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.