Respiratory System - History and Exam

Competence in history and examination should be acquired by the aspiring clinician.

An hour is often the allocated time for history, examination, management formulation and suitable explanation to the patient in medical training. In UK general practice patients are usually given 10 minute appointments. Hence it is necessary to be efficient in acquiring important information without taking too many shortcuts and missing the diagnosis.

"Listen to the patient. He is telling you the diagnosis," comes the wisdom of ages.

• To do this efficiently questions should be open-ended and allow for patients to speak freely.
• Be selective with direct questioning. The patient may gloss over something that demands deeper inquiry.
• Try not to interrupt unnecessarily (but there are times when it is essential to hone in on detail).
• Avoid irrelevant detail. Some patients can meander aimlessly with irrelevant anecdotes and these need to be gently curtailed.
• Avoid leading questions.
• Let the patient speak freely in his own words.

Following the principles above ask:

• What is the principle complaint? Examples include dyspnoea, wheezing or cough as below.
• Are there subsidiary complaints?
• What is the time scale of the complaint?
• Is the disease progressive or static?
• Is the problem constant or paroxysmal? If it is variable, are the good times symptom free or less severe?
• Are there any aggravating or relieving factors?
• How severely does it affect the patient's life?

Dyspnoea and wheeze

The questions may apply to both dyspnoea and wheezing.

• When do symptoms occur?
• Is there shortness of breath on exertion? How much exertion?
• Is it getting worse?
• Do symptoms occur at rest?
• Does anything else precipitate it? This can include cold air, pollution and lying flat.
• What does the patient do when it happens? He may stop for breath, he may seek fresh air, he may sit up.
• Are there any undue problems with a cold? Asthma and COPD are often aggravated by a cold.

Remember that respiratory symptoms may be caused by disease of other systems:

• Congestive heart failure may cause dyspnoea at night. The patient sits up and throws open the windows.
• Severe anaemia causes shortness of breath on exertion.
• Neuromuscular disease can cause dyspnoea.
• Dyspnoea can be psychogenic (with features of the hyperventilation syndrome).
• Only moderate asthmatics wheeze. In severe asthma there may be no wheeze and a silent chest.
• It is important to distinguish wheeze from stridor.

Cough

Questions to ask about cough include:

• Does anything bring it on? Think of the same precipitants as asthma.
• When does it tend to happen? A nocturnal cough could be heart failure, a postnasal drip or gastro-oesophageal reflux.
• Is it dry or productive? "Do you bring anything up?" is the question to ask the patient.
• If the cough is productive, what colour is the sputum? Green or yellow suggests infection.
• "Do you ever cough up blood?" You should have a mental differential diagnosis for haemoptysis.

Remember that mild asthma can present with cough. Paroxysmal nocturnal coughing can be from heart failure. ACE inhibitors may cause cough.

Between the history of the presenting complaint and past medical history, it is worth asking if there has been any previous consultation about the problem, a previous diagnosis and any previous treatment? This may seem a little like cheating in finals but in real life it is very important. Has there been previous investigation and a diagnosis? It may be right or it may be wrong but it is important to know about it. Has there been any previous attempt at treatment? If so, with what and how successful was it?

Blessed is he who sees the patient last.

It is often the past history that gives the clue to the aetiology. Ask about:

• Childhood asthma, wheezing or 'bronchitis'.
• Malignant disease (pulmonary metastases). Remember busulphan can cause pulmonary fibrosis.
• Infections including pneumonia, tuberculosis and whooping cough.
• Chest trauma and operations.
• Thromboembolic disease, specifically deep vein thromboses and pulmonary embolus.

Specifically:

• Use of inhalers (assess compliance and technique).
• Use of steroids (some measure of severity in asthma).
• Other drugs which may have relevance in respiratory disease (such as busulphan, ACE inhibitors, aspirin, NSAIDs).

Ask about all allergies including for example food, inhaled allergens and drugs.

Diseases can have a genetic component or aetiology such as asthma and cystic fibrosis. Ask also about:

• Infectious diseases such as tuberculosis (remember high risk groups).
• Atopic diseases such as hay fever and eczema.
• Emphysema (alpha-1-antitrypsin deficiency).

• An occupational history may be very important in respiratory disease. This is highlighted with conditions such as asbestosis where there may have been exposure in the building industry for example. It is important to ask about past occupations too. Remember an electrician, a carpenter and a sailor in the merchant navy may all have been exposed to asbestos.
• Hobbies and pets may also be responsible for respiratory disease.
• Lifestyle and alcohol consumption are also very relevant to respiratory diseases. Ask about illicit drugs. They may be smoked or inhaled.
• Smoking history should detail for example the type and number of cigarettes smoked currently and in the past. Remember that some children start to smoke very early in life. Ask about passive smoking.
• Sexual history may be relevant to risk of HIV and AIDS.

It is important to ask about other body systems. There may be undiagnosed illnesses in other systems which are relevant to the respiratory symptoms.

