Respiratory System History Taking and Clinical Examination

  

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RESPIRATORY SYSTEM — HISTORY TAKING 

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1. Patient Demographics

• Name, Age, Sex, Occupation, Address
  • Why relevant:
    • Age: Bronchiolitis (infants), asthma (children/young adults), COPD/lung cancer (older adults)
    • Sex: Smoking-related lung disease more common in men (but rising in women); autoimmune-related lung disease more in women
    • Occupation:
      • Coal miner → pneumoconiosis
      • Cotton mill worker → byssinosis
      • Farmer → hypersensitivity pneumonitis
    • Address: Endemic TB areas, industrial pollution zones, high altitude (chronic mountain sickness)

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2. Chief Complaint(s) with Duration

Examples:

• Cough × 2 weeks
• Breathlessness × 3 days
• Chest pain × 5 hours
• Hemoptysis × 1 week

Duration distinguishes acute (e.g., pneumonia, asthma attack) from chronic (e.g., COPD, bronchiectasis) conditions.

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3. History of Presenting Illness

A. Symptom Analysis (with connections)

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1. Cough

• Onset:
  • Sudden → aspiration, pulmonary embolism
  • Gradual → TB, chronic bronchitis
• Duration:
  • Acute (<3 weeks) → URTI, pneumonia, acute bronchitis
  • Chronic (>8 weeks) → TB, COPD, asthma, bronchiectasis, lung cancer
• Character:
  • Dry → viral infections, interstitial lung disease, ACE inhibitor use
  • Productive → bacterial pneumonia, chronic bronchitis, bronchiectasis
• Sputum:
  • Mucoid → asthma, COPD
  • Purulent (yellow/green) → bacterial infection
  • Rusty → pneumococcal pneumonia
  • Pink frothy → pulmonary edema
  • Foul-smelling → anaerobic infection, lung abscess, bronchiectasis
• Timing:
  • Nocturnal → asthma, left heart failure
  • Morning → chronic bronchitis
• Triggers: cold air, exercise, allergens (asthma)

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2. Breathlessness (Dyspnea)

• Onset:
  • Sudden → pulmonary embolism, pneumothorax, acute asthma
  • Gradual → COPD, ILD, heart failure
• Duration & Progression: Worsening over days (pneumonia) vs years (COPD)
• Severity:
  • NYHA grading (I–IV) or mMRC scale for chronic cases
• Relation to posture:
  • Orthopnea → heart failure
  • Platypnea → hepatopulmonary syndrome
  • Trepopnea → unilateral lung disease
• Associated symptoms: Wheeze (asthma/COPD), chest pain (PE, pneumonia), cough (multiple causes)

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3. Chest Pain

• Site: Localized vs diffuse
• Character:
  • Sharp, pleuritic (worse on deep breath) → pleurisy, pneumonia, PE
  • Dull/pressure → myocardial ischemia (needs cardiac evaluation)
• Radiation:
  • To shoulder → diaphragmatic irritation
  • To back → aortic dissection (emergency)
• Relation to respiration: Pleuritic pain increases with inspiration/cough

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4. Wheezing / Noisy Breathing

• Expiratory wheeze: asthma, COPD
• Inspiratory stridor: upper airway obstruction, foreign body, tumor

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5. Hemoptysis

• Amount: Streaks vs massive (>200–600 mL/24h)
• Color/character: Bright red (bronchiectasis, TB, carcinoma), frothy (pulmonary edema), clots (bronchiectasis, tumor)
• Onset: Single episode vs recurrent
• Associated: Fever (TB, pneumonia), weight loss (malignancy), night sweats (TB)
• Differentiate from hematemesis (GI bleed) — history & examination

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6. Fever

• Low-grade + night sweats: TB
• High-grade + chills: pneumonia, lung abscess, empyema
• Relapsing: malaria (if splenic enlargement with respiratory signs)

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7. Other Respiratory Symptoms

• Hoarseness: recurrent laryngeal nerve palsy (lung apex tumor), laryngitis
• Clubbing: chronic suppurative lung disease, lung cancer, ILD
• Cyanosis: hypoxemia (COPD, pneumonia)
• Swelling of face/neck: SVC obstruction from lung cancer

