History taking and general examination of respiratory system

History taking and general examination of respiratory system

1. HISTORY TAKING AND GENERAL EXAMINATION OF RESPIRATORY SYSTEM Seminar Presented by: Dr Himanshu Rana (JR-3)

2. 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

3. Symptoms Cough Sputum production breathlessness Chest Pain Hemoptysis Wheeze / Stridor

4. 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.

5. Acute cough (<3 wks) Upper respiratory tract infections Pneumonia Pulmonary embolism Congestive Cardiac Failure

6. Subacute cough (3- 8 weeks) Viral infections Post infective Post nasal drip GERD

7. Chronic cough >8 wks Pulmonary Tuberculosis Bronchial Asthma COPD Bronchogenic carcinoma Eosinophilic bronchitis Post nasal drip GERD Drugs like ACE inhibitors Congestive cardiac failure

8. Nocturnal cough Post nasal drip. GERD Chronic brochitis . Bronchial asthma. Obstructive sleep apnea Left Ventricular Failure Aspiration

9. Sputum Consistency Amount Color Postural variation Smell

10. Consistency Serous - Upper Respiratory tract Infection, Bronchoalvelolar carcinoma Mucoid - Chronic bronchitis, Bronchial Asthma Mucopurulent - Bacterial infection

11. Amount Copious Amount Bronchiectasis Lung Abscess Necrotizing pneumonia Alveolar cell carcinoma Empyema rupturing into bronchus ( Bronchorrhoea - >100ml sptum /day)

12. 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.

13. Postural variation Lung Abscess Bronchiectasis

14. Foul Smell Lung abscess Bronchiectasis Anaerobic bacterial infection

15. 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)

16. Onset Duration Severity Aggravating and relieving factors Postural variation Diurnal variation

17. Onset Within minutes Pneumothorax Pulmonary embolism Inhalation of foreign body Larygeal edema Left heart failure

18. Hours to Days Acute Respiratory Distress Syndrome Bronchial Asthma Pneumonia Left heart failure

19. Weeks to Months COPD ILD Pleural effusion Anemia Thyrotoxicosis Left ventricular failure

20. Grading of Dysponea (MMRC scale ) Grade Description of Breathlessness 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.

21. Aggravating factors Exposure to allergen Exercise Drugs Cold whether Relieving factors Medication Rest Removal of allergen

22. Diurnal and postural variation Bronchial asthma Lung abscess Bronchiectasis

23. 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

24. 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.

25. 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

26. Causes of hemoptysis Infection- TB Lung Abscess Bronchiectasis Pneumonia Fungal infection ( aspergillosis blastomycosis )

27. Neoplasm- Bronchogenic ca Bronchial adenoma Metastatic tumour

28. CVS MS PHT Pulmonary embolism AV malfromation

29. Collagen vascular disorder Vasculitis Wegener’ s granulomatosis Microscopic polyangitis Churgstrasuss syndrome Goodpastures’s syndrome Traumatic Iatrogenic. Bleeding disorder

30. Chest Pain Site Onset Duration Severity Character Radiation Associated symptoms Aggravating/Relieving factor Diurnal /seasonal variation Retrosternal Pain :-

31. causes Upper Tracheatis Mid and Lower Mediastinitis Mediastinal tumor GERD Achalasia cardia Diffuse esophageal spasm

32. 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 2 nd costochondral junction), unknown etiology . “Always keep ‘Angina’ in mind”

33. General Examination General condition Vitals Temperature Pulse Respiratory Rate & Breathing pattern. Blood pressure

34. Pallor Icterus Cyanosis Clubbing Lymphadenopathy Pedal oedema Built Nourishment Tripod position Purse lip breathing Paraneoplastic syndrome Cushing’s syndrome Gynecomastia Carcinoid syndrome

35. Pulse Bradycardia - Hypoxia. Tachycardia - Pneumonia, Pulmonary Embolism, ARDS Unequal - Pancost Tumour , Mediastinal syndrome. Pulsus Paradoxus – Acute severe asthma, COPD.

36. 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

37. 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

38. Pallor Chronic Infections – TB Chronic inflammatory disorders – interstitial lung disease, connective tissue disease. Malignancies.

39. Icterus Cor pulmonale Iatrogenic – Anti Tubercular Medications Metastasis to Liver Pulmonary infarction. Sepsis – secondary to chest infection.

40. Cyanosis Respiratory disorders Acute severe Asthma Tension Pneumothorax Pulmonary AV malformations Acute laryngeal oedema ARDS

41. Lymphadenopathy Sites Number Tender/Non-tender Discrete/matted Consistency Fixed/Mobile Overlying skin Sinus

42. 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.

43. Causes- URI Tuberculosis HIV Sarcoidosis Lung Carcinoma Lymphoma Secondaries

44. Clubbing Causes Bronchogenic carcinoma Bronchiectasis Lung abscess Empyema Cystic fibrosis Interstitial lung disease Congenital Unilateral clubbing — Pancoast tumour

45. 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

46. Pedal Edema Cor Pulmonale Chronic infections / inflammations – secondary to hypoalbuminemia . A/w renal involvement – Wegener’s granuomatosis Polyarteritis nodosa Microscopic polyangitis Goodpasture syndrome

47. Miscellaneous Scleroderma - nail bed telengectasias , raynod’s phenomenon, calcinosis cutis Sarcoidosis – lupus pernio