can walk

*Causes: Table pg. 110; ddx + COPD :pg 111; pg 112

 Dyspnea+ wheeze =asthama/COPD

 Progressive= interstitial lung disease
 Rapid onset= acute resp infxn
 Acute onset= pneumothorax
4. Wheeze
 Asthma/ COPD
 Bronchiolitis
 Obstruction: foreign body/tumour

*expiration
 5. Chest pain
 Pleural pain: pleuritic in nature (sharp and made worse by deep inspiration and
coughing); typically located to one area of chest.
 May be sudden onset: lobar pneumonia, PE + infarction, pneumothorax
 Often associated with dyspnea
 Urgent diagnostic problem- all these conditions are life-threatening.
6. Other
 Bacterial pneumonia: acute, fever, malaise and myalgia, pain and dyspnea
 Viral pneumonia: preceded by longer prodromal illness
 Constitutional symptoms: TB, Pneumonia, Lymphoma
 Dysphonia: laryngitis
 Sleep apnoea: daytime somnolence, chronic fatigue, morning headaches and personality
disturbances. Often obese and hypertensive. Snoring.

Other aspects of history which are important in a resp patient:

1. Treatment:
*drugs: inhaled/swallowed
 Previous/ current meds- clue to dx
 Bronchodilators and inhaled steroids- asthma, COPD
 Oral steroids: predispose to TB, PCP
 CF/ bronchiectasis: knowledgeable about diseases

*table: pg 113- drugs and the lungs

2. Past History
 Prev resp illness: pneumonia, TB, Chronic bronchitis
 HIV: increased risk of PCP, TB and other lung infections.
 N.B. ask about tests such as spirometry
 TB: on treatment, what treatment, how long on treatment, how was it diagnosed?
3. Occupational history
 Occupational lung diseases cause interstitial lung disease
 N.B Asthma
 Exposure to dusts in mining industries and factories
 N.b. what does patient actually do when at work, duration of exposure, use of
protective devices.
4. Social history
 Smoking: COPD and lung cancer (Pack year)
 Alcohol: aspiration pneumonia, pneumococcal/ klebsiella pneumonia
  IV drug users: lung abscesses, drug-related pulmonary oedema
5. Family history
 Asthma, atopic diseases, CF, lung cancer/ emphysema
 TB contacts
 Carcinoma of lung
 Pulmonary hypertension

RESPIRATORY EXAMINATION:
1. Undress patient to waist. Sitting at edge of bed or on chair.
2. General appearance: (from foot of bed)
 Surroundings: O2, inhalers, sputum mug
 Dyspnoea: RR, use of accessory mm, alar flaring
 COPD: Accessory mm (increase chest expansion), indrawing of intercostal and
subclavicular spaces, pursed-lips, leaning forward- arms on knees, tracheal tug.
3. Cyanosis:
 Tongue (central vs peripheral)
 V/Q mismatch
 Pneumonia, COPD, PE
 Severe hypoxaemia: O2 Sats <90% in person with Normal Hb level.
4. Ask patient to cough
 Muffled and wheezy: obstructive pulm dz
 Loose and productive: chronic bronchitis, pneumonia, bronchiectasis
 Dry, irritating: chest infxn, asthma, bronchus carcinoma, LVF, ACE-I
 Barking/ croupy: pharynx, larynx, pertussis
5. Examine sputum if it is available
6. Stridor: larynx/ trachea obstruction, inspiration
 Foreign body, tumour, infxn or inflammation.

The hands:
1. Clubbing
2. Staining: tar
3. Wasting and weakness
 Compression and infiltration of T1 nerve root by peripheral lung tumour: wasting of
small mm of hand and weakness of finger abduction
4. PR
 Tachycardia and pulsus paradoxus: severe asthma
 Tachycardia: B-blockers
 Tachycardia assoc. with dyspnea and hypoxia
5. Flapping tremor (asterixis)
  Dorsiflex wrist with arms outstretched
 Flapping
 CO2 retention- COPD

The face:
1. Mouth:
 Evidence of URTI (redness, pus)
 Dental hygiene
 Tenderness over sinuses- sinusitis
 Red, leathery, wrinkled skin: smoker
 Facial plethora
 Eyes: Horners Syndrome- constricted pupil, partial ptosis, loss of sweating. Can be due
to an apical lung carcinoma (SNS nerves in neck)
 Skin changes: scleroderma, CT-disease

Trachea:
Causes of displacement:

 Towards side of lung lesion: Upper lobe collapse, upper lobe fibrosis, Pneumonectomy.
 Away (uncommon): Massive pleural effusion, Tension Pneumo
 Upper mediastinal masses (retrosternal goiter)

The chest:
(anteriorly and posteriorly: I,P,P, A)

1. Inspection: NB! NB! NB! Must start at foot of bed before going around to side of bed.
 Shape and symmetry (barrel-shaped :asthma, COPD, emphysema)
-kyphoscoliosis
-pectus carinatum
-pectum excavatum
 Lesions of chest wall (thoracic operations, chest drains)
 Prominent veins: SVC obstruction
 Movement of chest wall: asymmetry (affected side: delayed/ decreased movement)
 NB: lower lobe expansion assessed posteriorly
 Asymmetrical: localized lung fibrosis, consolidation, collapse, pleural effusion or
pneumothorax.
 Bilateral: COPD, diffuse interstitial lung disease
 Paradoxical abdominal movements
2. Palpation:
 Chest expansion: decreased expansion on one side=lesion on that side
o Hoover’s sign – inward movement of fingers on inspiration
 With COPD
  Apex beat: impalpable in hyperexpanded chest.
: displacement towards side of lesion- collapse of lower lobe
: away from lesion: pleural effusion, tension pneumo
 Vocal fremitus: (see vocal resonance)
 Ribs: gently compress wall anteroposteriorly and laterally. Localised pain- rib
fracture. Costochondritis.
 Examine LN’s (axillary, cervical and supraclavicular)
3. Percussion:
 supraclavicular fossa + clavicle = apex
 posteriorly: rotate scapulae anteriorly
 stony dull: pleural effusion
 hyperresonant: pneumothorax
 liver dullness: upper border 5ICS, If chest is resonant below this level=
hyperinflation (hepatosis)
4. Auscultation:
 See diagram 5.11- pg 125 for where to auscultate
 Breathe through the mouth
 Normal= vesicular breathing
 Bronchial breathing= areas of consolidation
Causes: lobar pneumonia, localized pulm fibrosis, above the fluid in pleural effusion,
collapsed lung.
Amphoric breathing
 Normal/ reduced
 Reduced: COPD, Pleural effusion, pneumo, large neoplasm, pulmonary collapse,
bronchial obstruction.
 Added sounds: wheezes and crackles.
- Wheezes imply significant airway narrowing, louder on expiration: Asthma,
COPD
- Crackles: early inspiratory- disease of small airways: COPD
- Late inspiratory: disease confined to alveoli
*fine crackles: pulmonary fibrosis (Velcro)
* medium: LVF
* coarse: gurgling quality. – bronchiectasis

- pleural friction rub: pleurisy

 Vocal resonance: increased= consolidation

*CVS and GIT examinations are essential conjuctive exams.

*Pemberton’s sign: ask patient to lift arms over head and wait for one minute. Note development of
facial plethora, cyanosis, inspiratory stridor and non-pulsatile elevation of JVP= SVC obstruction.
*legs: swelling, cyanosis, DVT

*fever: acute/ chronic chest infection