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4. Associated Symptoms (Other systems)

• Cardiovascular: palpitations, chest discomfort (pulmonary hypertension)
• GI: reflux symptoms (GERD causing cough)
• Neuro: weakness (hypoxia-related), headaches (CO₂ retention)

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5. Past History

• Childhood asthma
• Pulmonary TB
• Hospitalizations for pneumonia, COPD exacerbation
• Occupational lung disease
• Allergic rhinitis, atopy
• Blood transfusions (HIV, hepatitis — relevant for TB risk)

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6. Personal History

• Smoking:
  • Type: cigarette, bidi, hookah
  • Pack-years = (cigarettes per day ÷ 20) × years smoked
  • Smoking → COPD, lung cancer, chronic bronchitis
• Alcohol: aspiration risk if intoxicated
• Diet: malnutrition → low immunity → TB risk
• Pets/birds: psittacosis, hypersensitivity pneumonitis
• Travel: COVID-19, TB, influenza exposure

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7. Family History

• TB contact
• Asthma/allergic diseases
• Cystic fibrosis

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8. Drug History

• ACE inhibitors (dry cough)
• Amiodarone, bleomycin (pulmonary fibrosis)
• Beta-blockers (bronchospasm in asthma)

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9. Socioeconomic & Environmental History

• Crowded housing (TB spread)
• Occupational dust/fumes
• Indoor smoke from cooking

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10. Immunization History

• BCG (TB prevention in childhood)
• Influenza & pneumococcal vaccines (for elderly, chronic lung disease)

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Step-by-step Respiratory System Examination 

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1) Preparation & safety

• Explain the procedure & obtain consent [consent = patient’s informed permission after explanation].
• Chaperone present [chaperone = third person (nurse/colleague) present during intimate exams for comfort/protection].
• Wash hands, warm stethoscope, ensure good lighting and privacy.
• Record vital signs: pulse [heart beats per minute], blood pressure [arterial pressure], respiratory rate [breaths per minute], temperature [body heat], SpO₂ [peripheral oxygen saturation measured by pulse oximeter].

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2) General inspection (while patient sits or on entry)

• Work of breathing / respiratory distress [use of accessory muscles or visible effort to breathe] — look for intercostal/substernal retraction [skin sinking between ribs/below sternum on inspiration], nasal flaring [nostrils widen on inspiration].
• Respiratory rate & pattern [rate = breaths/min; pattern = regular/irregular, e.g., Cheyne–Stokes (periodic waxing/waning of respirations) or Kussmaul (deep, laboured breathing)].
• Body habitus / nutrition: cachexia [severe weight loss/wasting] seen in chronic disease/TB/cancer.
• Cyanosis [bluish discoloration of lips/tongue from low arterial oxygen] — central (tongue/lips) vs peripheral (fingers).
• Clubbing [bulbous enlargement of fingertips and loss of the normal nail angle] — suggests chronic suppurative lung disease/ILD/bronchiectasis/cancer.
• Cough / sputum: note if patient is actively coughing; character of sputum if expectorated (mucoid/purulent/foul/hemoptysis).
• Facial/neck swelling or distended neck veins → consider superior vena cava syndrome [obstruction of SVC causing venous congestion].

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3) Hands & peripheral signs

• Finger clubbing (inspect/Schamroth’s window test) [absence of the diamond-shaped space when dorsal nail beds opposed].
• Peripheral cyanosis [bluish fingers/toes], cool peripheries (poor perfusion).
• Asterixis [flapping tremor of outstretched hands] suggests CO₂ retention/hepatic encephalopathy (in severe chronic respiratory failure).
• Capillary refill time [time for blanched nail bed to return colour; >2s suggests poor perfusion].

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4) Face, mouth, nose, throat (upper airway)

• Nasal mucosa & sinuses: discharge/obstruction/polyps — allergic rhinitis/sinusitis.
• Oral cavity & oropharynx: look for tonsillar enlargement/exudates (tonsillitis), oral thrush (immunosuppression).
• Voice quality (hoarseness) [change in voice] — recurrent laryngeal nerve palsy, laryngeal disease.
• Stridor [high-pitched inspiratory sound] → upper airway obstruction (laryngeal edema, foreign body, tracheal lesion).
• Palpate cervical lymph nodes [lymph gland enlargement] — tender (infective), firm/fixed (malignancy/TB).

