CHAPTER 5 The aim of taking the respiratory history is to construct a sensible differential diagnosis. The clinical examination will then help to narrow the differential diagnosis and determine which investigations are required to confirm the suspected diagnosis in most cases. Taking a detailed history in a fluent way is an important skill to learn and will improve with experience. While medical students are taught to take the history in a certain order, this is not critical so long as the history is comprehensive, and the relevant points are covered. A structured approach is, however, essential. Box 5.1 lists the important points to take in a patient presenting with respiratory symptoms or signs. This is demonstrated in the supplementary material (www.wiley.com/go/Paramothayan/Essential_Respiratory_Medicine). Demographic information includes the age, sex, ethnicity, and country of origin of the patient. This is important as certain conditions are more prevalent in males or females, and several respiratory conditions are more common in people from certain countries and ethnic backgrounds. It is important to elicit what the presenting complaint is, including the onset, nature, severity, and duration of the symptom. It is important to understand what factors exacerbate or relieve the symptom, whether the patient has suffered from this symptom before and if the cause was ever found. It is important to ask about associated respiratory symptoms and systemic symptoms, such as fever, malaise, night sweats, joint pains, rashes, and weight loss, as this information can lead to the correct diagnosis. Past medical history is always relevant and should include a history of prematurity, immunisations, childhood illnesses, tuberculosis, and contact with anyone with Mycobacterium tuberculosis. A history of previous malignancies and cardiac problems is particularly important. Smoking is a significant risk factor for several lung diseases, so a detailed history of smoking should be obtained. The number of pack years should be calculated as this can quantify the risk. Patients should be asked about exposure to passive smoking at home, at work, and in social situations. A comprehensive occupational history is important as exposure to industrial dusts, chemicals, asbestos, and silica can result in the development of pulmonary fibrosis, occupational asthma, and hypersensitivity pneumonitis. It may be necessary to ascertain the occupational history of the spouse if there is concern about mesothelioma. History of recent travel abroad may be relevant when the patient presents with symptoms of infection or eosinophilia. Patients with atopy and allergy may present with symptoms of cough, breathlessness, and wheeze, and may also suffer with nasal symptoms. These patients may have a history of hay fever or eczema. Many people are allergic to a variety of inhaled allergens, for example, house dust mite, which can be demonstrated by doing a skin prick test. It is important to ask about their home environment, whether they have any pets and if their house is damp. Some patients who are exposed to bird ‘bloom’ can develop hypersensitivity pneumonitis, often called ‘bird fancier’s lung’. A detailed drug history is essential as many drugs can have an adverse effect on the lungs in a variety of ways. This is discussed in Chapter 3. Radiotherapy to the thorax can result in fibrosis, either acutely or many years later. Patients should be specifically asked whether they take or have taken any recreational drugs or any over‐the‐counter medications. Ascertaining information about the family history is important as certain respiratory conditions can be inherited, for example, cystic fibrosis, primary ciliary dyskinesia, and alpha 1‐antitrypsin. The predisposition to develop lung cancer and asthma is also inherited. In Box 5.2 the differential diagnosis of common respiratory symptoms is discussed. Breathlessness is a common presentation with a wide differential diagnosis. Dyspnoea is the term for difficulty in breathing and tachypnoea means breathing at an increased respiratory rate. A normal respiratory rate at rest is between 12 and 16 breaths per minute but will, of course, increase with exertion. Orthopnoea describes difficulty with breathing when lying flat and may be secondary to cardiac failure, chronic obstructive pulmonary disease (COPD), obstructive sleep apnoea (OSA) or diaphragmatic palsy. Paroxysmal nocturnal dyspnoea (PND) describes the sudden onset of breathlessness, with the patient gasping, requiring them to sit upright in bed. This occurs most commonly with pulmonary oedema, but patients with