RESPIRATORY MEDICINE

Respiratory History
History of Presenting Complaint

Associated Symptoms (6):

o Shortness of breath
o Wheeze
o Chest Pain
o Cough, sputum or blood?
o Fevers or Night Sweats, shivers or rigors
o Snoring or sleep issues during the day

Past Medical History

COPD, Pneumonia, TB, bronchitis, CF

Asthma, eczema, allergic rhinitis (hayfever)
Recent respiratory investigations
o Chest x-ray, spirometry etc

Occupational History

Dusts, metal ores, asbestos

Animal exposures birds and cats
Paints, plastics, soldering

Travel History

Have you travelled overseas recently?

Where did you travel to?
How long did you stay? (each destination)
Where you able to maintain your normal hygiene?
o Unbottled water?
o Local foods?
o Adequate sewage systems
Did you receive any immunisations before travelling or
have you immune status checked?
Were you sexually active overseas? sexual history may
be relevant
o Did you engage in safe sex?

Family History

CF, lung cancer, emphysema

TB, asthma, eczema, hayfever

Richard Shaw

RESPIRATORY MEDICINE

Differential Diagnosis of Common

Presentations
Chest Pain

See Cardiovascular History and Examination Notes

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

Exertional dyspnoea, orthopnoea +/PND

o Valvular heart disease (AS, AR, MS, MR)
o Pulmonary oedema
o Dilated Cardiomyopathy

Strong alcohol hx
o Cardiac tamponade*
o Constrictive pericarditis
Respiratory
o Upper Airway (+/- stridor)

URTI

ASx - sore throat, fever,

dysphagia, dysphonia,
rhinorrhoea, post-nasal drip,
nasal blockage, sinus
headache

Anaphylaxis (laryngeal oedema)*

Hx of allergy

Epiglottitis

Children

Foreign body obstruction

Children, hx of choking

Laryngeal/pharyngeal tumour*
o Lower Airway (+/- wheeze)

Asthma

Highly variable symptoms

often worse at night

ASx - wheeze, cough,

tachypnoea

COPD

Richard Shaw

Gradual worsening over yrs

Hx of smoking
ASx- fever, productive cough,
change in sputum
production/colour, wheeze

Bronchiectasis

ASx - significant sputum

production, chronic cough

CF
o Parenchymal

ARDS*

Pneumonia

Rapid onset

ASx - fever, pleuritic chest

pain, cough

Tuberculosis

Travel hx to TB endemic
areas

Immunosuppressed status
(HIV/AIDS)

ASx -cough, dyspnoea,

anorexia, malaise, weight
loss, fever +/- night sweats,
productive sputum, joint
ache

ILD (e.g. idiopathic pulmonary

fibrosis)

Progressing over weeks to

years

ASx - cough

Pulmonary tumours*

ASx - cough, haemoptysis.

Chest pain, dyspnoea less

common
o Pulmonary Embolism*

Hx of immobilisaton, orthopaedic
procedures, COCP, PE Hx, travel

ASx - Pleuritic pain, haemoptysis,

palpitations, cyanosis, syncope
(massive PE), tachycardia

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

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Other
o
o
o
o

Acidosis (DKA, lactic acidosis, salicylates)

Anxiety/psychosomatic
Thyroid disease
Severe anaemia

ASx - Chronic fatigue

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

By time course of onset:

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)

ASx - nasal discharge/obstruction,

sinus congestion, sneezing, throat
clearing, headaches
o Aspiration

Gastric contents (GORD)

Heart burn, dysphagia, acid

regurgitation (taste?)

