Respiratory

Respiratory Clinical Assessment - History taking

Core symptoms

  • Breathlessness
  • Exercise tolerance
  • Chest pain
  • Orthopnea
  • Cough
  • Wheeze
  • Sputum
  • Haemoptysis
  • Fever
  • Weight loss
  • Smoking
  • Allergies/Atopy
  • Asbestos and dusts
  • Pets and animals
  • Social - Manage ADLS

Introduction

  • There is a great deal of overlap in the symptomatology of respiratory and cardiac disease. Patients often have both.
  • Get a good history of the current presenting complaints and try to get quantitative estimates e.g. amounts of sputum/haemoptysis, distance walked, cigarettes smoked, weight lost.
  • Always establish a time line - patients can be very imprecise but push "A little while", "Ask..Is that a day, a week, a month, a year..." "about 6 weeks doctor"
  • Smoking, animal exposure and occupational history play a major role in chest disease in many patients and should not be neglected.
  • Don't forget to ask how their disease impacts on their life, can they do stairs at home, are they too breathless to do house work or to even wash and dress themselves, do they need help...

Breathlessness

A key symptoms of many pathological processes

  • When did it start and how did it start - sudden or gradual, episodic or chronic, getting better or worse or static
  • Get quantitative evidence e.g. could walk 500 m and now can only do 20 m. Ask about stairs, exercise tolerance
  • Rate of onset is useful as is clinical context and past medical history

Rapid within minutes

  • Asthma ? younger (not always) patient, known history, wheeze, nocturnal cough, atopy
  • Left ventricular failure ? known impaired LV function from previous MI or other cause
  • Pulmonary embolism ? post op, immobility, pregnancy, past history of VTE
  • Respiratory obstruction e.g peanut, meat bolus
  • Laryngeal oedema ? anaphylaxis, ingested corrosives
  • Inhaled foreign body ? usually a child
  • Pneumothorax
  • Panic attacks/anxiety ? alcohol, young

Rapid over several hours

  • Acute Asthma attack
  • Exacerbation of COPD ? smoker, middle aged
  • Pulmonary oedema (improves sitting up)
  • Pneumonia- fever, sputum
  • ARDS ? post op, sepsis, trauma
  • Pulmonary embolism
  • Allergic alveolitis ? exposure to allergens
  • Pleural effusion ? smoker, asbestos
  • Metabolic acidosis ? Diabetic ketoacidosis

Gradual over weeks

  • Progressive massive fibrosis
  • Hamman Rich syndrome
  • Congestive cardiac failure

Gradual over months/years

  • COPD ? smoker, middle aged
  • Idiopathic pulmonary fibrosis, Sarcoidosis
  • Bronchiectasis, Cystic fibrosis
  • Congestive cardiac failure
  • Lymphangitis carcinomatosis
  • Hypoventilation - neuromuscular disease

Episodic breathlessness

  • Asthma
  • LVF secondary to arrhythmia e.g. Fast AF
  • LVF as an Angina equivalent
  • Pulmonary embolism
  • Hypersensitivity pneumonitis
  • Hyperventilation,
  • Panic attack

Cough

    Comments

    • Most often due to infection but always exclude malignancy when the cough persists (> 6 weeks) especially in a smoker.
    • A CXR at the minimum should be performed and a further opinion sought if it continues and cancer is a differential

    Causes

    • Tracheitis (cough is painful), Bronchitis
    • Asthma ? usually nocturnal
    • Pneumonia ? fever, rusty or green sputum
    • Bronchiectasis ? copious foul sputum
    • Post nasal drip ? often nocturnal. Worse with hayfever
    • Bovine cough with Recurrent laryngeal nerve damage with lung tumour
    • ACE Inhibitors (bradykinin mediated)

    Nocturnal Cough

    • Asthma in bed at night
    • Post nasal drip
    • Gastroesophageal reflux
    • Pulmonary oedema

    Investigations

    • CXR, Serial PEFR measurements, Spirometry
    • HRCT chest, Bronchoscopy
    • ENT exam in some

Haemoptysis

  • Lung cancer : smoker, lung mass on CXR
  • Infections : Pneumonia, Bronchitis ? fever, rigors
  • Bronchiectasis: bloody sputum with copious foul sputum
  • Tuberculosis ? fever, weight loss, immunosuppressed
  • Pulmonary embolism : new sudden onset breathlessness, haemoptysis
  • Pulmonary oedema "pink frothy sputum" ? oedema on CXR
  • Coagulopathy : warfarin, liver disease, DIC
  • Wegener's Granulomatosis: AKI too and haematuria and proteinuria
  • Epistaxis misinterpreted as haemoptysis

