Brief description of history taking in patients of pulmonary disease, that gave direction to further investication and treatment.

1. HISTORY TAKING & GENERAL PHYSICAL
EXAMINATION OF RESPIRATORY SYSTEM
Presented by:
Dr.Sachin Singh
1st year resident
Pulmonary Medicine
PDU Medical College
Churu, Rajasthan

2. Scheme of history taking
• Demographic data
• Chief complains
• History of present illness
• Past medical history
• Personal history
• Family history
• Social and environmental history

3. Demographic data
• Name
• Age
• Gender
• Address
• Religion
• Nationality
• Race
• Occupation

4. Chief Complaint
• The chief complain is a brief narration
explaining why the patient sought health care
• Each symptom should be recorded separately
with its duration or date of initial occurrence
• Eg ; fever for last 15 days
cough for last 10 days
SOB for last 5 days
• Ideally symptom description are written in
patients own world

5. History of present illness
• The HPI is the narrative portion of the history
that describes chronological and detail of each
symptom listed in chief complain and its effect
on patient life.
• In HPI the following information should be
gather for each symptom
* Description of onset – Date , time, sudden
or gradual
*Setting- cause, circumstance or active
surrounding onset

6. *Location – where on the body problem located &
where it radiate
*Severity – how severe it is & how it affect day to
day activity
*Quantity – how much, how large or how many.
*Quality – unique properties like colour, texture,
odour, composition, sharp or throbbing.
*Frequency – How often it occur
*Duration – How long it last, whether it is
constant or intermittent.
*Course – whether it is better, worse or staying
the same.

7. *Associated symptoms – symptom from same
body system or other system that occur before with
or after problem.
*Aggravating factors – things that make it worse
such as certain position, weather, temperature,
anxiety & exercise.
*Relieving factors – certain position, hot or cold,
after taking rest or medication.

8. Past Medical History
• PMH is the total sum of patient health status
prior to the present problem
• Information recorded in past history include a
chronologic list of the following
 Illness since birth
 Major illness in the past
Past history of hospitalization
 Past history of injuries & accidents
 Past history of surgery
 Allergic history

9. Family History
• To find heredofamilial disorder & focus on
patient lineage
• It is important in Bronchial asthma, allergic
rhinitis, collagen vascular disease, lung cancer
specially adenocarcinoma, cystic fibrosis.

10. Personal history
• Smoking
*There is strong relation b/w smoking & chronic
respiratory disease, respiratory infection, lung
cancer & cardiovascular diseases
*Consumption of cigarettes should be recorded in
pack year.
*One pack year is 20 cigarettes smoked each day
for one year.
• Alcohol
• Exposure to organic dust like coal, silica, asbestosis
• Exposure to pets or animals

11. Occupational history
• Record occupation that are known to relate to
respiratory disease
1. Pneumoconiosis – Coal workers
2. Asbestosis – Plumbers, Power station workers
3. Bagassosis – sugar mill workers
4. Byssinosis – cotton industry

12. Review of systems
• This information is obtained in head to toe review of all body system
1. General – Fever, weight loss, loss of appetite, lethargy
2. CVS – Chest pain, palpitation, SOB, orthopnea (breathlessness at
lying flat), leg swelling, dizziness.
3. Respiratory system – SOB, cough, hemoptysis, wheeze, chest
pain.
4. GIT – Nausea, vomiting, hematemesis, dysphagia, heartburn,
jaundice, abdominal pain, rectal bleed, tenesmus.
5. Genitourinary system – Dysuria, frequency, terminal dribbling,
urethral discharge
6. Neurological system – Headache, dizziness, LOC, seizures,
numbness, tingling, weakness.

13. Symptom’s
• Fever
• Cough
• Sputum
• Breathlessness
• Chest pain
• Hemoptysis
• Wheeze & Strider

14. Cough
• Reflex act of forceful expiration against a closed
glottis generating positive intrathoracic pressure
• Aim is to clean the airway
• History should cover the duration & characteristics
of cough whether it is DRY or PRODUCTIVE of
sputum or blood
• Provocative factor i.e. cold, smoke, change in
posture or eating

15. • Accompanying symptom to find out likely cause
1. Running nose and sore throat- post nasal drip
2. Fever, chills & pleuritic chest pain- pneumonia
3. Heartburn – GERD
4. Weight loss & night sweats – chronic infection or tumor
5. Choking sensation & difficulty in swallowing while eating or
drinking – aspiration
 Acute cough (< 3 weeks)
1. URTI (viral, sinusitis)
2. Pneumonia
3. Pulmonary embolism
4. Congestive cardiac failure
5. Allergic rhinitis
6. Exacerbation of asthma and COPD

16. Sub acute cough (3 to 8 weeks)
1. Post nasal drip
2. Viral infection
3. Post infection
4. GERD
5. Bordetella pertussis infection
 Chronic cough (> 8 weeks/ 2 month)
1. Chronic bronchitis
2. Lung cancer
3. Tuberculosis
4. ACE inhibitor
5. Sarcoidosis
6. Somatic cough syndrome
7. Non asthmatic eosinophilic bronchitis
8. Unexplained cough