Reflux coughing awakening

from sleep

Immediately after
eating/drinking

Positional, supine/slouching

Foreign body

Children, acute onset

Airway disease
o URTI (incl. postnasal drip and sinusitis)

Post infectious cough (3-8 weeks

after acute viral illness)

ASx - Nasal/sinus congestion, nonpurulent nasal discharge, sore throat

o Laryngitis

Barking, painful, acute or persistent

o Pertussis

Paroxysms of barking, painful cough

Post-tussive vomiting, inspiratory

whooping sound

Local area of increased prevalence?

o Croup

Barking, painful cough

Acute or persistent
o Bronchiolitis

Age < 1 yr, hx of prematurity

Underlying cardiopulmonary disease

or immunodeficiency

ASx - cough, wheeze, dyspnoea

o Tracheitis

Acute, painful
o Acute/chronic bronchitis
o Bronchiectasis

Chronic, highly productive

Foul-smelling, dark coloured sputum

Diurnal variation (worse in morning)

ASx - dyspnoea, wheeze, haemoptysis

o COPD (Chronic Bronchitis/Emphysema)

CB - productive cough, dyspnoea

(often exertional)

Strong smoking hx

Worse in morning
o Asthma

Intermittent, worse at night

Triggers - cold, exercise, dusts, URTI

FHx - asthma, atopy (eczema, rhinitis)

Richard Shaw

ASx - wheezing, chest tightness,

dyspnoea
o Non-asthmatic eosinophilic bronchitis
o External compression by node of mass lesion*

Loud and brassy cough (tracheal

compression)
Parenchymal Disease
o Pneumonia

ASx - fever, malaise, productive

sputum (usually), chest pain
o Lung Cancer*

Change in character of chronic cough

Smoking hx

ASx - haemoptysis, hoarseness,

weight loss, chest pain, SVC syndrome
(face/upper oedema, distended veins)
o Lung abscesses*

ASx - Foul, dark-coloured sputum

o Interstitial lung disease

Irritating, dry and persistent cough

Sub-acute onset

ASx - sub-acute dyspnoea

o Tuberculosis

Travel hx to TB endemic areas

Productive with haemoptysis

Immunosuppressed status (HIV/AIDS)

ASx - anorexia, malaise, weight loss,

fever +/- night sweats, productive
sputum, haemoptysis
o Pulmonary oedema

Worse lying down

ASx - pink, frothy sputum

Other
o CHF

Wakening from sleep, worse at night

o Drugs e.g. ACEI

Dry, scratchy and persistent

o Psychogenic

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

Coughing up of blood, mixed with sputum and

immediately after couhing
Differentiated from haematemesis which follows nausea
and is mixed with vomitus or after dry wretching.
Mild haemoptysis 15-30 mL in 24 hrs
Massive haemoptysis >250mL in 24hrs
Airway Disease
o Acute/Chronic Bronchitis

Small amounts of blood with sputum

CB - productive cough, dyspnoea

(often exertional)

Strong smoking hx, worse in morning

ASx - chest pressure/pain

Acute triggers - tobacco smoke,

cannabis, ammonia, trace metals, air
pollutants, various infectious agents
o Carcinoma* (primary ca, endobronchial
carcinoid tumour, lung metastases)

Frank blood in sputum

Smoking hx

ASx - hoarseness, weight loss, chest

pain, SVC syndrome (face/upper
oedema, distended veins)
o Bronchiectasis

Large amounts of sputum with blood

Chronic, highly productive cough

Foul-smelling, dark coloured sputum

Diurnal variation (worse in morning)

ASx - cough dyspnoea, wheeze

o Foreign Body

Hx of inhalation

ASx - cough, stridor

Parenchymal Disease
o Pneumonia

Recent onset of symptoms

ASx - fever, malaise, productive

sputum (usually), pleuritic chest pain
o Tuberculosis

Travel hx to TB endemic areas

Immunosuppressed status (HIV/AIDS)

ASx -cough, dyspnoea, anorexia,

malaise, weight loss, fever +/- night
sweats, productive sputum, joint ache
o Pulmonary Infarction

