Respiratory history and examination Flashcards
Respiratory history: questions to ask about cough
Duration? Character (e.g barking/hollow/dry)? Nocturnal (=asthma, ask about other atopic symptoms i.e. eczema, hay fever). Exacerbating factors? Sputum (colour, quantity)? Any blood/haemoptysis?
Respiratory history: questions to ask about haemoptysis
Always think about TB (recent foreign travel?) and malignancy (weight loss?).
Mixed with sputum? blood not mixed with sputum suggests pulmonary embolism, trauma, or bleeding into a lung cavity.
Melaena? occurs if enough coughed up blood is swallowed.
Respiratory history: questions to ask about dyspnoea
Duration?
Steps climbed/distance walked before onset?
NYHA classification?
Diurnal variation (= asthma)?
Ask specifically about circumstances in which dyspnoea occurs (e.g. occupational allergen exposure).
Respiratory history: causes of hoarseness
e.g. due to laryngitis, recurrent laryngeal nerve palsy, Singer’s nodules, or laryngeal tumour
Respiratory history: symptoms to ask about
Cough Haemoptysis Dyspnoea Hoarseness Wheeze Fever/night sweats Chest pain Stridor
Respiratory history: past medical history
Pneumonia/bronchitis TB Atopy (asthma, eczema, hay fever) Previous CXR abnormalities Lung surgery Myopathy Neurological disorders Connective tissue disorders, e.g. rheumatoid, SLE
Respiratory history: drug history
Respiratory drugs, e.g. steroids, bronchodilators?
Any other drugs, especially with respiratory side effects, e.g. ACE inhibitors, cytotoxics, beta-blockers, amiodarone.
Respiratory history: family history
Atopy? Emphysema? TB?
Respiratory history: social history
Quantify smoking in ‘pack-years’ (20 cigarettes/day for 1 year = 1 pack year).
Occupational exposure (farming, mining, asbestos) has possible compensatory implications.
Pets, e.g. birds?
Recent travel/TB contacts?
Respiratory history: stridor
Inspiratory sound due to partial obstruction of upper airways.
Obstruction may be due to something within the lumen (e.g. foreign body, tumour, bilateral vocal cord palsy), within the wall (e.g. oedema from anaphylaxis, laryngospasm, tumour, croup, acute epiglottitis, amyloidosis), or extrinsic (e.g. goitre, oesophagus, lymphadenopathy, post-op stridor, after neck surgery).
It is an emergency if gas exchange is compromised.
Respiratory history: characteristic coughs
Coughing is relatively non-specific, resulting from irritation anywhere from the pharynx to the lungs.
The character of a cough may, however, give clues as to the underlying cause.
Loud, brassy coughing.
Hollow, bovine coughing.
Barking coughs.
Chronic cough.
Dry, chronic coughing.
Do not ignore a change in character of a chronic cough- may signify a new problem, e.g. infection, malignancy.
Respiratory history: characteristic coughs, loud brassy coughing
Suggest pressure on the trachea, e.g. by a tumour.
Respiratory history: characteristic coughs, hollow bovine coughing
Associated with recurrent laryngeal nerve palsy.
Respiratory history: characteristic coughs, barking coughs
Occur in croup
Respiratory history: characteristic coughs, chronic cough
Think of pertussis, TB, foreign body, asthma (e.g. nocturnal).
Respiratory history: characteristic coughs, dry chronic coughing
May occur following acid irritation of the lungs in oesophageal reflux, and as a side effect of ACE inhibitors.
Respiratory history: causes of haemoptysis
Infective: TB, bronchiectasis, bronchitis, pneumonia, lung abscess, COPD, fungi (e.g. aspergillosis), viruses (from pneumonitis, cryoglobinaemia, e.g. with hepatitis viruses, HIV associated pneumocytosis, or MAI), helminths, paragonimiasis, hydatid, schistosomiasis.
Neoplastic: primary or secondary.
Vascular: lung infarction (PE), vasculitis (ANCA-associated, RA, SLE), hereditary haemorrhagic telangiectasia, AV malformation, capillaritis.
Parenchymal: diffuse interstitial fibrosis, sarcoidosis, haemosiderosis, Goodpasture’s syndrome, cystic fibrosis.
Pulmonary hypertension: idiopathic, thromboembolic, congenital cyanotic heart disease, pulmonary fibrosis, bronchiectasis.
Coagulopathies: any, e.g. thromboembolic congenital cyanotic heart disease, pulmonary fibrosis, bronchiectasis.
Trauma/foreign bodies: e.g. post-intubation, or an eroding implanted defibrillator.
Pseudo-haemoptysis: Munchausen’s, aspirated haematemesis, red pigment (prodigiosin) from Serratia marcescens (Gram negative bacteria) in sputum.
