Main symptoms of respiratory disease :

COUGH BREATHLESSNESS CHEST PAIN

COUGH -> ask if it is dry or does the patient cough up phlegm (sputum) ?

Causes :
Viral infections of upper respiratory tract
Smoking
Chronic bronchitis

Tuberculosis (mainly in the developing world but incidence is now increasing

in the UK )
Bronchogenic carcinoma
Asthma
Drugs ( β- blockers ; ACE inhibitors)
Psychogenic

If the cough is not dry but the patients coughs up sputum you have to enquire about its appearance
and quantity

Sputum :
1. Appearance
Non infected sputum - white, clear, like clear jelly
Infected sputum - yellow to green (green sputum is often called
‘purulent’ – looks like pus )
People working in
dusty conditions - grey to black sputum
Pulmonary oedema - copious frothy white or occasionally pink sputum
2. Quantity
Large quantities of purulent sputum all the time suggest bronchiectasis

3. Haemoptysis:
When there is blood in the sputum it is referred to as haemoptysis i.e. the coughing
up of blood.
The quantity of blood present will determine the appearance which will vary from the
mere :
1) streaking of sputum with a little blood to 2) ‘rusty’ sputum when there is more
blood coughed up (‘rusty sputum is in fact a bloody, inflammatory exudates coughed
up typically in pneumococcal pneumonia) to 3) the coughing up of fresh, frothy
blood to 4) the coughing up of copious blood with clots to 5) massive bleeding.
Causes of haemoptysis :
Infection : bronchiectasis ; pneumococcal pneumonia; tuberculosis
Infarction : pulmonary embolism
Neoplasia : bronchogenic carcinoma
Cardiac : pulmonary oedema ; mitral stenosis
BREATHLESSNESS

- the rate and mode of onset might give you a clue as to the underlying pathology :

1. Very sudden onset ( minutes)

Pneumothorax; Pulmonary embolus; Pulmonary oedema
2. Acute (hours)
Pneumonia; Asthma; Left ventricular failure
3. Sub acute ( days)
Pleural effusion; Bronchogenic carcinoma; sarcoid
4. Chronic ( over months or years)
COPD / emphysema
Diffuse fibrosing conditions
Non-pulmonary causes – anaemia
5. Intermittent episodes
Asthma ; LVF

– circumstances; occurrence

- Made worse by lying flat (orthopnoea) – suggests left ventricular failure

- Nocturnal waking with choking breathlessness – suggests left ventricular failure

- Nocturnal waking with cough and wheezing – suggests asthma

- Sudden episodes of breathlessness and wheezing triggered by a variety of factors –

suggests asthma

- Exertional breathlessness progressing rapidly - suggests heart failure

- Exertional breathlessness progressing over years - suggests diffuse pulmonary disease

like fibrosing alveolitis or emphysema

CHEST PAIN (discussed in some detail on sheet about chest pain in ‘CVS symptoms 2’)

The typical chest pain associated with chest disease is PLEURITIC PAIN.
Typically pleuritic pain is :
Sharp
Stabbing, like a knife
Localised
Made worse by deep breathing, coughing, sneezing and movement of the chest

It is probably due to friction between two roughened pleural surfaces and stretching of the inflamed
parietal pleura.
 Where felt?
- Over intercostal spaces over the involved pleura
- Side of neck and shoulder tip in diaphragmatic pleurisy ( sensory nerve supply to
the diaphragm comes from cervical segments 3&4 so the pain from the diaphragmatic pleura is
referred to the skin over the shoulder and side of the neck)

N.B. Occasionally in sub-acute situations e.g. when a pleural effusion develops slowly after post
pneumonic pleurisy, the pain may not be as localised as suggested above and may be felt more
diffusely. What makes it likely to be a pleuritic pain is that it is almost invariably affected by
position, movement and actions that cause movement of the pleural surfaces like coughing,
sneezing, or taking a deep breath. Careful questioning about what affects the pain, what makes it
better and what makes it worse will usually reveal this relationship.

Causes :

Infection : most often associated with pneumonia

Non-infective
inflammation : SLE ; RA

Infarction : pulmonary embolus;

Neoplasia : infiltration of pleura by tumour ( primary or metastatic)