ASx - pleuritic chest pain, dyspnoea

o Cystic Fibrosis

Hx of recurrent infections
o Lung Abscess*

ASx - high fever/night sweats, weight

loss, productive cough, purulent
sputum
o Goodpasture's Syndrome

Males, age 20-30 or 60-70

White, hx of smoking

Richard Shaw

ASx - cough, fever, dyspnoea, nausea,

oedema, urine output

Vascular Disease
o Pulmonary Embolism

Hx of immobilisaton, orthopaedic
procedures, COCP, PE Hx, travel

ASx - Pleuritic pain, haemoptysis,

palpitations, cyanosis, syncope
(massive PE), tachycardia
o Pulmonary Venous Pressure

Acute LVF

Hx of HTN, DM,
dyslipidaemia, tobacco use

ASx - dyspnoea, palpitations,

chest discomfort, fatigue

Severe mitral stenosis

Hx of recurrent respiratory
infection during childhood
(rheumatic heart disease)

ASx - dyspnoea, orthopnoea,

PND, palpitations
Other
o Haematological Disease

Thrombocytopoenia

Hx of HIV, liver disease,

Coagulopathy

liver disease, renal failure hx

Disseminated Intravascular Coagulation

Wegener's granulomatosis

Hx of sinusitis, saddle-nose deformity

ASx - cough, chest pain, dyspnoea,

rhinorrhoea, hoarseness, epistaxis,
fever, fatigue, anorexia, weight loss
o Drugs/Toxins

Anticoagulant drugs etc

Toxins (smoke, solvents)

o Rupture of mucosal blood vessel after vigorous
coughing
Massive Haemoptysis

Carcinoma

Cystic Fibrosis

Bronchiectasis

Tuberculosis

Chronic Lung Abscess

o

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

Patient undressed to waist (women can have gown or

other to cover anterior chest when not being examined)
Patient sitting on the edge of the bed or in a chair is ideal

General Observation

Well at rest, alert, orientated

Respiratory Distress/Work of Breathing/Dyspnoea
o Obvious tachypnoea
o Accessory muscle use

SCM, Platysma, strap neck muscles

o Tripod positioning
o Pursing of the lips
o Tracheal tug
o COPD, asthma, pneumonia, pneumothorax,
pulmonary embolism, CHF
Surrounding features
o O2 masks, nebulisers, inhalers
o Sputum cup look inside/describe contents
Stridor
o Sudden: anaphylaxis, epiglottitis, foreign body
o Gradual: laryngeal, pharyngeal, tracheal
tumours, vocal cord palsy
Hoarseness
o Laryngitis, drugs (asthma corticosteroids),
laryngeal carcinoma, lung carcinoma (recurrent
laryngeal nerve palsy)

Wrist swelling and tenderness

o HPOA lung carcinoma, pleural effusion,
congenital heart disease, IE
Pulse (normal 60-100) (rate, rhythm, character)
o Tachycardia

Asthma (B-agonist SE)

+ pulsus parodoxus severe asthma

Accompanies dyspnoea or hypoxia

o Bounding Pulse CO2 retention
o Pulse characters see cardiovascular notes
Respiratory Rate (normal 12-20) (measure for 30s)

Arm
Blood Pressure

Pulsus parodoxus (BP by > 10mmHg on inspiration)

o Severe asthma

Face
Inspection

Eyes
o

Partial Ptosis, Miosis, Anhydrosis, Enopthalmos

Horner's syndrome Pancoast tumor

o Conjunctival pallor

Anaemia
Fundoscopy for hypertensive changes (Keith-Wegerer)

Sinuses
o Palpate frontal and maxillary sinuses
Hands

Tenderness sinusitis (consider

transillumination)
Inspection

Nose (patient head tilted back and use torch)

Fingers
o Polyps associated with asthma
o Peripheral cyanosis

V/Q imbalance (COPD, PE, pneumonia)

o Engorged turbinates allergic conditions

Cyanotic heart disease and cold temp.

o Septum deviation nasal obstruction
o Clubbing

Mouth

Lung carcinoma
o Central cyanosis (tongue)