Sputum production

Types
  • Purulent - green/yellow (From neutrophil myeloperoxidase)
  • Bloody - pneumonia, PE, cancer.
  • Rusty - Pneumococcal pneumonia
  • Mucoid
  • Copious, thick, tenacious - Bronchiectasis, Cystic fibrosis

Causes

  • Chest infection ? Pneumonia, bronchitis, tracheitis
  • Chronic bronchitis
  • Bronchiectasis
  • Lung Tumour

Others

  • Wheeze
    • An expiratory noise seen with bronchoconstriction
    • Asthma, COPD or Pulmonary oedema
  • Stridor
    • Stridor is an Inspiratory noise and the important causes include Acute epiglottis in an child is a paediatric emergency
    • Laryngospasm or oedema due to anaphylaxis or local burn
    • Laryngeal obstruction - foreign body or tumour
    • Diphtheria or Croup in an infant
    • Acutely in an adult consider treating for anaphylaxis
  • Fever (temperature > 38C)
    • Infection - pneumonia, TB
    • Lymphoma or other malignancy
    • Connective tissue disease,
  • Unexpected weight loss
    • Malignancy
    • Tuberculosis
    • Idiopathic pulmonary fibrosis
    • COPD
  • Smoking history
    • Assume all smokers have a lung tumour and get a CXR until proven otherwise
    • A significant smoking history immediately focuses the diagnosis.
    • Is there a lung malignancy, is there COPD. Is the patient clubbed ? Recent weight loss ?
    • A mass on CXR. Assess pack years ie. how many packets of 20/day for how many years
  • Occupational history and animal exposure
    • Occupational history should always be asked about.
    • Get a complete working history e.g. A job lagging pipes for 6 months 50 years ago might be the source of the asbestos causing the mesothelioma.
    • Ask about Pets and exposure to organic and other allergens both at home and at work.
    • Enquire after Asbestos exposure, Passive smoking (eg bar workers)
  • Chest pain
    • Pulmonary embolism and infarction ? usually pleuritic
    • Localised infection - pneumonia with pleurisy
    • Pneumothorax
    • Tumour eg mesothelioma, rib metastases ?
    • Localised pain, Rib fractures from trauma or destructive malignancy ? localised pain
    • Acute coronary syndrome should always be considered if symptom suggestive
    • Pericarditis, Aortic Dissection, Oesophagitis, Oesophageal spasm
  • Sexual/IV drug history
    • where HIV considered presenting as PCP pneumonia
    • Lung abscess with IV drug use
  • Recent travel history
    • Hotel humidification systems and shower heads etc - Legionnaire's disease
    • Travel to certain parts of the world can bring back chest disease e.g. Tuberculosis, Coccidioidomycosis from Californian Deserts
    • Anthrax from hides or terrorist plot

Respiratory Examination

All physical examinations should start explaining what you are about to do, washing hands and seeking the patients consent before proceeding.

