Respiratory History
History of Presenting Complaint
Occupational History
Travel History
Family History
Richard Shaw
RESPIRATORY MEDICINE
Wheeze
Asthma
COPD
Infections
o Bronchiolitis
Airway obstruction
o Foreign body
o Tumour
Dyspnoea
How far can you walk on flat ground/up stairs before you
become breathless? What was normal for you before?
How many pillows do you sleep on? Orthopnoea, PND
NYHA Dyspnoea Classification
Class I
On heavy exertion
Class II
On moderate exertion
Class III On minimal exertion
Class IV At rest
Cardiovascular
o Acute MI*
o CHF/LV failure
Strong alcohol hx
o Cardiac tamponade*
o Constrictive pericarditis
Respiratory
o Upper Airway (+/- stridor)
URTI
Hx of allergy
Epiglottitis
Children
Children, hx of choking
Laryngeal/pharyngeal tumour*
o Lower Airway (+/- wheeze)
Asthma
COPD
Richard Shaw
Bronchiectasis
CF
o Parenchymal
ARDS*
Pneumonia
Rapid onset
Tuberculosis
Travel hx to TB endemic
areas
Immunosuppressed status
(HIV/AIDS)
ASx - cough
Pulmonary tumours*
Hx of immobilisaton, orthopaedic
procedures, COCP, PE Hx, travel
Pulmonary HTN
Pulmonary vasculitis
o Pleural
Pneumothorax
Instantaneous, pleuritic
chest pain
Tension pneumothorax*
Pleural effusion
Secondary to infection or
malignancy
Chest Wall
o Deconditioning, obesity, pregnancy
o Kyphoscoliosis
o C-spine injury
o Myasthenia gravis, Guillain-Barre syndrome
o Polymyositis, MND
RESPIRATORY MEDICINE
Other
o
o
o
o
Richard Shaw
TSH levels
Sputum Culture
Exacerbating/Alleviating Factors
o Allergens, weather, smoke, exertion, URTI
Relevant negatives
o Wheeze
o Cough +/- sputum
o Fever/night sweats
o Chest pain/discomfort
o PND/orthopnoea
o Leg swelling
Seconds to Minutes
o Asthma
o PE
o Pneumothorax
o Pulmonary Oedema
o Anaphylaxis
o Foreign body airway obstruction
Hours to Days
o COPD exacerbation
o Cardiac failure
o Asthma
o Respiratory infection
o Pleural effusion
o Metabolic acidosis
Weeks or Longer
o Pulmonary fibrosis
o COPD
o Pleural effusion
o Anaemia
Investigations
Pulse oximetry
o Hypoxaemia
Peak Expiratory Flow
o in COPD, asthma, CF
CXR
o Pneumothorax
o Pneumonia
o Pulmonary oedema
ABG
o PaCO2 in COPD (>45mmHg)
o PaCO2 in anxiety, PE (<45mmHg)
o PaO2 in ARDS, pneumonia, pulmonary
oedema, V/Q mismatch (COPD, asthma, PE)
(<70mmHg)
ECG
Spirometry
o Pre and post-bronchodilator
FBC
o Hb in anaemia
o WCC in infection
o Cardiac enzymes if chest pain
Electrolytes
o Hyponatraemia in CCF, CKD, liver failure
BNP
o in CCF
D-dimer
o PE
RESPIRATORY MEDICINE
Cough
Airway irritants
o Inhaled smoke, dusts, fumes
o Upper airway cough syndrome (UACS)
Immediately after
eating/drinking
Positional, supine/slouching
Foreign body
Acute or persistent
o Bronchiolitis
Acute, painful
o Acute/chronic bronchitis
o Bronchiectasis
Strong smoking hx
Worse in morning
o Asthma
Richard Shaw
Smoking hx
Sub-acute onset
Investigations
Chest X-Ray
o Lung cancer, pulmonary fibrosis, TB,
bronchiectasis, pneumonia, aspiration
If asthma suspected
o Spirometry (pre and post-bronchodilator)
o Bronchoprovocation challenges