• Loss of appetite is a common feature whenever people are unwell. It suggests that the disease is having a significant effect on wellbeing.
• Significant loss of weight may well be indicative of serious illness. Remember malignancy and tuberculosis.
• Ask about urinary symptoms. Middle-aged and older women, in particular, may be less concerned about the cough than the associated stress incontinence. Ask about it as they are often too embarrassed to complain directly.
• Heart disease may cause respiratory symptoms. Are there for example symptoms of heart failure, angina or ankle swelling?
• Rheumatoid arthritis and other connective tissue diseases may cause respiratory symptoms.
• Neuromuscular diseases may cause respiratory symptoms, particularly dyspnoea.

Before examination likely diagnoses and what to expect on examination will usually have been formulated. Examination should be performed in a competent manner to confirm the diagnosis and possibly to direct further investigations. In medical exams, getting the right answer by the wrong method may result in failure but achieving the wrong answer with the correct technique can achieve a pass.

It is impossible to give an adequate description of sounds with words and the reader is recommended to use an audio aid to become familiar with breath sounds. What is normal in terms of percussion, tactile vocal fremitus, etc can only be assessed on the basis of experience. Hence it is important to examine patients with and without abnormalities. The various breath sounds available on mentor media audio are recommended. (Make sure you have speakers turned on).

Observe the patient.

• Do his cheeks and temples look sunken as if he has lost much weight?
• Is he blue and bloated? Peripheral oedema may be noted.
• What is the general physique? Pneumothorax is most common in those who are tall and thin with a habitus rather similar to Marfan's syndrome.
• Do the lips look cyanosed?
• Is he breathing through pursed lips. This suggests premature airways closure as in COPD.
• Is he struggling to breath? Perhaps you can see that the accessory muscles of respiration are being used. The alae nasae may be in action. Such patients often look anxious too. The respiratory rate may be fast, especially in children.
• The face may have a Cushingoid appearance from current or frequent treatment with corticosteroids.
• You may be able to hear a wheeze from across the room.

Hands

• Is there nicotine on the fingers?
• Is there clubbing of the fingers? You should have a mental list of causes of clubbing (pulmonary, cardiac and other causes). If it is present, ask the patient if his nails have always been that shape or if he has noticed a change.
• Do the nails look blue as in peripheral cyanosis? In anaemia they may look pale and with iron deficiency there may be koilonychia.
• You may notice a tremor, especially with carbon dioxide retention.
• Note the radial pulse too. Tachycardia suggests significant respiratory difficulty or marked overuse of a beta agonist. Lung cancer can cause atrial fibrillation. A large pneumothorax or a tension pneumothorax can cause pulsus paradoxus.

Head and neck

The first part of the airways is the nose and mouth.

• Just briefly note if they look healthy?
• Does the tongue look cyanosed?
• Is there halitosis?
• Are there palpable lymph nodes in the neck? This may suggest lung cancer or tuberculosis.
• The jugular venous pulse may be raised in cor pulmonale.
• Eye examination may reveal Horner's syndrome or signs of sarcoidosis or tuberculosis (iridocyclitis). Papilloedema can be caused by carbon dioxide retention and cerebral metastases.
• Superior vena cava obstruction occurs with carcinoma of the bronchus and produces characteristic signs.

Chest wall

Ensure that the patient is adequately undressed and comfortable. Inspect the chest, front and back.

• Does it look normal? Pectus excavatum is very obvious but usually of no significance except that it may cause an innocent systolic murmur.
• Observe the pattern of breathing.
• Does it look hyperinflated?
• Does it move normally?
• In small children with airways obstruction, the chest is indrawn on inspiration. Children with respiratory trouble often have a very fast respiratory rate.
• Is there any asymmetry of movement?
• Sometimes a parasternal heave of right ventricular hypertrophy is visible.
• Are there any scars? Confirm what they indicate. There may have been resection of a lung or drainage of an empyema.
• Does the spine look normal. There may be kyphosis or scoliosis. If there is any doubt, run your finger along the spine. It is often easier to feel than to see an abnormal curve.

• The patient may feel hot if he is pyrexial (acute infection).
• You have already inspected for asymmetry of movement but grasp both sides of the chest and ask the patient to take a big breath right in then right out. It is often easier to feel asymmetry than to see it.
• If the chest seems overinflated and does not move much, pass a tape measure around the chest. This should be at nipple level in a man but it may be easier to pass under the breasts in a women. Ask for a deep breath in and then right out. The difference in chest circumference should be at least 5cm. Expansion may also be limited in diseases such as ankylosing spondylitis.
• Use the index finger to feel the trachea. Does it feel central or is it deviated?
• Also feel for the apex beat of the heart. It will be displaced if the mediastinum is displaced or distorted.
• Now percuss the chest. It is usual to use the middle finger of the dominant hand to do this. The clavicle is percussed directly, usually about a third of the way between the sternum and the acromium. The rest of the chest is percussed by placing the non-dominant hand on the chest and using the dominant middle finger to tap the other middle finger over the middle phalanx. Percuss over all the lobes of the lung, front and back except that the middle lobe does not have surface anatomy on the back. Percuss over the heart. In hyperinflation there is loss of cardiac dullness.
• A very resonant sound suggests hyperinflation or a pneumothorax. A dull sound is easier to distinguish from normal. It may suggest collapse or consolidation. It may suggest fluid. It may be possible to tap out the margins of dullness. It is suggested that an effusion rises up into the axilla laterally whilst with collapse the dullness sinks down laterally. This is not a reliable sign.
• To assess tactile vocal fremitus, use the medial side of the hand, by the hypothenar eminence with the palms facing upwards. Place it at various levels over the back, each time asking the patient to say,"Ninety-nine". Note how the sound is transmitted to the hand.

