Respiratory System Assessment: History and Symptoms
A thorough respiratory assessment involves systematically gathering patient history, including chief complaint, present illness, and detailed past medical, drug, and social histories. This process is crucial for interpreting common symptoms like dyspnea, cough, and wheeze, allowing clinicians to differentiate between infectious, chronic, and occupational lung diseases effectively and identify critical red flag symptoms.
Key Takeaways
History taking must cover past illnesses, drug effects, and social factors like smoking.
Dyspnea severity is measured using the mMRC scale, noting onset and timing.
Wheeze indicates lower airway narrowing, while stridor suggests upper airway obstruction.
Chronic cough requires investigation into causes like GERD, ACE inhibitors, or cancer.
Unexplained weight loss, fevers, and night sweats are critical red flag symptoms.
What are the essential components of a comprehensive respiratory history?
A comprehensive respiratory history systematically builds a clinical picture, starting with the chief complaint and history of present illness. It then delves into past medical and surgical history, focusing on previous respiratory conditions like asthma, bronchiectasis, or tuberculosis, and non-respiratory issues like connective tissue diseases or VTE risk factors. Crucially, the assessment includes drug and allergy history, family history, and detailed social history, such as smoking status (calculated in pack-years) and occupational exposures, concluding with a systemic review to uncover related pathologies. This structured approach ensures no critical diagnostic clues are missed, optimizing the pathway to accurate diagnosis and management.
- Chief Complaint and History of Present Illness are the initial focus.
- Past Medical History includes specific respiratory issues like asthma (linked to atopy/eczema), bronchiectasis (from severe infections), and previous TB (risk for reactivation).
- Non-Respiratory History covers connective tissue diseases (causing fibrosis/effusions), neuromuscular disorders (risk of aspiration/respiratory failure), and VTE risk factors (suggesting PE).
- Drug History identifies medications causing adverse effects, such as ACE inhibitors (cough), beta-blockers (bronchoconstriction), or cytotoxic agents (Interstitial Lung Disease).
- Family History screens for genetic conditions like cystic fibrosis or A1 Antitrypsin deficiency, and familial asthma/atopy.
- Social History details smoking (calculating pack-years), alcohol use (linked to aspiration), occupational exposure (longer exposure means more severe symptoms), and daily activity level.
- Systemic Enquiry reviews other systems, potentially revealing pathologies like ovarian cancer (presenting with SOB/chest pain) or fluid overload.
How are common respiratory symptoms like dyspnea, cough, and hemoptysis assessed?
Common respiratory symptoms are assessed by defining their characteristics, timing, and associated factors. Dyspnea, the subjective feeling of breathlessness, is evaluated using the mMRC scale, noting onset (e.g., instantaneous in PE) and provoking factors (e.g., orthopnea). Cough duration classifies it as acute, subacute, or chronic, requiring investigation into causes like ACE inhibitors or GERD. Hemoptysis, or coughing up blood, must be confirmed as respiratory in origin, with lung cancer and pulmonary embolism always considered, especially if recurrent or associated with chest pain. Furthermore, systemic symptoms like fevers, rigors, and unexplained weight loss serve as critical red flags indicating severe infection or malignancy.
- Dyspnea (Shortness of Breath): Defined as an uncomfortable need to breathe, caused by mechanisms like lung nerve stimulation, muscle loading, or hypoxia; severity is graded using the mMRC scale.
- Wheeze: A musical, whistling sound caused by turbulent airflow in narrowed small airways, typically heard during expiration in conditions like asthma or COPD.
- Stridor: A harsh, grating sound indicating major airway compression, which can be inspiratory (extrathoracic obstruction) or expiratory (intrathoracic obstruction).
- Cough: Classified by duration (chronic is >8 weeks) and type (e.g., bovine cough from vocal cord paralysis); common causes include GERD, ACE inhibitors, and post-nasal drip.
- Sputum Analysis: Volume, consistency, and color are assessed; colors range from clear (stable COPD) to green (infection) or pink/frothy (acute pulmonary edema).
- Hemoptysis: Coughing up blood from below the glottis; always requires ruling out serious causes like lung cancer, PE, or severe bronchiectasis.
- Chest Pain: Assessed using SOCRATES; pain sources include the parietal pleura (pleuritic pain) or chest wall (musculoskeletal pain), but not the lung tissue itself.
- Systemic Symptoms: Fevers, rigors (suggesting severe sepsis), and night sweats (classic for TB or lymphoma) are critical indicators of systemic illness.
- Weight Loss: Unintentional loss is a major red flag associated with malignancy, tuberculosis, or the high energy cost of breathing in severe COPD.
- Sleepiness: Excessive daytime sleepiness is strongly linked to Obstructive Sleep Apnoea (OSA), characterized by loud snoring and witnessed apnoeas at night.
What are the key differences between stridor and wheeze, and how does occupational history influence diagnosis?
Differentiating respiratory sounds is crucial for localization: wheeze originates in the lower airways (bronchioles), is musical, and primarily expiratory, commonly seen in asthma or COPD. Conversely, stridor originates in the upper airway (larynx/trachea), sounds harsh, and is typically inspiratory, suggesting conditions like croup or foreign body obstruction. Furthermore, a detailed occupational history is essential, as long-term exposure to agents like asbestos (shipbuilders) or silica (miners) can lead to specific, delayed lung diseases such as asbestosis or silicosis, while exposure to isocyanates or mouldy hay can trigger occupational asthma or hypersensitivity pneumonitis. The duration of exposure often correlates with symptom severity.
- Stridor vs. Wheeze: Stridor originates in the upper airway (larynx/trachea), is harsh, and often inspiratory (e.g., Croup); Wheeze originates in the lower airway (bronchioles), is musical, and primarily expiratory (e.g., Asthma).
- Occupational Lung Disease: Exposure to asbestos (shipbuilders) causes diseases like asbestosis, pleural plaques, and mesothelioma, often with a long latency period (10–40 years).
- Silica Exposure: Trades like stonemasonry or coal mining risk silicosis and progressive massive fibrosis.
- Occupational Asthma: Triggered by agents like isocyanates (paint sprayers) or flour (bakers); symptom timeline relative to work is key.
- Hypersensitivity Pneumonitis: Linked to farm or animal contact, such as mouldy hay (farm labourer) or bird feathers (pigeon fancier).
Frequently Asked Questions
Why is past medical history, specifically non-respiratory history, important in a respiratory assessment?
Non-respiratory conditions like connective tissue diseases (e.g., RA, SLE) can cause lung fibrosis or pleural effusions. Neuromuscular disorders increase aspiration risk, and VTE risk factors suggest potential pulmonary embolism. Immunomodulatory treatments for these conditions can also cause lung toxicity.
What is the significance of sputum color in diagnosing respiratory conditions?
Sputum color provides clues about the underlying pathology. Green sputum indicates current infection due to neutrophil breakdown. Rusty sputum is classic for pneumococcal pneumonia, while pink and frothy sputum suggests acute pulmonary edema (heart failure). Clear sputum is often stable chronic disease.
When assessing chest pain, why is the lung parenchyma not considered a source of pain?
The lung parenchyma and visceral pleura lack pain-sensitive somatic nerves. Chest pain originates from structures like the parietal pleura (causing sharp, pleuritic pain), chest wall (musculoskeletal pain), myocardium, or mediastinal structures (e.g., aorta or esophagus).