severe OSA often report waking up gasping for breath. Apnoea means cessation of breathing for more than 10 seconds and may occur repeatedly in OSA. Kussmaul breathing, often described as ‘air hunger’, is deep and laboured breathing that occurs with severe metabolic acidosis, for example, diabetic ketoacidosis or chronic renal failure, when the respiratory centre is stimulated to blow off carbon dioxide as a compensatory mechanism. Cheyne‐Stokes respiration occurs in patients with severe heart failure and in those with central sleep apnoea due to the oscillation in the level of carbon dioxide in the blood; there is a cyclical pattern of breathing, from hypoventilation, even apnoea, to hyperventilation. The onset of breathlessness can be acute or chronic in nature. Table 5.1 lists some common causes of acute and chronic breathlessness. Table 5.1 Causes of breathlessness. When asking patients about their symptom of breathlessness, it is essential to establish whether this was acute or gradual in onset, whether it occurs at rest or on exertion. If it occurs on exertion, then it is important to find out how far they can walk and whether their breathlessness affects their activities of daily living. The severity of breathlessness can be graded using the Medical Research Council’s Dyspnoea Grade (MRC Grade) which is described in Box 5.3. The BORG scale can also be used to grade perceived breathlessness, especially in the context of exercise testing. Other important points in the history include the overall duration of breathlessness, whether it is progressively getting worse, whether there is any diurnal variation, or if it is worse when lying down. Patients with diaphragmatic weakness will complain of breathlessness when lying flat and when under water, for example, swimming, as the abdominal contents push up on the diaphragm, reducing ventilation. Collateral history from a member of the family who has observed the patient can be very useful. Breathlessness can be life‐threatening and anyone presenting with this will need immediate attention. The patient should be assessed quickly with regards to the airways and breathing, have their oxygen saturation and arterial blood gas measured, and commenced on the appropriate amount of oxygen through the correct device. If a respiratory arrest is imminent, then the anaesthetist should be called urgently with view to intubation. If intubation and ventilation are not necessary, the patient should have continuous monitoring of oxygen saturation, serial measurement of arterial blood gases, a chest X‐ray, and an electrocardiogram (ECG). The management of type 1 and type 2 respiratory failure is discussed in Chapter 13. Cough is a violent, forceful, protective reflex provoked by the stimulation of receptors in the larynx, trachea and bronchial tree to remove inhaled irritants, including secretions. Violent coughing can result in cough syncope due to reduction in venous return and cerebral perfusion. Acute cough is a common presentation to General Practice, is often secondary to a respiratory infection and therefore self‐limiting. When taking a history of cough from a patient, it is important to ask whether the cough is acute or chronic, dry or productive, the duration of the cough, whether the patient is a smoker, and whether the patient has any associated symptoms. Patients with a chronic cough, which affects 8% of the population, are often referred for a specialist opinion. Chronic cough (more than six weeks in duration) may be due to several different pathologies, for example, asthma, COPD, or lung cancer. In many cases, there are multiple causes for the cough. It is important to ask about the volume, content, and colour of any sputum produced as this can give clues as to the aetiology of the cough. Yellow or green sputum usually indicates a bacterial infection, persistently green and foul‐smelling sputum may suggest bronchiectasis, and large volumes of watery sputum (bronchorrhoea) can occur in those with bronchoalveolar cell carcinoma (Adenocarcinoma in situ). Patients who present acutely with a productive cough and other symptoms, such as breathlessness and fever, may have a more serious respiratory tract infection, such as community acquired pneumonia, and may require antibiotics. As well as a careful physical examination, they will need blood tests to check the inflammatory markers, and a chest X‐ray (CXR) to see if there are any signs of consolidation. A sputum sample should be sent for microscopy, culture, and sensitivity and to look for acid‐alcohol‐fast bacilli. Patients with recurrent chest infections should have further investigations (see Chapters 6 and 8). Box 5.4 lists the possible causes of a dry cough in a non‐smoker with a normal CXR. A careful history and examination should point to the most likely diagnosis. If cough‐variant asthma is suspected, then a chest X‐ray, spirometry, skin prick testing, peak flow homework, methacholine challenge, and high‐resolution computed tomography (HRCT) may be required to exclude other pathology and to confirm the diagnosis. Treatment with inhaled steroids should result in the resolution of the cough. If GORD is suspected, then pH studies may be required, although many doctors will prescribe a trial of a proton pump inhibitor to see if there is improvement. If a post‐nasal drip is felt to be the most likely cause, then a CT sinus may be helpful. Antihistamines and steroid nasal sprays given in the head‐down position should improve the cough. If the likely cause of the cough is not clear, then a nose and throat examination may be helpful in determining whether there are any signs of acid reflux, infection, cobblestoning (which might indicate chronic throat clearing), nasal pathology, and to rule out a foreign body in the airways. Post‐infectious coughs are common and can persist for months. Treatment with oral or inhaled steroids for a minimum of two weeks can result in an improvement in symptoms. In cases of cough secondary to allergy, it is important to identify the triggers and remove them if possible. Antihistamines may also be helpful. Up to 20% of patients on an ACE inhibitor can develop a dry, irritating cough; this may not necessarily occur immediately after commencing the medication. Most smokers have a persistent ‘smoker’s’ cough and those with COPD and chronic bronchitis have a daily productive cough, mainly in the mornings. However, a persistent cough is the commonest symptom of lung cancer, so a careful history, a clinical examination, and a chest X‐ray should be conducted in all patients with a smoking history. Patients with damage to the vagus nerve or with recurrent laryngeal nerve palsy may present with a ‘bovine’ cough which is a non‐explosive cough due to an inability to close the glottis. These patients will also have a hoarse voice or dysphonia. These patients should have a computed tomography (CT) thorax and a bronchoscopy. Coughing up blood indicates lung pathology and is alarming for the patient. Occasionally epistaxis, haematemesis, or bleeding from the gums can be misinterpreted as haemoptysis, so a careful history with specific questions about the nature of the blood must be obtained. In most cases, fresh, red blood mixed with sputum indicates lung pathology. Dark, altered blood may be of gastrointestinal origin. Infection and inflammation of the respiratory tract are the commonest cause of small volume haemoptysis and patients will have other symptoms and signs of infection, including cough and fever. Bronchiectasis, pulmonary tuberculosis, and aspergilloma are also in the differential diagnosis for haemoptysis. Sputum microscopy and culture are essential to identify the causative organism and to test for antibiotic sensitivities. Haemoptysis is a common presentation of lung cancer, so patients at risk of lung cancer should be investigated quickly with a chest X‐ray followed by a CT thorax and a bronchoscopy. Sputum cytology may have a role in patients who are suspected of having lung cancer but who are too frail for invasive tests. Table 5.2 lists the causes of haemoptysis. Table 5.2 Causes of haemoptysis. Bleeding secondary to a biopsy at bronchoscopy is common and usually settles after a few minutes. Topical adrenaline, 10 ml of 1 : 10,000, should be administered slowly and directly to the site of bleeding while monitoring the patient’s pulse and blood pressure. If the bleeding does not settle, then the patient will have to be managed as described below for life‐threatening haemoptysis. Patients having a bronchial biopsy, or a CT‐guided biopsy should be informed that they could cough up blood for several days post procedure. If there is evidence of continuous, but non‐life‐threatening bleeding, then they should be discharged home on oral Tranexamic acid, an antifibrinolytic agent, 1–1.5 g twice or three times a day. The term massive haemoptysis should be avoided as the definition of what this is varies widely in the literature and it is impossible to quantify the amount of blood loss, as much of the blood may be in the lungs. Most experts agree that the term life‐threatening haemoptysis is preferable and the definition is bleeding of >200 ml in 24 hours which results in airway obstruction and abnormal gas exchange, which does