It is now time to use the stethoscope placing the diaphragm lightly on the chest.

• Listen to the heart in the 4 standard places for the 4 valves as described in examination of the cardiovascular system. Severe lung disease may cause pulmonary hypertension and a loud P2. A gallop rhythm will suggest heart failure. This brief examination of the heart is to exclude cardiac disease as a cause of the respiratory symptoms. This is usually conducted quite briefly with the patient sitting up when attention is on the respiratory system, ignoring the full technique for auscultation of the heart, such as having the patient lying on his left side to hear the mitral valve and sitting forward in full expiration for the aortic valve.
• Place the stethoscope over each of the 5 lobes of the lungs in turn, on the front of the chest and ask the patient to take a deep breath in and out. Do the same over 4 lobes of the back and also over the bases of the lungs.
• If there are rales over the bases, ask the patient to cough or take a few deep breaths to see if they disappear. If they do, they can be dismissed as atelectasis from sitting still or lying down and it is of no consequence.
• Bronchial breathing is when sounds are harsh and poor in nature. Unlike normal vesicular breath sounds, there is a gap between the inspiratory and expiratory phase sounds.
• Some people test vocal fremitus with the stethoscope rather than the hand. Place the stethoscope at various levels over the back and ask the patient to whisper "ninety-nine" each time. Note how well the sound is transmitted.
• Another sign that is often overlooked in these days of ready access to imaging, is whispering pectoriloquy It is elicited as for vocal fremitus but ask the patient to whisper "one, two three."

It may be debated if peak flow measurement is part of examination or investigations but as most GPs carry a mini Wright's peak flow meter in their cases, it may be seen as a tool for examination, as is the ophthalmoscope, auriscope or stethoscope. A smaller, lower reading version may be required for children or adults with severe airways obstruction.

Take 3 readings and record the highest figure. If they are rising significantly each time then take a 4th as the patient is getting used to correct use of the instrument. Peak flow will be significantly reduced in asthma and COPD but may be remarkably normal in restrictive lung disease such as pulmonary fibrosis.

Normal values for peak flow are taken from a chart. They vary with height, age and sex of the patient.

Eliciting the signs is of very limited value without being able to interpret them too.

Inspection

• Central cyanosis means that there is at least 5g of deoxygenated haemoglobin per 100 ml of blood. It tends to imply severe hypoxia but it occurs more readily with polycythaemia and is rare with anaemia.
• An overinflated chest implies COPD and premature airways closure. It may also occur in severe acute asthma. The patient breathes out through pursed lips to raise the pressure in the airways to reduce premature closure.
• If expansion is asymmetrical, the abnormality is on the side that moves less. This may be pneumothorax, collapse, consolidation or effusion.
• Clubbing tends to be particularly severe in lung cancer.

Tactile signs

• The trachea is deviated away from pneumothorax and effusion and towards collapse and consolidation.
• Dull percussion is heard over collapse, consolidation and effusion. It is hyper-resonant over a pneumothorax.
• Tactile vocal fremitus is increased over areas of consolidation and decreased or absent over areas of effusion or collapse.

Auscultation

• Normal breath sounds are called vesicular. They are sometimes described as quiet and gentle like the sound of a breeze rippling through the leaves of a tree.
• Rhonchi are wheezes. They are a musical sound heard on expiration. In severe cases they may be both inspiratory and expiratory. They imply narrowing of the airways so that turbulent flow occurs. Whether with air or with blood, laminar flow is silent but turbulent flow makes a sound. Turbulent flow is responsible for heart sounds, whether a murmur or the normal closure of a valve. If rhonchi are purely inspiratory and not expiratory, it may suggest that obstruction is outside the thoracic cavity. Perhaps there is a foreign body in the upper airways or disease of the larynx or vocal cords. The loudness of rhonchi gives no indication of the severity of the condition. Severe asthma is too tight to wheeze.
• Rales are sometimes called crackles. They probably represent opening of small airways and alveoli. As mentioned above, they may be normal at the lung bases if they clear on coughing or a few deep breaths. Basal rales are a classical feature of pulmonary congestion with left ventricular failure. They may be more diffuse in pulmonary fibrosis.
• Bronchial breathing suggests consolidation or fibrosis. The sounds of bronchial breathing are generated by turbulent air flow in large airways and similar sounds can be heard in healthy patients by listening over the trachea. The sounds are not normally conducted to the chest wall because they are attenuated by air filled alveoli and lung parenchyma. Consolidation or fibrosis permits the sound of air flow in the bronchi to be conducted more effectively to the chest.
• Whispering pectoriloquy is the increased quality and loudness of whispers that are heard with a stethoscope over an area of lung consolidation.