History and Examination
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.
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).
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.