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5) Neck & central checks

• Tracheal position: midline vs deviated — deviation towards collapse/fibrosis; away from large effusion/tension pneumothorax.
• Jugular venous pressure (JVP) [height of venous column seen in neck] — raised in right heart failure; observe for Kussmaul’s sign [paradoxical rise in JVP on inspiration].
• Thyroid (if relevant) — goitre causing compression.

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6) Chest inspection (anterior, lateral, posterior)

• Chest shape: barrel chest [increased AP diameter, seen in emphysema/COPD].
• Surgical scars, tracheostomy, stomas.
• Asymmetry of chest expansion [one side moves less than the other] — suggests consolidation, effusion, collapse, pneumothorax, or pain limiting movement.
• Accessory muscle use (sternocleidomastoids, scalene) on inspiration — severe airflow limitation.
• Respiratory excursion [measure of movement—usually with hands/mark on posterior ribs at T10] — reduced in pleural effusion, lobar consolidation, diaphragmatic paralysis.

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7) Palpation (systematic)

• Chest expansion: place hands laterally on lower ribs with thumbs midline; ask deep inspiration — compare both sides.
  • Reduced expansion = pleural effusion, lobar collapse, pain.
• Tactile (vocal) fremitus [vibration felt on chest wall when patient speaks, e.g., says “ninety-nine”]:
  • Increased fremitus = consolidation (pneumonia) [solid lung transmits vibration better].
  • Decreased/absent fremitus = pleural effusion/pneumothorax/COPD [air or fluid blocks vibration].
• Tracheal tug / mediastinal shift (if palpable).

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8) Percussion (systematic, compare side-to-side)

• Percussion [tapping the chest to elicit sound] — map resonance across chest.
• Resonant [normal hollow note over healthy lung].
• Dullness [short, muffled note] → consolidation (lobar pneumonia), pleural effusion, atelectasis [collapse of lung tissue].
• Stony dull [very dull, heavy sound] — large pleural effusion.
• Hyperresonant / tympanic [loud, hollow note] → pneumothorax (air in pleural space) or hyperinflation (COPD, asthma).
• Diaphragmatic excursion [difference in percussion note of diaphragm between inspiration and expiration; reduced in pleural effusion or elevated hemidiaphragm].

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9) Auscultation (systematic: posterior → lateral → anterior; compare symmetrical areas)

• Use diaphragm of stethoscope; ask patient to breathe normally then deeply through an open mouth.
• Vesicular breath sounds [soft, low-pitched, inspiration > expiration] — normal over most lung fields.
• Bronchial breath sounds [loud, tubular, expiration ≥ inspiration] — heard over consolidation where air-filled bronchi are adjacent to solid lung (lobar pneumonia).
• Reduced/absent breath sounds — massive effusion, pneumothorax, severe emphysema.
• Added sounds (adventitious sounds):
  • Crackles / rales [brief popping sounds]:
    • Fine crackles = soft, high-pitched at end-inspiration — interstitial fibrosis, pulmonary oedema (early inspiratory/late inspiratory depending on cause).
    • Coarse crackles = louder, lower-pitched — secretions in bronchi (bronchiectasis, resolving pneumonia).
  • Wheeze [continuous musical sound, usually expiratory] — asthma/COPD/airway narrowing.
  • Monophonic wheeze [single note] → localised airway obstruction (tumour, foreign body).
  • Pleural friction rub [creaky/scratchy sound synchronous with breathing] → pleuritis (inflamed pleural surfaces).
• Vocal resonance tests (perform if abnormal percussion/auscultation):
  • Bronchophony [patient says “ninety-nine”; increased clarity over consolidation].
  • Egophony [patient says “eee” but heard as “ay” over area of consolidation/effusion].
  • Whispered pectoriloquy [whispered words heard loudly over consolidation].