17.  Nocturnal cough
1. Chronic bronchitis
2. GERD
3. Bronchial asthma
4. LVF
5. Aspiration

18. Sputum
• Consistency
• Amount
• Colour
• Postural variation
• Smell

19. • Consistency
1. Serous – URTI, Bronchoalveolar carcinoma
2. Mucoid – chronic bronchitis, bronchial asthma, COPD
3. Mucopurulent – bacterial infection
• Amount
Copious amount
o bronchiectasis
o Lung abscess
o Necrotising pneumonia
o Alveolar cell carcinoma

20. • Colour of sputum
1. Yellow / green – bacterial infection
2. Black – coal worker pneumoconiosis
3. Pink frothy sputum – pulmonary oedema
4. Rusty sputum – pneumococcal pneumonia
5. Red current jelly sputum – Klebsiella pneumonia
6. Blood tinged sputum – tuberculosis
• Postural variation
1. Lung abscess
2. Bronchiectasis
• Foul smell
1. Lung abscess
2. Anaerobic bacterial infection

21. Dyspnea
• Dyspnea is an unpleasant or uncomfortable awareness of breathing.
• It occur due to an imbalance b/w neurological stimulus & mechanical
changes that occur in the lung & chest wall resulting in mismatch of
ventilation & its demand.
Onset
Duration
Aggravating & releaving factor
Postural variation
Diurnal variation

22. Onset
• Within minutes
1. Pneumothorax
2. Pulmonary embolism
3. Inhaled foreign body
4. Laryngeal oedema
5. Left heart failure
• Hours to days
1. ARDS
2. Bronchial asthma
3. Pneumonia
• Weeks to month
1. COPD
2. Interstitial lung disease
3. Pleural effusion
4. Anaemia
5. Thyrotoxosis

23. MMRC grading of dyspnea

24. • Aggravating factor
1. Exposure to allergent
2. Exercise
3. Drugs
4. Cold weather
• Relieving factor
1. Medication
2. Rest
3. Removal of allergent
• Diurnal & postural variation
1. Bronchial asthma
2. Lung abscess
3. Bronchiectasis

25. • Hemoptysis
is coughing out blood from respiratory tract,
mainly the lungs
Types
1. Frank – expectoration of blood only
2. Spurious – secondary to URTI above the level of larynx
3. Pseudo hemoptysis – due to pigment produce by gram
negative bacteria
 Severity
1. Mild - <100 ml /day
2. Moderate – 100 to 150 ml/day
3. Severe – up to 200 ml/day
4. Massive - >600 ml/day

26. Chest pain
• Chest pain may have its origin from disorders of
chest wall, pleura, lung, heart, great vessels,
oesophagus and subdiaphragmatic structures.
• h/o chest pain include – duration, location,
radiation to other area and character (heaviness,
tearing, burning, stabbing, sharp niddle like, merely
discomfort )
• Precipitating factors
• Associated symptoms
i.e. leg pain & swelling may point to DVT & pulmonary
embolism.

28. • Cause of hemoptysis
Infection
1. Tuberculosis
2. Lung abscess
3. Pneumonia
4. Fungal infection (aspergillosis, blastomycosis)
5. Bronchiectasis
 Neoplasm
1. Bronchogenic carcinoma
2. Bronchial adenoma
3. Metastatic tumour
 Cardiovascular cause
1. Mitral stenosis
2. Pulmonary embolism
3. AV malformation
 Traumatic
 Iatrogenic
 Bleeding disorder

29. Physical examination
• Begins with assessment of general appearance, mental faculty & breathing pattern
• An anxious look indicate acute disease
• While presence of fatigue & cachexia point to chronic disease or malignancy
• A plethoric appearance in polycythemia ( mc in chronic lung disease and SVC
obstruction)
• Look at tongue, soft palate and nail bed for cyanosis, anaemia or polycythemia
• Fingers for clubbing
• Face, neck, hand & feet for oedema (generalised, localised, differential)
• Neck for lymphadenopathy or abnormal pulsation
• Record vital sign
1. Pulse – rate, rhythm, character
2. Respiration – type, rate & regularity
3. Blood pressure
4. temperature

30. • Breathing pattern
normal breathing is quiet with frequency of 12-
18/min
 Tachycardia seen in – anxiety, anaemia, restrictive lung disease,
pulmonary HTN and hypoxia of any etiology
 Bradypnea seen in – drug overdose & CNS lesion
 Noisy breathing indicate narrowing of central airway in
carcinomatous lesion of vocal cord or trachea
 Wheezing breath sound audible to unaided ears- narrowing of
intrathoracic airway i.e. asthma
 Periodic breathing pattern – cheyne -stokes & biots breathing
associated with Lt heart failure & CNS lesion
 In Kussmaul breathing – the depth of respiration is increased more
than rate mc associated with severe metabolic acidosis