not stop, and which causes haemodynamic compromise. The cause of death from uncontrolled haemoptysis would be from asphyxiation. Life‐threatening haemoptysis is rare, estimated as <1.5% of all cases of haemoptysis. In the past, pulmonary tuberculosis and bronchiectasis were the common causes, now lung cancer, aspergilloma, and cystic fibrosis are the commonest causes. In these cases, the bleeding occurs due to erosion in the bronchial artery. The mortality depends on the age of the patient, any underlying lung and cardiac disease, the rate of bleeding and the ability of the patient to clear the blood from the airways. Mortality may be up to 25% in those managed conservatively and up to 20% with surgery, although the estimates vary greatly in the literature. Patients presenting with life‐threatening haemoptysis must be managed in the intensive care unit or high dependency unit by intensivists and respiratory physicians. The patient will require immediate resuscitation with intravenous fluids, airway protection, oxygen supplementation, cross‐matched blood, fresh frozen plasma, and the correction of any coagulopathy. Bloods should also be sent for urgent vasculitic screen. Tranexamic acid has been shown to reduce overall bleeding time, the duration of bleeding, and the overall volume of blood loss, with no short‐term thromboembolic complications. Intravenous tranexamic acid should be given as a slow infusion at a dose of 100 mg min−1 followed by 25–50 mg kg−1 over 24 hours. If the patient is haemodynamically stable, then an urgent computed tomography pulmonary angiography (CTPA) should be carried out to exclude pulmonary embolus and to identify any obvious masses or cavities. The source of the bleeding should be identified, ideally with rigid bronchoscopy, although this may not be easy if there is a lot of blood, and the patient may require selective lung intubation before this can be carried out. Topical adrenaline, a potent vasoconstrictor, may reduce the bleeding and endobronchial tamponade may be effective in stemming the flow of blood. The patient should be nursed lying on the side of the bleeding lung. The source of the bleeding can be identified by bronchial angiography with embolization of the bronchial artery. Early discussion with a thoracic surgeon is important as surgical resection of the affected part of the lung may be required if the bleeding cannot be stopped. Chronic haemoptysis secondary to lung cancer can be treated by palliative radiotherapy. Patients in whom the source of bleeding cannot be identified are managed conservatively. Chest pain is a common and worrying symptom. It can be due to significant pathology, so should always be taken seriously. When taking the history of chest pain, it is important to be specific about the nature of the pain, the onset, duration, site, radiation, periodicity, exacerbating factors, and relieving factors. Chest pain of cardiac origin is generally described as a dull ache with radiation down the left arm, towards the jaw or to the back. Patients with cardiac‐sounding pain may also describe breathlessness. Pain arising from the gastrointestinal system (epigastrium, liver, gall bladder, spleen) can radiate to the chest and the shoulders and this can be confused with cardiac or respiratory pain. Musculoskeletal pain, which is pleuritic in nature, is worse with inspiration and with movement and there will be musculoskeletal tenderness on palpation. The patient may complain of breathlessness if he or she is unable to fully expand his or her lungs due to the pain. Musculoskeletal pain can occur secondary to chest wall trauma and the pain can be severe if ribs have been fractured. Costochondritis occurs due to inflammation of the costochondral, costosternal, or sternoclavicular joints and is a common cause of musculoskeletal chest pain in young adults. Costochondritis is commoner in females and in patients with fibromyalgia. It is self‐limiting, with symptoms resolving within eight weeks. The term Tietze’s syndrome is used when there is swelling of these joints. Bornholm disease is caused by Coxsackie virus B, which results in muscle aches and pains in the chest wall. Chest pain secondary to respiratory pathology is usually pleuritic in nature. It is described as sharp and stabbing and aggravated by inspiration and coughing. It occurs due to inflammation of the pleura from any cause. Rubbing of the visceral and parietal pleura against each other stimulates the nerve endings. Crackles may be heard when there is ‘pleurisy’ of any aetiology. Pleuritic chest pain responds well to non‐steroidal anti‐inflammatory drugs which