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10) Special manoeuvres & signs (targeted tests)

• Peak expiratory flow (PEF) [maximal speed of expiration measured by peak flow meter] — quick assessment of obstructive severity (asthma).
• Spirometry [lung function test measuring volumes and flows — FEV₁/FVC etc.] — diagnostic for obstructive vs restrictive disease.
• Percussion for pleural effusion: stony dullness at base, shifting dullness on position change [shifting dullness = dull area moves when patient rolls].
• Test for pneumothorax: hyperresonance + absent breath sounds + absent fremitus; tension pneumothorax may show tracheal deviation + hemodynamic compromise (hypotension, distended neck veins).
• Tests for consolidation: increased fremitus + dull percussion + bronchial breathing + positive egophony/bronchophony.

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11) ENT / upper airway focused exam (if indicated)

• Flexible nasoendoscopy / indirect laryngoscopy [visualization of nasal passages & larynx] — indicated for persistent hoarseness, stridor or suspected vocal cord palsy. (Refer ENT for procedure.)

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12) Peripheral limb / DVT exam (if PE suspected)

• Calf/leg inspection & palpation: swelling, erythema, tenderness — consider DVT [deep venous thrombosis], a common source of pulmonary embolism (PE).
• Homan’s sign [pain in calf on passive foot dorsiflexion] — historically used but non-specific/unreliable.

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13) Bedside adjuncts to support findings

• Pulse oximetry [noninvasive SpO₂] — hypoxia if <90% (depends on clinical context).
• Arterial blood gas (ABG) [blood test measuring PaO₂, PaCO₂, pH] — for respiratory failure/hypercapnia assessment.
• Chest X-ray (CXR) [radiographic imaging] — consolidation, effusion, collapse, pneumothorax.
• Ultrasound chest [bedside imaging] — detect pleural effusion, guide thoracentesis [pleural fluid aspiration].
• Sputum tests: Gram stain/culture, AFB smear/culture for TB, PCR panels as indicated.
• D-dimer / CTPA [CT pulmonary angiography] — in suspected pulmonary embolism per clinical probability.

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14) Mapping common signs → likely causes (quick clinical pocket)

• Increased fremitus + dull percussion + bronchial breathing + egophony → lobar consolidation (pneumonia).
• Decreased fremitus + stony dullness + reduced breath sounds → pleural effusion.
• Hyperresonance + absent fremitus + absent breath sounds → pneumothorax.
• Diffuse hyperresonance + quiet chest sounds → emphysema/COPD (hyperinflation).
• Fine bibasal end-inspiratory crackles + clubbing → pulmonary fibrosis / interstitial lung disease.
• Polyphonic expiratory wheeze + prolonged expiration + reversibility with bronchodilator → asthma.
• Foul-smelling sputum + localized coarse crackles + recurrent infections → bronchiectasis / lung abscess.

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15) Red flags — act immediately

• Severe respiratory distress (use of accessory muscles, inability to speak in full sentences).
• SpO₂ persistently <90% despite oxygen [hypoxaemia].
• Tension pneumothorax (sudden severe dyspnea, hypotension, tracheal deviation, unilateral silent chest) — emergency decompression.
• Massive hemoptysis (large volume bleeding into airways) — secure airway and urgent haemoptysis protocol.
• Suspected pulmonary embolism with hemodynamic instability — urgent thrombolysis/ICU as per local protocol.

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16) Documentation template (concise for notes / OSCE)

1. Consent/chaperone present. Vitals: RR, SpO₂, T, HR, BP.
2. General: distress, RR pattern, cyanosis, clubbing present/absent.
3. ENT/neck: tracheal position, JVP, nodes.
4. Chest: inspection (symmetry, scars), palpation (expansion, fremitus), percussion (notes and areas), auscultation (breath sounds, added sounds; egophony/bronchophony if done).
5. Peripheral: signs of DVT, asterixis if present.
6. Impression: e.g., “Findings consistent with right lower lobe consolidation (↑ fremitus, dullness, bronchial breathing); plan CXR, sputum cultures, start empiric antibiotics after senior review.”
7. Urgent actions if red flags present.

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