APPROACH TO THE PATIENT

WITH DISEASE OF
THE RESPIRATORY SYSTEM

Viên Vinh Phú, MD

School of Medicine – VNU HCMc
 OUTLINE

➢ Medical history

➢ Clinical examination

➢ Investigation
 MEDICAL HISTORY

• Patient Information
• History of present illness
• Past medical history
Patient Information:
• Name
• Age
• Sex
• Address
• Telephone number
• Occupation
• Family status
• …
History of present illness
• Chief complaint
• Common symptoms of respiratory disease:
cough, sputum production, hemoptysis, dyspnea
(breathlessness), wheezing, chest pain, voice
change (dysphonia), hiccups…
• Common symptoms: fever, appetite, fatigue,
weight, bowel, skin, edema, lymph node…
Past medical history
Personal history
• Medical management: diagnosis (respiratory
diseases), drugs…
• Surgery
• Habits: smoking (cigarettes a day), alcohol,
narcotic…
• Allergies
• Vaccination: diphtheria, tetanus, whooping
cough, poliomyelitis, tuberculosis, hepatitis…
Family history
 FUNCTIONAL SYMPTOMS
• Cough
• Sputum production
• Hemoptysis
• Dyspnea (breathlessness)
• Chest pain
• Voice change (dysphonia)
• Hiccups
• …
 COUGH
Explosive expiration against a closed glottis
Purpose: clearance of airways
Protective superficial reflex
Cough triggers:
• Exogenous: Fumes, smoke, dust,
foreign body
• Endogenous: Secretions, gastric contents
• Initiate inflammation: Persistence of cough
• Constriction
• Infiltration
• Compression
 COUGH REFLEX
Afferent: chemical /mechanical stimuli
→ Cough receptors in the epithelium of the
upper and lower respiratory tracts,
pericardium, esophagus, and stomach
→ Afferent nerves (vagus, glossopharyngeal,
trigeminal, and phrenic)
→ Cough center in the medula

Efferent: cough center with cortical input

→ Efferent signals travel down the vagus,
phrenic, and spinal motor nerves
→ Expiratory muscles
→ Cough
 COUGH CAUSES
Inflammation • Infections
• Post-nasal drip
• GERD
Constriction • Asthma
• Scarring
• Tumors
Infiltration • Granulomatous diseases
• Malignancy
Compression • Lymph nodes
• Mediastinal tumors
• Aortic aneurysm
Other • ACE inhibitors
Acute cough (<3 weeks)
Causes • Acute respiratory tract
infections
• Asthma
• Allergic rhinitis
• Congestive heart failure
(CHF)
Chronic cough (>8 weeks)
NON- • Post-nasal drip
PULMONARY • Gastroesophageal reflux
disease (GERD)
• ACE inhibitors
• Occult congestive heart
failure
PULMONARY AIRWAY
• Asthma
• Chronic bronchitis
• Bronchiectasis
• Neoplasm
• Foreign body
• Post-viral
PARENCHYMA
• Occult infection
• Occult aspiration
• Interstitial lung disease
• Lung abscess
VASCULAR
• Early pulmonary hypertension
 COUGH
Essential inquires
• Age
• Duration of cough
• Seasonal
• Tobacco use history
• Sputum, dyspnea (at rest or with exertion)
• Vital signs
• Chest examination
• Chest radiography when unexplained cough
lasts more than 3-4 weeks
 SPUTUM
Quantity: nil, scanty, moderate, copious

Quality:
• Mucoid
• Muco-purulent
• Purulent
• Current Jelly
• Greenish
• Granules – yellow /black
• Hydatid cysts
• Anchovy sauce (brown)

Odour (smell)
 HEMOPTYSIS
Hemoptysis is the spitting of blood derived
from the lungs or bronchial tubes as a result
of pulmonary or bronchial hemorrhage.

Differentiate from:
• Epistaxis
• Nasopharyngeal bleed
• Hematemesis (upper GI bleed)