Chronic pulmonary suppuration

V/Q imbalance (COPD, PE,

Bronchiectasis
pneumonia), cyanotic heart disease

Lung Abscess
o Pharyngeal/tonsillar erythema +/- pus (white)

Empyema

URTI

HPOA, idiopathic pulmonary fibrosis

o Velopharyngeal lumen obstruction

CF, asbestosis, TB, fibrosing alveolitis,

Tonsils, tongue, soft palate

pleural mesothelioma/fibroma

Sleep apnea
o Tar staining
o Dental hygiene/tooth decay

Palms

Lung abscess, pneumonia

o Palmar erythema
Neck

Hypercapnia
Inspection
o Palmar crease pallor

Trachea

Anaemia
o Displaced trachea
o Muscle wasting

Towards side of lesion

Peripheral lung tumour (e.g. Pancoast

Upper lobe atelectasis

infiltration of T1 lower trunk nerve

Upper lobe fibrosis

root) Test abduction power if suspected

Pneumonectomy

Wrists

Away from side of lesion (uncommon)

o Asterixis (hold for ~30s)

Massive pleural effusion

Hypercapnia (e.g. from COPD)

Tension pneumothorax
Palpation
o Tracheal tug (thyroid cartilage movement)

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Respiratory distress/COPD
Confirm accessory m. use (if dyspnoea evident),
palpate for scalenus m. in supraclavicular fossae
Forced Expiratory Time

Time taken for patient to completely exhale forcefully (x3)

Time by auscultating over trachea

o Normal <3s time in obstruction COPD
Cough Test

Assess character of cough

o Bovine

Vocal cord paralysis

o Muffled, wheezy, ineffective

COPD
o Loose Productive

Chronic bronchitis

Pneumonia

Bronchiectasis
o

Chest
Inspection

Chest wall deformity and asymmetry

o Barrel-chest (AP:Lat thoracic ratio is > 0.9)

Severe asthma, emphysema

o Pectus carinatum

Chronic childhood respiratory illness,

rickets
o Pectus excavatum

Causing lung capacity

o Kyphoscoliosis

Causing lung capacity and WOB

Scars (look under axilla too)

o Trauma, chest drains
o Surgery pneumonectomy, lobectomy, 'ports'
o Radiotherapy marks

Erythema, skin thickening

Small tattoo markings

Subcutaneous emphysema
o Pneumothorax, oesophageal rupture,
pneumomediastinum

Prominent veins (determine direction of flow)

o SVC obstruction

Chest wall movements (anteriorly, posteriorly, superiorly)

o Less movements on affected side
o Bilateral movements

COPD, interstitial lung disease

o Unilateral movements

Pleuritic chest pain, rib fracture

o Costal in-drawing

WOB
o Parodoxical inspiratory abdominal in-drawing

Diaphragmatic paralysis
Move posteriorly to finish inspection (WARN THE PATIENT)

Cervical Lymph Nodes

o
Ideally palpate all 8 groups supraclavicular
nodes most important
o Lung /chest carcinoma spread, infection
Palpation

Chest Expansion (grip firmly, thumbs off chest)

Richard Shaw

Upper and lower on the back and once on front

Normal chest expansion >5cm
Hoover's sign (thumbs at xiphisternum)

+ve thumbs (ribs) move inwards

COPD

Ribs (should be done during chest expansion)

o Compress chest anteroposteriorly and laterally
o Localised pain rib fracture

Trauma, tumour deposition, bone

disease, severe coughing

Axillary Lymph Nodes

o Tumour metastases, infection
Percussion

The patients arms should be folded in front when

examining the posterior chest (anterior scapula rotation)

Don't forget supraclavicular fossae (lung apices), clavicle

and sides (R. middle lobe otherwise missed), move in an S

Percuss to just below nipple anteriorly

o
o
o

REVIEW LUNG SURFACE ANATOMY

Dull (solid)
o Consolidation (pneumonia)
o Atelectasis
o Solid structures (e.g. liver)