Respiratory history: aetiology of acute dyspnoea
Foreign body Pneumothorax Pulmonary embolus Acute pulmonary oedema Psychogenic
Respiratory history: aetiology of subacute dyspnoea
Asthma
Parenchymal disease, e.g. alveolitis pneumonia
Effusion
Psychogenic
Respiratory history: aetiology of chronic dyspnoea
COPD and chronic parenchymal diseases
Non-Respiratory causes, e.g. cardiac failure, anaemia
Respiratory history: dyspnoea, lung causes
Airway and interstitial disease.
May be hard to separate from cardiac causes.
Asthma may wake patient, and cause early morning dyspnoea and wheeze.
Respiratory history: dyspnoea, cardiac causes
e.g. ischaemic heart disease or left ventricular failure, mitral stenosis.
LVF is associated with orthopnoea and paroxysmal nocturnal dyspnoea.
Ankle oedema, lung crepitations, raised JVP.
Respiratory history: dyspnoea, anatomical causes
e.g. disease of the chest wall, muscles, pleura.
Ascites can cause breathlessness by splinting the diaphragm, restricting its movement.
Respiratory examination: general inspection
Assess general state (ill/well/cachexic).
Look for clues (oxygen, inhalers, nebulisers, venturi mask).
Colour (pale, cyanosed, flushed?).
Short of breath? Accessory muscle use?
Scars on chest wall?
Ask the patient to take a deep breath in, watch chest movement and symmetry, any coughing?
Respiratory examination: hands
Inspect: tobacco staining, peripheral cyanosis, clubbing, signs of systemic disease (systemic sclerosis, rheumatoid arthritis).
Asterixis: ask the patient to hold their hands out and cock their wrist back, tremor as a sign of CO2 retention.
May also have fine tremor from beta-agonist use (salbutamol in asthmatics/COPD).
Respiratory examination: arms
Time pulse rate, with fingers still on the pulse, check respiratory rate, and pattern.
Bounding pulse (CO2 retention)?
Check blood pressure.
Respiratory examination: neck
Trachea: feel in sternal notch (deviation? towards collapse or away from large pleural effusion tension pneumothorax), assess cricosternal distance in finger breadths and feel for tracheal tug.
Lymphadenopathy: from behind the patient sat forward palpate lymph nodes of head and neck- TB/Ca?
JVP: raised in cor pulmonale, fixed and raised in superior vena cava obstruction.
Respiratory examination: face
Inspect for signs of Horner’s (ptosis and constricted pupil, if Pancoast’s tumour), conjunctival pallor, central cyanosis (ask patient to stick out tongue), pursed lip breathing.
Respiratory examination: front of chest
Apex beat- impalpable = PE/COPD/dextrocardia. Expansion. (Tactile vocal fremitus.) Percussion. Auscultation. Vocal resonance.
Respiratory examination: front of chest, expansion
Ask patient to ‘breathe all the way out’.
Place hands around chest under nipples, anchor with the fingers and leave thumbs free-floating, ‘now deep breath in’ and note distance of thumbs to midline, is expansion equal? repeat with hands laid on upper chest.
Respiratory examination: front of chest, tactile vocal fremitus
Palpate the chest wall with your fingertips and ask the patient to repeat ‘99’, each time they feel your hand, comparing right to left. Rarely used.
Respiratory examination: front of chest, percussion
Percuss over different respiratory segments, comparing right to left.
Apex, axilla, and at least 2 other places on the chest.
Dull percussion note = collapse, consolidation, fibrosis, pleural thickening, or pleural effusion (stony dull).
Hyperresonant percussion note = pneumothorax or hyperinflation (COPD).
Respiratory examination: front of chest, auscultation
Ask patient to take ‘steady breaths in and out through your mouth’ and listen with the diaphragm from apices to bases, comparing right and left.
Listen in the same places as percussed.
Respiratory examination: front of chest, vocal resonance
Repeat auscultation, asking patient to repeat ‘99’ each time they feel the stethoscope.
If marked increased resonance is heard, repeat with asking patient to whisper ‘99’.
If clearly heard this time it is ‘whispering pectoriloquy’ and is a sensitive sign for consolidation.
Respiratory examination: back of chest
Expansion. (Tactile vocal fremitus.) Percussion. Auscultation. Vocal resonance.
Respiratory examination: to complete the examination
Palpate for sacral and ankle oedema.
Check peripheral pulses, observation chart for temperature and O2 sats.
Examine the sputum pot and check PEFR.
CXR if indicated.
Respiratory examination: breath sounds
Vesicular. Bronchial breathing. Diminished breath sounds. Silent chest. Wheeze (rhonchi). Crackles (crepitations). Pleural rub. Pneumothorax click.
Respiratory examination: breath sounds, vesicular
Rustling quality, normal.
Respiratory examination: breath sounds, bronchial breathing
Harsh with gap between inspiration and expiration.
Increased vocal resonance and whispering pectoriloquy.
Consolidation, localised fibrosis, above pleural/pericardial effusion.
Respiratory examination: breath sounds, diminished breath sounds
Difficult to hear.