Quantity:
• Streaking
• Rusty, Mixed
• Massive (>500 ml blood in 24h)
 Origin Causes
PULMONARY Airway
• Bronchitis
• Bronchiectasis
• Bronchogenic carcinoma
• Foreign body
• Trauma
Parenchyma
• Infections
• Alveolar hemorrhage
• Vascular
• Malignancy
CARDIAC • Left ventricular failure
• Mitral stenosis
Parenchyma Causes
INFECTIONS • Pneumonia
• Abscess
• Septic emboli
• TB
• Fungal
ALVEOLAR • Wegener’s granulomatosis
HEMORRHAGE • Churg-Strauss
• Goodpasture disease
• Pulmonary capillaritis
• Connective tissue disease
Parenchyma Causes
VASCULAR • Pulmonary embolism
• Pulmonary hypertension
• Arteriovenous malformations
• Iatrogenic
MALIGNANCY • Lung cancer
• Metastasis
 HEMOPTYSIS
Essential inquires:
• Characterize hemoptysis: amount, frequency,
previous history
• Fever, cough, and other symptoms of lower
respiratory tract infection.
• Smoking history.
• Nasopharyngeal or gastrointestinal bleeding.
• Chest radiography, complete blood count.
 DYSPNEA
Dyspnea is a subjective experience or perception
of uncomfortable breathing.
Mechanism is complex
• Sensory endings stimulation
• Work of breathing (muscles)
• Small airway obstruction
• Chemoreceptor stimulation (acidosis)
Acute severe dyspnea
• Pulmonary edema
• Pulmonary embolism
• Acute severe asthma
• Acute exacerbation of COPD
• Pneumonia
• Pneumothorax
• Foreign body /mucous plug
• Epiglottitis (children)
• Metabolic Acidosis
• Psychogenic
Chronic exertional dyspnea
• COPD
• Asthma
• Heart disease
• Interstitial /alveolar disease
• Chest wall /respiratory muscle disease
• Chronic pulmonary thrombo-embolism
• Psychogenic hyperventilation
 DYSPNEA
Essential inquires
• Fever
• Cough
• Chest pain
• Vital sign measurements; pulse oximetry
• Cardiac and chest examination
• Chest radiography
• Arterial blood gas measurement
 CHEST PAIN
Chest pain is a common complaint in the
hospitalized patient.
The severity of chest discomfort does not
always correlate with the gravity of the
cause.
 Origin Causes
Cardiac • Acute coronary syndrome
• Aortic dissection
• Pericarditis
Pulmonary • Pulmonary embolism
• Pneumothorax
• Pneumonia
• Lung cancer
Gastrointestinal • Esophagitis
• Peptic ulcer disease
Musculoskeletal • Costochondritis shingles
• Trauma to chest wall
Others • Panic /Anxiety disorders
 CHEST PAIN
Essential inquires
• Chest pain onset, character, location /size,
duration, periodicity, exacerbators
• Shortness of breath
• Vital signs
• Chest and cardiac examination
• Electrocardiography
• Biomarkers of myocardial necrosis
 CLINICAL EXAMINATION

1. General examination
2. Cardio-vascular system
3. Respiratory system
4. Gastro-intestinal tract
5. Genito- Urinary system
6. Nervous system
7. Musculo-skeletal system
CLINICAL EXAMINATION
Introduce yourself
Confirm patient details
Explain examination
Gain consent
EXAMINATION:
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
General examination
General assessment: conscious (or restlessness,
agitation, confusion, delirium. coma), pursed-lip
breathing, spO2
Vital signs: pulse, temperature, blood pressure,
respiratory rate
Cyanosis
Finger clubbing
Inspection of the chest

Chest wall shape: kyphosis, scoliosis, deformity,

distended veins, scars
Respiratory rate (tachypnea, bradypnea…),
depth, pattern.
Paradoxical respiratory motion of chest and
abdomen.
Intercostal recession: use of accessory muscles
(scalene, sternocleidomastoid muscles).
Palpation
• Tracheal deviation
• Chest expansion
• Tactile vocal fremitus (1-2-3)
➢ Normal
➢ Increased: consolidation or large cavity
➢ Decreased /absent: pleural effusion or
pneumothorax
Percussion of chest wall
• Normal degree of resonance

• Increased resonance: hyper-resonance:

➢ Emphysema
➢ Pneumothorax

• Diminished resonance: dullness:

➢ Consolidation
➢ Collapse
➢ Pleural effusion
➢ Hemothorax – empyema
Auscultation of breath sounds

Respiratory sounds come from the lungs when a

person breathes in and out.
Abnormal breath sounds can indicate a lung
problem, such as obstruction, constriction,
inflammation, infection…
Auscultation of breath sounds
Vesicular breathing

Bronchial breathing
• Tubular: high-pitched
• Amphoric: low-pitched
• Brocho-vesicular

Added sounds:
• Sonorous: low-pitched rhonchi
• Sibilant: high-pitched rhonchi
• Fine crepitations
• Coarse crepitations: bubbling noises
➢ Stridor: a harsh, vibratory sound caused by
narrowing of the upper airway.
➢ Wheezing: a high-pitched whistling sound
caused by narrowing of the bronchial tubes.
➢ Pleural rub
AUSCULTATION
 CASE HISTORY
➢ Summarize • Functional symptoms
• Physical symptoms
→ Syndromes

➢ Diagnostic • Differential diagnosis

hypothesis
➢ Investigations
➢ Diagnosis
➢ Treatment
 DIAGNOSIS
➢ Pneumonia
➢ Asthma
➢ COPD
➢ Tuberculosis
➢ Lung Abscess
➢ Pleural effusion
➢ Pneumothorax
➢ Bronchiectasis
➢ Lung cancers
➢ …
 TESTS
• Blood Test: complete blood count, urea and
electrolytes, biochemistry and C-reactive protein
• Chest X-ray
• Sputum culture
• Pulse oximetry, arterial blood gas
• Lung function test
• Bronchoscopy
• CT imaging
• Others: electrocardiography (ECG),
echocardiography (ECHO), biomarkers…
 KHÁM HÔ HẤP
Chào hỏi – chuẩn bị khám
Kỹ năng nhìn
• Tổng quát: tỉnh, thở chu môi, khó thở, tím môi –
đầu chi, ngón tay dùi trống.
• Lồng ngực: cân đối, cột sống gù – vẹo, dấu hiệu
co kéo cơ HH phụ, vết mổ cũ, tuần hoàn bằng hệ
Kỹ năng sờ
• Khí quản
• Độ dãn nở lồng ngực (ngực sau)
• Rung thanh: vị trí (ngực sau), kỹ thuật, kết luận
Kỹ năng gõ
• Gõ ngực: vị trí (ngực sau), kỹ thuật, kết luận
Kỹ năng nghe
• Âm phế bào: vị trí (ngực sau), kỹ thuật, kết luận