Symptoms / Chief complaintCough
Chest pain (chest tightness / discomfort)
Symptoms / Chief complaintCough
Chest pain (chest tightness / discomfort)
CoughType Dry, Productive , Short, Brassy, Bovine ,Barking , whooping, Cough syncope, Nocturnal, Drug induced
Onset & Duration
Pattern : activities, time of day, weather
Timing and associated features
Causes of cough: Normal chest X-rayAbnormal chestX-ray
Acute cough(8 weeks)GERD, Asthma, Post viral bronchial hyper reactivity, Rhinitis/sinusitis, Cigarette smokingDrugs (ACE inhibitors, Irritant dusts/fumes) Lung tumor, TB, Interstitial lung disease, BronchiectasisSputumSputum is mucus produced from the respiratory tract. The normal lung produces about 100 ml of clear sputum each day, which is transported to the oropharynx and swallowed
Presence of blood (hemoptysis)
Color & Consistency:TypeAppearanceCauseSerousClear, watery, Frothy, pinkAlveolar cell cancer, Acute pulmonary oedema
Mucoid Clear, grey
White, viscidChronic bronchitis/COPD
GreenAcute bronchopulmonary infectionAsthma (eosinophils) Longer-standing infection, PneumoniaBronchiectasis, Cystic fibrosis, Lung abscess
RustyRusty red Pneumococcal pneumoniaHaemoptysiscoughing up blood from the respiratory tract
TypesFrankHaemoptysis in suppurative lung diseaseSpuriousPseudohaemoptysisEndemicCausesMalignant Lung cancer Endobronchial metastasesBenign Bronchial carcinoidInfection Bronchiectasis Tuberculosis Lung abscess Mycetoma Cystic fibrosisVascular Pulmonary infarction Arteriovenous malformation Vasculitis Goodpastures syndrome Iatrogenic Bronchoscopic biopsy Transthoracic lung biopsy Bronchoscopic diathermy Acute left ventricular failure Anticoagulation Polyangiitis Trauma Inhaled foreign body Chest trauma Mitral valve disease Haematological Blood dyscrasiasDyspnoea
Dyspnoea (breathlessness) is undue awareness of breathing and is normal with strenuous physical exercise.
Patients use terms such as shortness of breath,difficulty getting enough air in, or tiredness
Grades: M R C classification:
Grade I: Breathless when hurrying on the level or walking up a slight hill
Grade II: Breathlessness when walking with people of own age or on level ground
Grade III: Walks slower than peers, or stops when walking on the flat at own pace
Grade IV: Stops after walking 100 metres, or a few minutes, on the level
Grade V: Too breathless to leave the house (Too breathless to wash or dress Sherwood )Modes of onset, duration and progressionMinutes Pulmonary thromboembolismPneumothorax, Asthma, Inhaled foreign bodyAcute left ventricular failureHours to daysPneumonia, Asthma , Exacerbation of COPD, LHFWeeks to monthsAnaemia, Pleural effusion, Respiratory neuromuscular disordersMonths to yearsCOPD, Pulmonary fibrosis, TB, Muscle weakness
Orthopnoea :Breathlessness when lying flat (LVF)
Platypnoea: Breathlessness on sitting up with relief on lying down right-to-left shunting
Trepopnoea : Breathlessness when lying on one side is due to unilateral lung disease dilated Cardiomyopathy13Paroxysmal nocturnal dyspnoea : wakes the patient from sleep
Breathlessness improving at weekends or holidays occupational asthma.
Causes of Breathlessness Cardiorespiratory Anaemia Metabolic acidosis Obesity Psychogenic NeurogenicCardiac Left ventricular failure Mitral valve disease Cardiomyopathy Constrictive pericarditis Pericardial effusion
RespiratoryAirways Laryngeal tumour Foreign body Asthma COPD Bronchiectasis Lung cancer Bronchiolitis Cystic fibrosisPulmonary circulation Pulmonarythromboembolism Pulmonary vasculitis Primary pulmonaryhypertensionParenchyma Pulmonary fibrosis Alveolitis Sarcoidosis Tuberculosis Pneumonia Diffuse infections, e.g.Pneumocystis jirovecipneumonia Tumour (metastatic,lymphangitis)Pleural Pneumothorax Effusion Diffuse pleural fibrosisChest wall Kyphoscoliosis Ankylosing spondylitis
Neuromuscular Myasthenia gravis Neuropathies Muscular dystrophies GuillainBarr syndrome
Chest pain can originate from the parietal pleura, the chest wall and mediastinal structures .