Pleural effusion, pleural thickening, pneumothorax, bronchial obstruction, asthma or COPD.
Respiratory examination: breath sounds, silent chest
Inaudible breath sounds.
Life-threatening asthma.
Respiratory examination: breath sounds, wheeze (rhonchi)
Air expired through narrow airways.
Monophonic (single note, partial obstruction one airway)- caused by tumour occluding airway.
Polyphonic (multiple notes, widespread airway narrowing)- caused by asthma, cardiac wheeze (LVF).
Respiratory examination: breath sounds, crackles (crepitations)
Reopening of small airways on inspiration.
Fine and late in inspiration = pulmonary oedema.
Coarse and mid-inspiratory = bronchiectasis.
Early inspiratory = small airway disease.
Late/pan inspiratory = alveolar disease.
Disappear post cough = insignificant.
Respiratory examination: breath sounds, pleural rub
Movement of visceral pleura over parietal when both are roughened (eg. due to inflammatory exudate).
Pneumonia, pulmonary infarction.
Respiratory examination: breath sounds, pneumothorax click
Shallow left pneumothorax between layers of parietal pleura overlying heart, heard during cardiac systole.
Respiratory examination: signs of respiratory distress
Tachypnoea.
Nasal flaring.
Tracheal tug (pulling of thyroid cartilage towards sternal notch in inspiration).
Use of accessory muscles (sternocleidomastoid, platysma, infrahyoid).
Intercostal, subcostal, and sternal recession.
Pulsus paradoxus.
Respiratory examination: breathing patterns, hyperventilation
Tachypnoea (>20 breaths/min) or deep (hyperpnoea, i.e. increased tidal volume).
Hyperpnoea is not unpleasant, unlike dyspnoea.
It may cause respiratory alkalosis, hence paraesthesia ± muscle spasm (low Ca2+).
The main cause is anxiety: associated dizziness, chest tightness/pain, palpitations, and panic.
Rare causes: response to metabolic acidosis, brainstem lesions.
Respiratory examination: breathing patterns, Kussmaul respiration
Deep, sighing breaths in severe metabolic acidosis (blowing off CO2), e.g. diabetic or alcoholic ketoacidosis, renal impairment.
Respiratory examination: breathing patterns
Hyperventilation.
Kussmaul respiration.
Neurogenic hyperventilation- produced by pontine lesions.
Cheyne-Stokes breathing
Respiratory examination: breathing patterns, Cheyne-Stokes breathing
Breaths get deeper and deeper, then shallower (± episodic apnoea) in cycles.
Causes: brainstem lesions or compression (stroke, raised ICP).
If the cycle is long, e.g. 3 mins, the cause may be a long lung-to-brain circulation time, e.g. in chronic pulmonary oedema or reduced cardiac output.
It is enhanced by opioids.
Respiratory examination: sputum examination
Inspect sputum and send suspicious sputum for microscopy (Gram stain and auramine/ZN stain, if indicated), culture, and cytology.
Black carbon specks suggest smoking: commonest cause of increased sputum.
Yellow/green sputum suggests infection, e.g. bronchiectasis, pneumonia.
Pink frothy sputum suggests pulmonary oedema.
Bloody sputum (haemoptysis) may be due to malignancy, TB, infection, or trauma, and requires investigation for these causes.
Clear sputum is probably saliva.
Respiratory examination: important presentations, pleural effusion
Reduced expansion.
Stony dullness on percussion.
Reduced air entry.
Reduced vocal resonance.
Trachea and mediastinum central (shift away from affected side only with massive effusions ≥1000mL).
There may be bronchial breathing at the top of an effusion.
Respiratory examination: important presentations, consolidation
Reduced expansion. Reduced percussion note. Increased vocal resonance. Bronchial breathing ± coarse crackles (with whispering pectoriloquy). Trachea and mediastinum central.
Respiratory examination: important presentations, spontaneous pneumothorax/extensive collapse (lobectomy/pneumonectomy)
Reduced expansion.
Increased percussion note.
Reduced breath sounds.
Trachea and mediastinum shift towards the affected side.
Respiratory examination: important presentations, tension pneumothorax
Reduced expansion.
Increased percussion note.
Reduced breath sounds.
Trachea and mediastinum shift away from the affected side.
Respiratory examination: important presentations, fibrosis
Reduced expansion.
Reduced percussion note.
Breath sounds bronchial ± crackles.
Trachea and mediastinum central or pulled towards the area of fibrosis.
Respiratory examination: chest deformities
Barrel chest- increased AP diameter, tracheal descent and chest expansion reduced, seen in chronic hyperinflation e.g. asthma/COPD.
Pigeon chest (pectus carinatum).
Funnel chest (pectus excavatum)- developmental defect involving local sternum depression.
Kyphosis- ‘humpback’ from increased AP thoracic spine curvature.
Scoliosis- lateral curvature, may cause restrictive ventilatory defect.