CT Chest/Bronchoscopy
RESPIRATORY MEDICINE
Richard Shaw
RESPIRATORY MEDICINE
Haemoptysis
Smoking hx
Hx of inhalation
Hx of recurrent infections
o Lung Abscess*
White, hx of smoking
Richard Shaw
Vascular Disease
o Pulmonary Embolism
Hx of immobilisaton, orthopaedic
procedures, COCP, PE Hx, travel
Acute LVF
Hx of HTN, DM,
dyslipidaemia, tobacco use
Hx of recurrent respiratory
infection during childhood
(rheumatic heart disease)
Thrombocytopoenia
Coagulopathy
Wegener's granulomatosis
Carcinoma
Cystic Fibrosis
Bronchiectasis
Tuberculosis
Investigations
FBC
o Infection, blood loss, haematological disease
Coagulation studies coagulopathies
ABGs
U/A pulmonary-renal syndrome
ECG +/- echocardiogram cardiovascular causes
Imaging
o Chest X-Ray Cancer, TB, bronchiectasis etc
o Chest CT with contrast sensitivity
o Bronchoscopy
RESPIRATORY MEDICINE
Richard Shaw
Examination
General Observation
Arm
Blood Pressure
Face
Inspection
Eyes
o
Anaemia
Fundoscopy for hypertensive changes (Keith-Wegerer)
Sinuses
o Palpate frontal and maxillary sinuses
Hands
Fingers
o Polyps associated with asthma
o Peripheral cyanosis
Mouth
Lung carcinoma
o Central cyanosis (tongue)
Bronchiectasis
pneumonia), cyanotic heart disease
Lung Abscess
o Pharyngeal/tonsillar erythema +/- pus (white)
Empyema
URTI
Sleep apnea
o Tar staining
o Dental hygiene/tooth decay
Palms
Hypercapnia
Inspection
o Palmar crease pallor
Trachea
Anaemia
o Displaced trachea
o Muscle wasting
Pneumonectomy
Wrists
Tension pneumothorax
Palpation
o Tracheal tug (thyroid cartilage movement)
RESPIRATORY MEDICINE
Respiratory distress/COPD
Confirm accessory m. use (if dyspnoea evident),
palpate for scalenus m. in supraclavicular fossae
Forced Expiratory Time
COPD
o Loose Productive
Chronic bronchitis
Pneumonia
Bronchiectasis
o
Chest
Inspection
Subcutaneous emphysema
o Pneumothorax, oesophageal rupture,
pneumomediastinum
WOB
o Parodoxical inspiratory abdominal in-drawing
Diaphragmatic paralysis
Move posteriorly to finish inspection (WARN THE PATIENT)
Richard Shaw
COPD
Hyperresonant
o Pneumothorax
o Emphysema
o Bowel
Hyperinflation
Emphysema or asthma
Auscultation (diaphragm + bell in supraclavicular fossae)
RESPIRATORY MEDICINE
Atelectasis
Tension pneumothorax
Decreased Intensity
o COPD (especially emphysema), Pneumothorax
o Pleural effusion, Pneumonia
o Neoplasm, Atelectasis
o Unilateral/focal foreign body, tumour
Added (Adventitious) Sounds
o Wheeze (low pitch wheeze = rhonchi)
Asthma
COPD
Foreign body
o Crackles (low-pitch = rales, high-pitch =
crepitations)
Fine Crackles
Medium Crackles
LVF/pulmonary oedema
(late inspiratory)
Coarse
Bronchiectasis
Richard Shaw
Pleural effusion
Tension pneumothorax
Heave
o RV heave at left sternal edge RHF
Abdomen
Palpate Liver
o Ptosis emphysema
o Hepatomegaly lung carcinoma metastases
Back
Effusion
Consolidation
Percussion
Note
Vocal
Resonance
+ harsher
Atelectasis
in pneumonia
with
tumour/mucus
Pneumothorax
Breath
Sounds
+ harsher +
higher pitch
with
pneumonia
with
tumour/mucus
RESPIRATORY MEDICINE
10
Richard Shaw