should be prescribed regularly, so long as there are no contra‐indications. Table 5.3 lists common causes of pleuritic chest pain and the basic investigations that would be required. Table 5.3 Common causes of pleuritic chest pain. Patients with lung cancer may have chest wall infiltration with tumour which can cause severe pain. Metastases to ribs and bones can also cause severe pain. In these cases, there are likely to be several other symptoms and signs and abnormal radiology. Patients with malignant mesothelioma (see Chapter 9) often present with a persistent dull ache in their chest which progressively gets worse over time. Pain secondary to lung cancer or malignant mesothelioma often requires high doses of opioid drugs to control it. Palliative radiotherapy is also indicated as a treatment for bony pain. Wheeze is a high‐pitched whistling sound made when the airways are narrowed and can occur during inspiration or expiration. Patients may not complain of wheeze but may report breathlessness or chest tightness. Family members may report that they have heard wheezing. Widespread, polyphonic, expiratory wheezing is commonly associated with obstructive airways disease, such as asthma or COPD. Diurnal symptoms or symptoms made worse with exercise or cold air suggest a reversible cause, such as asthma. Patients with an occupational cause of asthma will report breathlessness and wheezing while at work which improves when they are away from the work environment. Similarly, those who are allergic to pets usually feel better when they are away from the animal. Patients who develop wheezing secondary to obstructive airways disease will improve with bronchodilators and corticosteroids. Cardiac failure can present with widespread wheeze, sometimes termed ‘cardiac asthma’. A monophonic wheeze can be a sign of a fixed obstruction which may be secondary to endobronchial narrowing, for example, with tumour. Wheezing can be audible from the end of the bed, but usually requires a stethoscope to be heard. Patients with vocal cord dysfunction present with what appears to be a wheeze. However, all the noise is generated in the throat from closure of the vocal cords which move paradoxically and there will be no wheeze heard on auscultation of the chest. The diagnosis and management of this are discussed in Chapter 6. Many viral and bacterial infections can result in a brief period of laryngitis which improves over a few days and weeks. A persistent hoarse voice indicates inflammation or damage to the larynx or to its nerve supply. The left recurrent laryngeal nerve has a long course through the left hemithorax (see Chapter 2) and can be damaged by trauma, thoracic and neck surgery (particularly thyroid surgery), and lung cancer. Persistent hoarse voice in a smoker requires immediate investigation with CXR, CT thorax, and a bronchoscopy. Snoring is a common symptom during sleep which is often not pathological. It describes a sound made by the turbulent flow of air through narrowed upper airways. Snoring is often positional, usually worse when lying on the back, exacerbated by alcohol and sedatives, and worse in older people with lax muscles, and in those who are overweight. It can become a problem when it disturbs the patient’s sleep or their partner’s sleep. Such patients are often referred for polysomnography to rule out obstructive sleep apnoea. This is discussed in Chapter 14, and is demonstrated in the supplementary material. Examination of the respiratory system should be thorough and systematic. It is important to observe the patient from the end of the bed, if possible, positioned at a 45° angle. The respiratory rate at rest should be counted. A normal respiratory rate is between 12 and 16 breaths per minute at rest. The tidal volume is 500 ml with a minute ventilation rate of 6 L min−1. Expiration, which is a passive process, takes slightly longer than inspiration, which is an active process. Hyperinflation will result in a prolonged expiratory phase of breathing. From the end of the bed, with the patient taking a deep breath in, it is possible to note any abnormality or asymmetry of the chest wall and whether one side of the chest moves less than the other (Figure 5.1). The side that moves less is always the side with the pathology. Observation should also be made of pursed‐lip breathing, use of accessory muscles, intercostal recession, and tracheal tug, all of which are signs of hyperinflation. Figure 5.1 Observing chest expansion on inspiration. Box 5.5 lists some common chest wall deformities which can cause abnormal breathing and lead to the development of respiratory failure.