Initial assessment

  • End of bed - surroundings
    • Patient sitting at 45 degrees in bed with chest exposed (treat females discretely)
    • Tripod position of severely emphysemic patient with arms extended and holding bed or often on bedside shelf
    • Is patient on supplementary oxygen - Nasal specs, venturi mask, Non rebreather mask, NIV
    • Packet of cigarettes, patient smell of smoking
    • Salbutamol or steroid Inhaler, Peak flow meter
    • Sputum pot and look at contents
  • Patient appearance
    • Cyanosed (> 5g/dl of deoxygenated Hb)
    • Plethora - polycythaemia, SVC obstruction
    • Anaemia or Jaundiced (eg liver metastases from lung cancer)
  • Habitus
    • Obese ( Hypoventilation, Obstructive sleep apnoea)
    • Cushingoid appearance (steroid treatment)
    • Thin, cachexia - malignancy, end stage COPD, pulmonary fibrosis
    • Tall and thin - Primary pneumothorax, Marfan's syndrome
    • Smell of cigarettes, Unkempt, emaciated - possibly TB, Alcoholism
    • Hoarse voice - Recurrent laryngeal nerve palsy from bronchogenic carcinoma
    • Kyphosis and/or scoliosis (Ankylosing spondylitis - apical lung fibrosis)
  • Breathing pattern
    • Respiratory rate - normal 12-15/minute
    • Hypoventilating - obese, sedated, COPD "Blue bloater"
    • Cheyne-Stokes : alternating fast and slow seen in those with very poor prognosis, preterminal
    • Increased respiratory rate
    • Intercostal in drawing of ribs suggests increased effort
    • Prolonged expiratory phase - COPD, Asthma
    • Normal but increased rate - PE, LVF
    • Pursed lips - seen in emphysema as patient maintains a positive airway pressure to prevent small airway collapse
  • Hands
    • Warm with finger pulses, peripheral cyanosis - CO2 retention
    • Clubbed and tender wrists (HPOA*) - lung malignancy or suppuration or idiopathic pulmonary fibrosis
    • Nicotine staining from heavy smoking
    • Wasting - Pancoast tumour, cachexia, ageing, motor neurone disease
  • Clubbing
    • Bulbous swelling of terminal phalanges with loss of angle of nail bed.
    • Associated with Hypertrophic pulmonary osteoarthropathy - onion skin like bone formation at the wrist associated with clubbing.
    • Aetiology is unclear with circulating prostaglandins
    • Causes (You need to know this list)
      • Lung cancer
      • Mesothelioma
      • Lung abscess
      • Empyema
      • Bronchiectasis
      • Cryptogenic fibrosing alveolitis
      • Cryptogenic organising pneumonia
      • Endocarditis
      • Atrial myxoma
      • Congenital cyanotic cardiac disease
      • Cirrhosis
      • Inflammatory bowel disease
      • Inherited Autosomal dominant - if no cause found then look at hands of children or parents or siblings
  • Pulse
    • Bounding pulse and distended veins : CO2 retention
    • Irregularly irregular: Atrial fibrillation
    • Tachycardia: fever, distress, arrhythmia
    • Irregularly irregular: AFF
  • JVP elevated
    • Right heart failure due to lung disease - Cor pulmonale, Congestive cardiac failure
    • Fixed and elevated - Superior vena caval obstruction - malignancy
  • Face
    • Wasting of face muscles e.g. temporalis - cachexia
    • Jaundiced sclera - ? liver malignancy
    • Conjunctiva - pale and anaemic or pink and suffused with SVC obstruction
    • Horner's syndrome - ? Pancoast tumour

Chest Examination

  • Inspection - expose chest in the exam or request to.
    • Allow female patients to cover up when done.
    • Chest Scars
    • Thoracotomy (look front and back and side) or Thoracoplasty
    • Plaster or gauze covering recent pleural tap
    • Phrenic nerve crush scar in supraclavicular fossa used previously for TB
    • Midline sternotomy scar - CABG, Valve replacement or both
    • Tattoos markings from previous radiotherapy
    • Pectus excavatum, Ankylosing spondylitis, kyphoscoliois
    • Gripping chest with both hands and thumbs in midline and see do both sides moving equally with respiration
  • Palpation
    • Check trachea central using forefinger and sliding index and ring fingers gently on either side to ensure same space
    • Place hands across chest thumbs touching and make sure that both sides move the same with inspiration.
    • Reduced movement on one side suggests pathology on that same side.
    • Tactile fremitus "99"
    • Axillary and supraclavicular lymph nodes if suspect a malignant process
  • Percussion
    • Percuss rib spaces each side front and back comparing left and right side. Make sure that your technique is good.
    • Don't forget over lung apices as well as percussion over clavicles and axillae
    • Dullness suggests underlying a lack of underlying aerated lung eg consolidation,collapse or fibrosis
    • Resonance seen with emphysema or even more so with pneumothorax
    • Stony dull suggests underlying fluid within the pleural space. Determine its upper margin
  • Auscultation with diaphragm of stethoscope
    • Ask the patient to cough first to remove any phlegm that can add noises to the auscultatory findings
    • Ask patient to breath through open mouth as less resistance pathway and more air shifted and so more to hear
    • Normal breathing pattern expiration more prolonged then inspiration 2:1
    • Reduced air entry suggests pathology - collapse, consolidation, fibrosis, pleural thickening or hypoventilation if bilateral
  • Breath sounds
    • Vesicular - Normal breath sounds and are soft and low pitch with a more blowy quality.
    • Bronchial breath - harsh high pitch and equal duration inspiratory and expiratory phases. Sounds like listening over one's trachea. They are abnormal when heard on chest surface. They usually suggest consolidation.
    • Vocal resonance "99" and is increased over consolidation to the point that one gets "whispering pectriloquy"
    • Reduced breath sounds : Hypoventilation, pleural effusion, pneumothorax
  • Added sounds
    • Pleural rub: fine crackling noise with respiration
    • Rhonchi/Wheeze suggests asthma or COPD
    • Fine crepitations "crackles" or rales can suggest pulmonary oedema, resolving consolidation or infection or pulmonary fibrosis
    • Coarser crackles heard with bronchiectasis/cystic fibrosis
  • Extras
    • Ask if you can measure patient's PEFR (ensure you can do this properly)
    • Look at observations chart for O2 sats and temperature and respiratory rate