31. Cyanosis
• Cyanosis is bluish discoloration of tongue & soft
palate
Central cynosis Peripheral cynosis
due to arterial hypoxia
May occur due to severe
chronic hypoxia of pulmonary
or cardiac origin and often
associater with polycythemia
due to low blood flow
Often occur with oedema
affect neck, face & upper limb
& indicate SVC obstraction

32. Clubbing
• Bulbous enlargement of terminal phalanges early changes consist of
thickening phalanges of fibroelastic tissue or nail bed
• detected by loss of normal angle b/w base of nail bed & adjacent
dorsal surface of figures
• Demonstrated best when viewed from side

34. Lymphadenopathy
• Is abnormal enlargement of LN at neck, axilla, groin
• Note down number, size, consistency & fixity of LN
to each other, to underlaying tissue or overlying
skin
• Large fixed massive indicate – Metastasis
• Firm & matted nodes – tuberculosis
• LN in Hodgkin's lymphoma are classically described
as large, soft, rubbery in nature

36. Examination of chest
• Inspection
• Palpitation
• Percussion
• Ascultation

37. Inspection
• Appearance, shape, size of chest
• Normal chest is b/l symmetrical & elliptical in cross section
 But in disease it may be asymmetrical
1. Generalised or localised flattening of fullness in congenital disorder of lung,
plura, ribs, vertebra or sternum
 Abnormal shape – rickets
 Pectus carinatum (Pigeon chest) – localised prominence of sternum &
adjacent ribs
 Pectus excavation (funnel chest) – localised depression of sternum & adjacent
ribs
 Kyphosis – forward bending
 Scoliosis – lateral banding
 Flattening – decrease anteroposterior diameter
 Hyperinflation or barrel shape – increase anteroposterior diameter
 Observe for scar, injury mark, lumps & stains

41. Movement of chest wall
• Normal both side of chest moves equally
• Decrease or absent movement on one side may
indicate disease of chest wall, pleura or lung on that
side
1. Symmetrical decrease in movement – emphysema,
asthma, end stage diffuse pulmonary fibrosis
2. Intercostal recession (indrawing of i/c space) – in severe
upper airway obstruction (laryngeal or trachial tumour)
3. Inward movement of lower rib – in asthma &
emphysema
4. Accessory muscle of respiration – in emphysema

42. • Shift of mediastinum – observe for prominence of
the tendon of sternomastoid muscle at the
suprasternal notch
• The trachea shifted to side of prominence – positive
trail sign
• Indicates shift of upper mediastinum to the same
side – fibrosis or collapse
• To opposite side – in pleural effusion,
pneumothorax, lung mass

43. Palpation
• Palpation is done to confirm the finding of inspection.
• Begins at the part of chest showing swelling or where c/o pain to detect
1. Inflammatory oedema due to rib fracture, cellulitis, infected cyst or tumour.
2. Air – subcutaneous emphysema
3. Pus – abscess, empyema
4. Nodule – purpura, sarcoid nodule, metastatic nodule
• Access position of trachea in suprasternal notch & apex beat at lower chest wall
• Access for symmetry movement on both side
 In general pathological side moves less
• Access with intercostal space on both side to confirm flattening of fullness
• Vocal fremitus is detected by placing the ulnar side of hand over the
equivalent area on the two side of patient chest when narrates 1,2,3
or 99

44. Percussion
• Compare the degree of resonance over the
equivalent area on the two side of chest
• Note fot the area of tenderness
• Stony dull percussion note – in pleural effusion
(more so when breath sound & vocal resonance
decrease)
• Hyperresonant note indicate pneumothorax (more
so when chest appear fuller & breath sound & vocal
resonance decrease or absent.

45. Table

46. Auscultation
• Breath sound listen to lung sound for its character & quality over all
the parts of the chest wall on both side using the diaphragm of
stethoscope
• Breath sounds are vascular in character (low frequency rustling with
longer inspiration than expiration & without a pause in between)
over the healthy lung & best heared at base of lung.
• Bronchial breathing – high pitch blowing sound, heared during
inspiration & expiration & separate by brief pause, it is normal over
trachea & larynx.
* But if heared over chest wall it indicate consolidation.
• Breath sound decreased in intensity when
1. Fluid (effusion)
2. Air (pneumothorax)
3. Atelectasis

48. Adventitious sounds
• Wheezes – continuos high pitch sound, often musical in character,
which arise from air moving in narrow airway e.g. asthma
- most marked during expiration & associated with prolong
expiratory sound.
• Crackles – are discontinuous “popping” or “bubble” sound, coarse,
gurgling sound are caused by secretion in large airway.
- heared during inspiration & expiration
• Fine crackles – heared during early inspiration in restrictive lung
disease (pulmonary oedema & pulmonary fibrosis
- produces due to sudden opening of small airways
• Rub is localised cracking or rubbing sound, often associated with
chest pain.
- heared during inspiration & expiration.
- indicates pleural inflammation.

49. Vocal resonance
• It is audible perception of the transmitted vibration
from vocal cord over the chest as patient narrate
1,2,3 or 99
- it increase in consolidation &
- decrease in atelectasis, pneumothorax & plural
effusion.