Respiratory System - History and Exam

Competence in history and examination is one of the fundamentals of being a clinician, but that does not mean that it is easy.

An hour is allowed for the long case in both finals and MRCP. Many consultant physicians allow themselves an hour for a new patient. This includes history, examination, plan of management and explanation to the patient. The usual time allocated for a patient in general practice is 10 minutes. Hence it is necessary to be efficient in extracting the important information in a short space of time. That is not in any way to detract from the skills and diligence of the consultant who spends an hour with the patient.

"Listen to the patient. He is telling you the diagnosis," comes the wisdom of ages. This is true and, within reason, questions should be open-ended, allowing the patient to speak freely.

The patient may gloss over something that demands deeper inquiry. You should know what is important and what needs further probing. Try not to interrupt unnecessarily but there are times when it is essential to hone in on detail. Be focussed and do not let yourself be distracted by irrelevances. Sometimes patients meander aimlessly with unnecessary detail or irrelevant anecdotes and they need to be led back. Avoid leading questions or implying that there is a certain answer that you want. Try to let the patient speak freely in his own words.

Before even starting with the history, it is usual to confirm the patient's name, age and occupation. The last may be very important in respiratory medicine as there may be exposure to fumes or particles that can cause disease. If the patient has not been in the job for long, ask about previous jobs. More detailed employment history may be required later. For example, if it transpires that asbestosis is a possibility then an occupational history may have to go back in excess of 20 years.

Let the patient tell his story freely. What he chooses to say may illuminate what he feels are important aspects of the problem and perhaps give insight into his conceptions about aetiology and fears about the possible diagnosis. When he has finished you should be able to answer several questions about the problem:

• What is the principle complaint? Examples include dyspnoea, wheezing or a cough.
• 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?

These features may demand further inquiry.

Dyspnoea

Many of the questions may also apply to wheezing.

• When does dyspnoea occur?
• Is there shortness of breath on exertion? How much exertion?
• Is it getting worse?
• Is there dyspnoea 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.

Always keep an open mind, remembering 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. There is cardiac asthma as well as respiratory asthma. Severe anaemia causes shortness of breath on exertion. Neuromuscular disease can cause dyspnoea. Dyspnoea can be hysterical. The patient may admit to tingling in the fingers and numbness in the face whilst struggling for breath but this may require direct questioning if this is suspected.

Asthma, whether presenting as wheezing or dyspnoea, may be precipitated by factors such as stepping out into a cold morning or entering a smokey room. Try to keep questions open rather than leading. "When you go out in the morning, does the weather make any difference?" or "Are there any situations or places that cause you problems?" Failure to get the expected response may necessitate a more direct approach but be careful not to imply that you want the patient to say something. They can be so obliging that they will mislead you.

Cough

Remember that the mildest asthma is a cough. Only moderate asthma wheezes whilst severe asthma is too tight to wheeze and the silent chest is life-threatening. Remember the broad picture too. Paroxysmal nocturnal coughing can be from heart failure and perhaps the patient is treated with ACE inhibitors. 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.

By now you have obtained a considerable amount of history about the problem. You may well have an idea of the diagnosis but keep an open mind as there may still be unexpected developments on the way.

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. 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 sucessful was it?

You now have the benefit and wisdom of hindsight. You do not have to repeat the mistakes of others or repeat unnecessary investigations. One of the beatitudes that is omitted from The Sermon on the Mount is Blessed is he who sees the patient last.

There may be a history of childhood asthma. There may be a history of malignancy and now there are pulmonary metastases. It may have been sucessfully treated with drugs such as busulphan that can cause pulmonary fibrosis. It may be the past history that gives the clue to the aetiology.

Diseases can have a genetic component or aetiology such as asthma and cystic fibrosis. There may be infectious diseases such as tuberculosis. Do not forget tuberculosis, especially in those whose racial origins are from the Indian subcontinent. It occurs in others too and is a disease that is easily overlooked.

• 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.
• Smoking is an obvious question. Remember that some children start to smoke very early in life. Ask about passive smoking.
• Ask about drugs. ACE inhibitors often cause a cough. Beta blockers may precipitate latent asthma. Some drugs can cause pulmonary fibrosis. The patient may have been diagnosed as having asthma and has just a beta agonist inhaler that he uses 8 to 10 times a day.
• Ask about illicit drugs. They may be smoked or inhaled.
• Ask about alcohol consumption and allergies as a matter of routine.
• This is probably a good time to take a more extensive occupational history if suggested. Go back some years. Find out exactly what the job involves. Ask about exposure to potentially toxic substances. An electrician, a carpenter and a sailor in the merchant navy may all have been exposed to asbestos.

By the end of the history, you probably have a fairly good idea of the diagnosis and even what to expect on examination. It should be performed in a competent manner to confirm the diagnosis and possibly to direct further investigations. Practice good technique. It is the best way to get accurate results. In both finals and MRCP exams, getting the right answer by the wrong method will result in failure but achieving the wrong answer by using correct technique may still 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).

Look

Keep the stethoscope hidden away. It is not required until the last part of the examination. Look at 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 alnae 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.

Now look at the hands.

• Is there nicotine on the fingers?
• Is there clubbing of the fingers? You should have a mental list of causes of clubbing. 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.

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.

Look at the chest

Only now is it time to look at the chest and it is still not time to extract the stethoscope. Make sure that the patient is adequately disrobed and is comfortable. Make sure that you are comfortable too. Look at the chest, front and back.

• Does it look normal? Pectus excavatus is very obvious but usually of no significance except that it may cause an innocent systolic murmur.
• 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 very pyrexial, suggesting 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 extract the stethoscope. Use the diaphragm, placed 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, auroscope or stethoscope. A smaller, lower reading version may be required for children or adults with severe airways obstruction.

Give a clean mouth piece. Most people use cardboard disposable mouth pieces. Set the reading to zero and tell the patient that you want a short, sharp puff into the meter, as hard as possible. The first part of the puff is important. The final part, as examined in spirometry, does not register. Note the reading, reset to zero and ask him to repeat the performance, again emphasizing the importance of the first hard part of the puff. 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 100ml 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 particulary 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.
• Rhonci 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 rhonci 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 rhonci gives no indicaton 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.