History taking and general examination of respiratory system
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History taking and general examination of respiratory system
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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.
- 6. Acute cough (<3 wks) • Upper respiratory tract infections • Pneumonia • Pulmonary embolism • Congestive Cardiac Failure
- 7. Subacute cough (3- 8 weeks) • Viral infections • Post infective • Post nasal drip • GERD
- 8. Chronic cough >8 wks • Pulmonary Tuberculosis • Bronchial Asthma • COPD • Bronchogenic carcinoma • Eosinophilic bronchitis • Post nasal drip • GERD • Drugs like ACE inhibitors • Congestive cardiac failure
- 9. Nocturnal cough • Post nasal drip. • GERD • Chronic brochitis. • Bronchial asthma. • Obstructive sleep apnea • Left Ventricular Failure • Aspiration
- 10. Sputum • Consistency • Amount • Color • Postural variation • Smell
- 11. Consistency • Serous - Upper Respiratory tract Infection, Bronchoalvelolar carcinoma • Mucoid - Chronic bronchitis, Bronchial Asthma • Mucopurulent - Bacterial infection
- 12. Amount Copious Amount – Bronchiectasis – Lung Abscess – Necrotizing pneumonia – Alveolar cell carcinoma – Empyema rupturing into bronchus (Bronchorrhoea - >100ml sptum/day)
- 13. 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.
- 14. Postural variation – Lung Abscess – Bronchiectasis
- 15. Foul Smell – Lung abscess – Bronchiectasis – Anaerobic bacterial infection
- 16. 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)
- 17. • Onset • Duration • Severity • Aggravating and relieving factors • Postural variation • Diurnal variation
- 18. Onset Within minutes – Pneumothorax – Pulmonary embolism – Inhalation of foreign body – Larygeal edema – Left heart failure
- 19. Hours to Days – Acute Respiratory Distress Syndrome – Bronchial Asthma – Pneumonia – Left heart failure
- 20. Weeks to Months – COPD – ILD – Pleural effusion – Anemia – Thyrotoxicosis – Left ventricular failure
- 21. Grading of Dysponea (MMRC scale) Grade Description of Breathlessness 0 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.
- 22. • Aggravating factors – Exposure to allergen – Exercise – Drugs – Cold whether • Relieving factors – Medication – Rest – Removal of allergen
- 23. Diurnal and postural variation – Bronchial asthma – Lung abscess – Bronchiectasis
- 24. 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
- 25. 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.
- 26. 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
- 27. Causes of hemoptysis Infection- – TB – Lung Abscess – Bronchiectasis – Pneumonia – Fungal infection (aspergillosis blastomycosis)
- 28. Neoplasm- – Bronchogenic ca – Bronchial adenoma – Metastatic tumour
- 29. CVS – MS – PHT – Pulmonary embolism – AV malfromation
- 30. • Collagen vascular disorder – Vasculitis – Wegener’ s granulomatosis – Microscopic polyangitis – Churgstrasuss syndrome – Goodpastures’s syndrome • Traumatic • Iatrogenic. • Bleeding disorder
- 31. Chest Pain • Site • Onset • Duration • Severity • Character • Radiation • Associated symptoms • Aggravating/Relieving factor • Diurnal /seasonal variation • Retrosternal Pain :-
- 32. causes • Upper – Tracheatis • Mid and Lower – Mediastinitis – Mediastinal tumor – GERD – Achalasia cardia • Diffuse esophageal spasm
- 33. • 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 2nd costochondral junction), unknown etiology. “Always keep ‘Angina’ in mind”
- 34. • General Examination • General condition • Vitals – Temperature – Pulse – Respiratory Rate & Breathing pattern. – Blood pressure
- 35. • Pallor • Icterus • Cyanosis • Clubbing • Lymphadenopathy • Pedal oedema • Built • Nourishment • Tripod position • Purse lip breathing • Paraneoplastic syndrome – Cushing’s syndrome – Gynecomastia – Carcinoid syndrome
- 36. Pulse • Bradycardia - Hypoxia. • Tachycardia - Pneumonia, Pulmonary Embolism, ARDS • Unequal - Pancost Tumour , Mediastinal syndrome. • Pulsus Paradoxus – Acute severe asthma, COPD.
- 37. 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
- 38. 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
- 39. Pallor • Chronic Infections – TB • Chronic inflammatory disorders – interstitial lung disease, connective tissue disease. • Malignancies.
- 40. Icterus – Cor pulmonale – Iatrogenic – Anti Tubercular Medications – Metastasis to Liver – Pulmonary infarction. – Sepsis – secondary to chest infection.
- 41. Cyanosis Respiratory disorders – Acute severe Asthma – Tension Pneumothorax – Pulmonary AV malformations – Acute laryngeal oedema – ARDS
- 42. Lymphadenopathy • Sites • Number • Tender/Non-tender • Discrete/matted • Consistency • Fixed/Mobile • Overlying skin • Sinus
- 43. 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.
- 44. Causes- • URI • Tuberculosis • HIV • Sarcoidosis • Lung Carcinoma • Lymphoma • Secondaries
- 45. Clubbing Causes • Bronchogenic carcinoma • Bronchiectasis • Lung abscess • Empyema • Cystic fibrosis • Interstitial lung disease • Congenital • Unilateral clubbing — Pancoast tumour
- 46. 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
- 47. Pedal Edema • Cor Pulmonale • Chronic infections / inflammations – secondary to hypoalbuminemia. • A/w renal involvement – – Wegener’s granuomatosis – Polyarteritis nodosa – Microscopic polyangitis – Goodpasture syndrome
- 48. Miscellaneous • Scleroderma - nail bed telengectasias, raynod’s phenomenon, calcinosis cutis • Sarcoidosis – lupus pernio