Common presentations of respiratory disease
Abbreviations
Respiratory history
Breathlessness
System
Acute onset (minutes to hours)
Sub‐acute onset
(hours to days)
Chronic onset
(weeks to months)
Respiratory
Pulmonary embolus
Pneumothorax
Acute asthma
Upper airway obstruction
Foreign body inhalation
Epiglottitis
Anaphylaxis
Hypersensitivity pneumonitis
Exacerbation of asthma
Exacerbation of COPD
Community acquired pneumonia
Bronchiectasis
Hypersensitivity pneumonitis
Idiopathic pulmonary fibrosis
Sarcoidosis
Chronic pulmonary emboli
COPD
Lung cancer
Pleural effusion
Idiopathic pulmonary fibrosis
Sarcoidosis
COPD
Any interstitial lung disease
Pulmonary hypertension
Obstructive sleep apnoea
Cardiac
Pulmonary oedema
Ruptured heart valves
Myocardial infarction
Arrhythmia
Aortic dissection
Cardiac tamponade
Left ventricular failure
Congestive cardiac failure
Pericardial effusion
Arrhythmia
Congestive cardiac failure
Cardiomyopathy
Neuromuscular
Guillain‐Barré
Botulism
Poliomyelitis
Diaphragmatic palsy
Myasthenia gravis
Diaphragmatic palsy
Poliomyelitis
Motor neurone disease
Muscular dystrophies
Multiple sclerosis
Myasthenia gravis
Amyotrophic lateral sclerosis
Musculoskeletal
Traumatic fracture
Costochondritis
Chest wall disease
Post‐thoracic surgery
Chest wall disease
Kyphosis
Scoliosis
Chest wall surgery (thoracoplasty)
Central nervous system
Acute stroke
Acute stroke
Parkinson’s disease
Metabolic
Diabetic ketoacidosis
Ethylene glycol poisoning
Salicylate poisoning
Diabetic ketoacidosis
Chronic renal failure
Salicylate poisoning
Chronic renal failure
Endocrine
Thyrotoxicosis
Phaeochromocytoma
Hypothyroidism
Large goitre
Haematology
Chronic anaemia
Psychological
Panic attack
Hyperventilation
Anxiety
Chronic anxiety
Phobias
Physiological
Strenuous exercise
Acute mountain sickness
Deep sea diving
Mountain sickness
Pregnancy
Mountain sickness
Obesity
Management of severe breathlessness
Cough
Haemoptysis
Malignancy (see Chapter 9)
Carcinoma of lung
Carcinoma of trachea
Infection (see Chapter 8)
Mycobacterium tuberculosis
Aspergilloma
Community acquired pneumonia
Aspiration pneumonia
Lower respiratory tract infection
Bronchiectasis
Cystic fibrosis
Lung abscess
Histoplasmosis
Vascular (see Chapter 11)
Pulmonary emboli
Arterio‐venous malformation
Hereditary haemorrhagic telangiectasia
Goodpasture’s syndrome
Polyangiitis (Wegener’s granulomatosis)
Autoimmune
SLE pneumonitis
SarcoidosisBehçet’s disease
Cardiac
Pulmonary oedema
Mitral stenosis
Miscellaneous
Coagulopathies
Anticoagulant therapy
Trauma, including violent coughing
Inhalation of foreign body
Pulmonary haemosiderosis
Pulmonary endometriosis
Broncholithiasis
Management of life‐threatening haemoptysis
Chest pain
Onset
System
Diagnosis
Investigations
Acute (minutes to hours)
Respiratory
Pneumothorax
Pulmonary embolus
Chest X‐ray
CTPA or VQ scan
Acute (minutes to hours)
Musculoskeletal
Trauma
Rib fractures
Costochondritis
Tietze’s syndrome
Chest X‐ray
CT thorax
Clinical examination
Sub‐acute (hours to days)
Respiratory
Pneumothorax
Pulmonary embolus
Pleural effusion
Chest X‐ray
CTPA or VQ scan
Sub‐acute (hours to days)
Musculoskeletal
Costochondritis
Tietze’s syndrome
Bornholm disease
Clinical examination
Chronic (days to weeks)
Respiratory
Pneumothorax
Community acquired pneumonia
SLE pneumonitis
Pleural effusion
Chest X‐ray
Chest X‐ray
CT thorax
Clinical examination
Chest X‐ray
CT thorax
Pleural ultrasound
Chronic (days to weeks)
Musculoskeletal
Costochondritis
Tietze’s syndrome
Bornholm disease
Chest wall infiltration with tumour
Clinical examination
CT thorax
MRI thorax
Wheeze
Hoarse voice
Snoring
Examination of the respiratory system
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