Chest wall pain
Causes of Chest painNon- CentralPleural Infection: pneumonia,bronchiectasis, tuberculosis Malignancy: lung cancer,mesothelioma, metastatic Pneumothorax Pulmonary infarction Connective tissue disease:rheumatoid arthritis, SLEChest wall Malignancy: lung cancer, mesothelioma, bony metastases Persistent cough/breathlessness Muscle sprains/tears Bornholms disease (Coxsackie B infection) Tietzes syndrome (costochondritis) Rib fracture, Intercostal nerve compression, Thoracic shingles (herpes zoster)Central CentralTracheal Infection Irritant dustsCardiac Massive pulmonarythromboembolism Acute MI/ischaemia
Oesophageal Oesophagitis Rupture
Great vessels Aortic dissection
Mediastinal Lung cancer Thymoma Lymphadenopathy Metastases Mediastinitis
Past HistorySimilar illnessTB, Asthma, IHD, DMChildhood illness- measles, inflenza, whooping coughRecent travel
Family historySimilar illnessDM,TB, HT, IHD,Parents marriage: consanguineousAsthma, Eczema
Personal historyAppetiteVeg/non-vegBowel & bladder Alcohol- amount & durationSmoking-No., duration (smoking index)
Menstrual historyMenarche, LMPRegular, amountAssociated pain
General examinationBuiltNourishmentDyspnoeaCyanosisAnemiasJaundice ClubbingLymphadenopathyEyePedal edema
Grades and Examination of Clubbing
Lymphatic and VeinsLymph node: Parietal pleura axillary lymph nodeWhole right lung& left lower lobe right supraclavicular lymph nodeLeft upper lobe left supraclavicular lymph nodeVeins: Superior vena caval syndrome
Examination of the neckScalene Lymph NodeLarge and fixed : Primary lung malignancyHard, craggy, matted, with/out sinus formation: calicified TB lymphadenopathy Other significant nodes:Supraclavicular CervicalAxillary External manifestationsAsterixisHalitosisGynaecomastiaHorners syndromeSmall muscle wastingExternal markers of TBExternal markers of cor pulmonaleExaminationWhat is the most important start to any exam ??ALWAYSALWAYSALWAYS
Introduce yourself to the patient and let them know what you are about to do Systemic Examination of Respiratory systemInspection/Observation Upper Respiratory TractOral- TonsilsNosecavity -ThroatPharynxLower Respiratory Tract Supraclavicular area - Suparscapular regionInfraclavicular area -Interscapular regionMammary region - Infrascapular regionAxillary regionInfra axillary region
ShapeBilateral movementSubcoastal angleDyspneaAccessory musclesTrachea positionApex beatShoulder droopingSpine positionVisible scars/ dilated veins/ sinuses
Position of Trachea:Trails sign
Position of the apex beat
Chest DeformitiesFlat chest
Pectus excavatum: Its the exaggeration of the normal hollowness over the lower end of the sternem.
Spine AbmormalitesKyphosis: Causes the patient to be bent forward.
Ankylosing spondylitis: Diminished volume of lung & capacity of the chest
Scoliosis: spine is curved to either the left or right.
Movement of the chestRate
Type of breathing
RateNormal: 14-18 breaths/minType of breathingPulse : Respiratory rate (4:1)Tachyponea:Nervousness, fever, hypoxia, exertionAPE, Pneumonia, Pul. Emobolism, ARDS, Metabolic acidosisBradypnoea: Alkalosis, Hypothyroidism, raised ICTHyperpnoea:Acidosis, brainstem lesion, Hysteria
Inspiration: by the contraction Of the external intercostal muscles and the diaphragm
Expiration: Depends upon the elastic recoil of the lungsAbnormal breathing patternsCheyne-Stokes respirations
Hyperpnoea followed by apnoeaperiods of respirations during which the tidal volume starts shallow and gets progressively deeper, and then gets progressively shallower. Causes: strokes, traumatic brain injuries, brain tumors, CO poisoning, and metabolic encephalopathy, normal side-effect of morphine administration.
Labored hyperventilation characterized by a deep and rapid respiratory pattern.
Causes: late stages of a severe metabolic acidosis (DKA).
prolonged inspiratory phases with each breathe, followed by a prolonged expiratory phase
causes: lesion to the upper part of the pons
A completely irregular breathing pattern with irregular pauses and unpredictable periods of apnea.
Cause: lesion to the medulla oblongata secondary to trauma or stroke.
very poor prognosis.
Apnoea between several shallow or few deep inspirations
It is very similar to Cheyen-Stokes except the spontaneous t