History and Examination
History
A comprehensive history exploring the
time course, nature and severity of symptoms is the most important factor in
establishing the cause of respiratory (or any other) disease. A systematic
logical approach is outlined below and ensures a thorough, complete enquiry.
·
General
features: age, sex, race and
marital status are recorded as these may be associated with specifi diseases.
Thus, tuberculosis (TB) is more common in Asians, sarcoidosis in Afro Caribbeans.
·
Presenting
complaint: lists the main symptoms,
usually chest pain, breathlessness, cough or haemoptysis in respiratory disease.
·
History of
the presenting complaint: explores
the specifi features (e.g. onset and progress) of the main symptoms and
associated systemic manifestations (e.g. fever, rigors, night sweats, malaise,
weight loss, lymphadenopathy, arthritis and rashes). Thus, drenching night sweats
and weight loss are associated with TB and cancer and erythema nodosum
(inflammator skin nodules) with sarcoidosis or TB. Obstructive sleep apnoea
causes daytime sleepiness and is associated with snoring, obesity and collar
size of more than 17 in. (43 cm).
Chest pain: establish site, sort (pleuritic, aching),
severity, onset (gradual, sudden), periodicity (intermittent, constant),
duration (minutes, days), aggravating and relieving factors (i.e. worse/better
with breathing, posture) and time off work. Pleuritic pain is a localized,
sharp pain aggravated by deep breathing.
Breathlessness: occurs at rest, on exercise or when lying fla (orthopnoea).
Determine rate of onset (sudden, gradual), when it occurs (i.e. nocturnal),
exercise tolerance (i.e. when walking, running or climbing stairs?) and
associated symptoms (e.g. hayfever, wheeze and stridor). In chronic obstructive
pulmonary disease (COPD) breathlessness is worse on exercise. In contrast,
breathlessness due to pulmonary oedema may suddenly wake a sleeping (i.e.
supine) patient with heart failure. Nocturnal breathlessness with wheeze or
seasonal breathlessness with hayfever suggests asthma.
Cough: in the morning indicates chronic bronchitis
(smoker's cough), at night suggests asthma or may be persistent after viral respiratory
tract infections with bronchial hyperresponsiveness. Cough may be dry or
productive of sputum. In a smoker, persistent cough, change in character or a
bovine cough (due to recurrent laryngeal nerve palsy) indicates development of
bronchial carcinoma.
Sputum: morning cough and sputum production for 3 months a
year for more than 1 year define chronic bronchitis. Yellow or green,
mucopurulent sputum occurs in chest infections and when copious and foul
smelling may indicate bronchiectasis. Pink frothy sputum is typical of
pulmonary oedema.
Haemoptysis: determine frequency and quantity (i.e. f ecks in
sputum, fresh red blood); more than 500 mL haemoptysis in 24 hours is
life-threatening. Infection (e.g. TB, pneumonia, bronchiectasis and Aspergillus)
accounts for approximately 80% of haemoptysis; bronchial carcinoma and rarer
cause (pulmonary infarction, vasculi- tis) for approximately 20%.
· Past medical history: enquire about previous respiratory conditions;
childhood whooping cough is associated with adult bronchiectasis; TB may reactivate
in later life. Atopy and eczema are often associated with asthma. Assess understanding
of current diseases and compliance with medications. Review previous chest X-rays,
hospital admissions and the need for mechanical ventilation.
· Medications: review current and previous medications, including inhalers, nebulizers and
oxygen. Determine whether recent changes are associated with new symptoms (e.g.
β-blockers may precipitate or worsen asthma; cytotoxics (e.g. methotrexate) can
cause pulmonary fibrosis) Record allergies to medications and foods.
· Family, occupational and social history: a family history of atopy, tuberculosis, COPD or
cystic fibrosi may help establish a diagno- sis. Smoking history including
duration and amount (1 pack/day for 1 year 1 pack/year). Alcohol abuse predisposes
to tuberculosis. Occupation may predispose to respiratory disease (e.g.
asbestos exposure is associated with pleural plaques, fibrosi and mesothelioma;
isocyanate exposure with asthma). Environmental factors may be important
(e.g. pet birds may cause psitticosis). Travel is associated with
specifi infections (e.g. Legionnaire's disease).
Examination (Fig. 19)
Detection of typical constellations of
clinical signs helps establish a diagnosis, although poor inter-observer
agreement questions their reli- ability and emphasizes the need for other
investigations.
General examination
Determine if the patient is well or
unwell and whether breathing, air-way and circulation are adequate. Examine
breathing rate and pattern. Assess the degree of breathlessness at rest or
while undressing. Check observation charts (e.g. temperature and Sao2)
and bedside sputum pots. Note general features such as obesity, cachexia,
jaundice, respiratory distress, anxiety and pain. Examine:
Hands: for nicotine staining, finge clubbing (Fig. 19;
Table 1), peripheral cyanosis, the fin tremor of excessive B2-agonist
therapy and the coarse tremor of a CO2 retention f ap. A 'bounding'
pulse also suggests CO2 retention.
Face and neck: for lymph nodes and features of systemic diseases.
Examine the conjunctiva for anaemia and the tongue (lips) for central cyanosis
(blue discoloration due to an increase in deoxygenated arterial haemoglobin).
Measure the jugular venous pressure (JVP) and changes with respiration (i.e. fi
ed and raised in superior vena cava (SVC) obstruction). Check for tracheal
deviation and stridor (inspiratory wheeze due to upper airway obstruction).
Chest examination
Includes anterior and posterior
inspection, palpation, percussion and auscultation, with comparison of the left
and right sides. The pattern of physical signs will indicate likely diagnoses
(Table 2).
Inspection: includes chest and spinal shape, scars of previous
radiotherapy or surgery, subcutaneous nodules, engorged chest wall veins (SVC
obstruction), hyperinflation symmetry of chest wall movement and use of
accessory muscles of respiration.
Palpation: examine for tenderness, apex beat position and
adequate chest wall expansion (>3 cm).
Percussion: assess for dullness and hyper-resonance.
Auscultation: assess breath sounds and their distribution
including nature (i.e. vesicular, bronchial), intensity (i.e. absent,
diminished) and added sounds (wheezes, crackles, rub). ‘Vesicular’ breath
sounds are normal inspiratory and expiratory sounds; there is no gap
between inspiration and expiration. Bronchial breath sounds are
high-pitched ('blowing') sounds with a gap between inspiration and expiration.
They occur with consolidation, collapse and above pleural effusions. Reduced
breath sounds occur with effusions, consolidation, pneumothorax and raised
diaphragm. Crepitations may befine, fixed and inspiratory due to
pulmonary fibrosi or early consolidation, or coarse due to excessive bronchial
secretions (e.g. bronchiectasis). Vocal resonance and tactile vocal
fremitus increase over areas of consolidation and diminish over effusions
and collapsed lung.