Stony Dull (fluid)

o Pleural effusion

Hyperresonant
o Pneumothorax
o Emphysema
o Bowel

Liver and Cardiac Dullness

o Chest resonance below 5th rib in R. MCL
o area of cardiac dullness on left side of chest

Hyperinflation

Emphysema or asthma
Auscultation (diaphragm + bell in supraclavicular fossae)

Patient breathing comfortably through the mouth

Listen through full cycle of inspiration/expiration

RESPIRATORY MEDICINE

Don't forget axilla as well

Quality
o Normal breath sounds = vesicular
o Bronchial breath sounds

Audible throughout expiration, often

gap between expiration/inspiration

Consolidation (lobar pneumonia)

(above consolidation)

Pleural effusion (above the fluid)

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

Lung carcinoma (obstructing airway)

Foreign body
o Crackles (low-pitch = rales, high-pitch =
crepitations)

Fine Crackles

Pulmonary fibrosis (ILD)

Medium Crackles

LVF/pulmonary oedema
(late inspiratory)

COPD (early inspiratory)

Coarse

Bronchiectasis

Others infection, atelectasis, cancer

o Pleural Friction Rub

Pulmonary infarction, pneumonia

Rare: pleural malignancy, spontaneous

pneumothorax, pleurodynia
Vocal Resonance
o If localised abnormality is found, determine
extent of involvement (what lobe and segments?)
o resonance consolidation
o resonance pleural effusion

Richard Shaw

Localised interstitial lung disease

Contralateral displacement

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

Palpate for sacral oedema

Legs

Inspect for peripheral cyanosis, swelling, erythema

Palpate for peripheral oedema (15s)

Palpate for calf-tenderness and inspect other DVT signs

Pemberton's sign

Arms up over head for 1 minute

+ve development of facial plethora, cyanosis, stridor and

non-pulsatile JVP elevation
o SVC obstruction

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 Examination Summary

I performed a respiratory examination on Mr/Mrs. X who

is a X old male/female who presented with X.

Major findings were:

o Most significant finding second most

significant or findings related to most

significant finding (positive and negative)

My other findings were:

o No peripheral signs of X, Y or any other
respiratory disease on the hands, face or chest
walls
Other
o RR = X and HR = Y, BP = Z and JVP was nonelevated at X cm.
Cardiac (lie the patient down to 45)
o
Trachea was midline and no axillary, cervical or

Jugular Venous Pressure (vertical height to sternal angle)

supraclavicular lymph nodes were palpable.
o Patient looks left, can use torch for tangent light
o
Chest expansion was normal at X cm
o JVP vs Carotid Pulse (TnO p58) - 6 reasons
o
Lung fields were resonant and symmetrical to
o Elevated JVP (>3cm)
percussion

RHF, pulmonary hypertension

o
Breath sounds were vesicular and of normal

Auscultation loud P2 of pulmonary hypertension

intensity in all lung fields with no adventitious

Cor pulmonale (pulmonary hypertensive heart disease)

sounds
o COPD, ILD, pulmonary thromboembolis, obesity,
o
Vocal resonance was symmetrical across all
sleep apnoea, severe kyphoscoliosis
lung fields.

Apex Beat (patient lying down)

Based on my current findings, my provisional diagnosis

o Ipsilateral displacement
is X with differentials including X, Y, Z.

Lower lobe atelectasis

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10

Ideally I would also like to:

o Anything up to vocal resonance that was not
performed
o Perform peak flow and forced expiratory time
tests
o Conduct a full cardiovascular examination
specifically looking for evidence of pulmonary
hypertension and cardiac failure
o Conduct a full abdominal examination
specifically looking for hepatomegaly and
hepatic ptosis.
The investigations I would like to perform are X, Y, Z
(specifically looking for x, y, z).

Richard Shaw