HISTORY TAKING AND GENERAL EXAMINATION

OF RESPIRATORY SYSTEM

Seminar Presented by: Dr Himanshu

Rana (JR-3)
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
• Symptoms
• Cough
• Sputum production
• breathlessness
• Chest Pain
• Hemoptysis
• Wheeze / Stridor
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.
Acute cough (<3 wks)
• Upper respiratory tract infections
• Pneumonia
• Pulmonary embolism
• Congestive Cardiac Failure
Subacute cough (3- 8 weeks)
• Viral infections
• Post infective
• Post nasal drip
• GERD
Chronic cough >8 wks
• Pulmonary Tuberculosis
• Bronchial Asthma
• COPD
• Bronchogenic carcinoma
• Eosinophilic bronchitis
• Post nasal drip
• GERD
• Drugs like ACE inhibitors
• Congestive cardiac failure
Nocturnal cough
• Post nasal drip.
• GERD
• Chronic brochitis.
• Bronchial asthma.
• Obstructive sleep apnea
• Left Ventricular Failure
• Aspiration
Sputum
• Consistency
• Amount
• Color
• Postural variation
• Smell
Consistency
• Serous - Upper Respiratory tract Infection,
Bronchoalvelolar carcinoma
• Mucoid - Chronic bronchitis, Bronchial Asthma
• Mucopurulent - Bacterial infection
 Amount
Copious Amount
– Bronchiectasis
– Lung Abscess
– Necrotizing pneumonia
– Alveolar cell carcinoma
– Empyema rupturing into bronchus

(Bronchorrhoea - >100ml sptum/day)

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.
Postural variation
– Lung Abscess
– Bronchiectasis
Foul Smell
– Lung abscess
– Bronchiectasis
– Anaerobic bacterial infection
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)
• Onset
• Duration
• Severity
• Aggravating and relieving factors
• Postural variation
• Diurnal variation
 Onset
Within minutes
– Pneumothorax
– Pulmonary embolism
– Inhalation of foreign body
– Larygeal edema
– Left heart failure
Hours to Days
– Acute Respiratory Distress Syndrome
– Bronchial Asthma
– Pneumonia
– Left heart failure
Weeks to Months
– COPD
– ILD
– Pleural effusion
– Anemia
– Thyrotoxicosis
– Left ventricular failure
 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.

• Aggravating factors
– Exposure to allergen
– Exercise
– Drugs
– Cold whether

• Relieving factors
– Medication
– Rest
– Removal of allergen
Diurnal and postural variation
– Bronchial asthma
– Lung abscess
– Bronchiectasis
 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
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.
 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

 Causes of hemoptysis
Infection-
– TB
– Lung Abscess
– Bronchiectasis
– Pneumonia
– Fungal infection (aspergillosis blastomycosis)
Neoplasm-
– Bronchogenic ca
– Bronchial adenoma
– Metastatic tumour
CVS
– MS
– PHT
– Pulmonary embolism
– AV malfromation
• Collagen vascular disorder
– Vasculitis
– Wegener’ s granulomatosis
– Microscopic polyangitis
– Churgstrasuss syndrome
– Goodpastures’s syndrome
• Traumatic
• Iatrogenic.
• Bleeding disorder
Chest Pain
• Site
• Onset
• Duration
• Severity
• Character
• Radiation
• Associated symptoms
• Aggravating/Relieving factor
• Diurnal /seasonal variation
• Retrosternal Pain :-
causes
• Upper
– Tracheatis
• Mid and Lower
– Mediastinitis
– Mediastinal tumor
– GERD
– Achalasia cardia
• Diffuse esophageal spasm
• 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”

• General Examination
• General condition
• Vitals
– Temperature
– Pulse
– Respiratory Rate & Breathing pattern.
– Blood pressure
• Pallor
• Icterus
• Cyanosis
• Clubbing
• Lymphadenopathy
• Pedal oedema
• Built
• Nourishment
• Tripod position
• Purse lip breathing
• Paraneoplastic syndrome
– Cushing’s syndrome
– Gynecomastia
– Carcinoid syndrome
Pulse
• Bradycardia - Hypoxia.
• Tachycardia - Pneumonia, Pulmonary
Embolism, ARDS
• Unequal - Pancost Tumour , Mediastinal
syndrome.
• Pulsus Paradoxus – Acute severe asthma,
COPD.
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
 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

Pallor
• Chronic Infections – TB
• Chronic inflammatory disorders – interstitial
lung disease, connective tissue disease.
• Malignancies.
Icterus
– Cor pulmonale
– Iatrogenic – Anti Tubercular Medications
– Metastasis to Liver
– Pulmonary infarction.
– Sepsis – secondary to chest infection.
Cyanosis
Respiratory disorders
– Acute severe Asthma
– Tension Pneumothorax
– Pulmonary AV malformations
– Acute laryngeal oedema
– ARDS
Lymphadenopathy
• Sites
• Number
• Tender/Non-tender
• Discrete/matted
• Consistency
• Fixed/Mobile
• Overlying skin
• Sinus
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.
Causes-
• URI
• Tuberculosis
• HIV
• Sarcoidosis
• Lung Carcinoma
• Lymphoma
• Secondaries
Clubbing
Causes
• Bronchogenic carcinoma
• Bronchiectasis
• Lung abscess
• Empyema
• Cystic fibrosis
• Interstitial lung disease
• Congenital
• Unilateral clubbing — Pancoast tumour
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

Pedal Edema
• Cor Pulmonale
• Chronic infections / inflammations –
secondary to hypoalbuminemia.
• A/w renal involvement –
– Wegener’s granuomatosis
– Polyarteritis nodosa
– Microscopic polyangitis
– Goodpasture syndrome
Miscellaneous
• Scleroderma - nail bed telengectasias,
raynod’s phenomenon, calcinosis cutis
• Sarcoidosis – lupus pernio