Lekcja 3: Badanie i Ocena Stanu Pacjenta | Patient Examination and Assessment

Respiratory History

Taking a detailed and structured respiratory history is crucial in identifying risk factors and symptoms indicative of pulmonary disease. The history should be comprehensive, patient-centered, and provide insights into the patient’s presenting complaint, associated symptoms, and relevant past medical history.

Chief Complaint

The respiratory history starts by identifying the patient’s chief complaint. Common respiratory complaints include:

  • Cough
  • Dyspnea (shortness of breath)
  • Wheezing
  • Chest pain
  • Hemoptysis (coughing up blood)
  • Sputum production

Each symptom provides clues to the potential underlying respiratory condition.

History of Present Illness

A detailed history of present illness explores the characteristics, onset, progression, and factors related to the patient’s current symptoms.

Cough

Cough is a frequent symptom in respiratory diseases and can be acute, subacute, or chronic, depending on its duration. Key elements to assess include:

  • Onset: Is the cough acute (less than 3 weeks), subacute (3–8 weeks), or chronic (more than 8 weeks)? Acute cough is often related to infections, while chronic cough suggests conditions like asthma, chronic bronchitis, or gastroesophageal reflux.
  • Character: Is the cough dry or productive? A dry cough is typical of viral infections or asthma, while a productive cough with sputum suggests infections or chronic obstructive pulmonary disease (COPD).
  • Sputum: Assess the color, consistency, and amount of sputum. Purulent (yellow or green) sputum indicates infection, while clear sputum is more common in viral infections or asthma.
  • Associated symptoms: Wheezing, shortness of breath, or fever accompanying the cough may indicate an underlying infection, airway obstruction, or asthma exacerbation.

Dyspnea

Shortness of breath (dyspnea) is a key symptom in respiratory diseases and can be classified by its onset and triggers:

  • Onset: Is the dyspnea acute or chronic? Acute onset may suggest conditions such as pneumonia, pulmonary embolism, or pneumothorax. Chronic dyspnea often points to COPD, asthma, or interstitial lung disease.
  • Exertional or Rest: Exertional dyspnea is common in conditions such as COPD and heart failure, while dyspnea at rest may suggest more severe pathology, such as pulmonary embolism or severe asthma exacerbation.
  • Orthopnea: Difficulty breathing while lying flat is often associated with heart failure but can also be seen in severe pulmonary diseases like COPD.
  • Paroxysmal Nocturnal Dyspnea (PND): Sudden shortness of breath during sleep that wakes the patient is typically associated with congestive heart failure but may also occur in severe obstructive lung diseases.
  • Severity: Ask the patient to describe the impact on daily activities, such as walking, climbing stairs, or even dressing, to gauge the extent of the respiratory dysfunction.

Wheezing

Wheezing refers to a high-pitched sound produced during breathing due to airway narrowing.

  • Timing: Wheezing may occur during inspiration or expiration. Expiratory wheezing is more common in asthma and COPD, while inspiratory wheezing may indicate an upper airway obstruction.
  • Triggers: Wheezing triggered by allergens, cold air, or exercise is typical of asthma.
  • Associated symptoms: Cough and shortness of breath often accompany wheezing in obstructive lung diseases.

Chest Pain

Chest pain in respiratory conditions can be due to pleuritic causes (inflammation of the pleura), muscular strain, or infection.

  • Character: Pleuritic chest pain is sharp and worsens with breathing or coughing. This pain suggests conditions such as pneumonia, pulmonary embolism, or pleurisy.
  • Location: Localized chest pain often indicates pleuritic causes, while diffuse pain may suggest musculoskeletal strain or infection.

Hemoptysis

Hemoptysis refers to coughing up blood and can indicate serious respiratory conditions.

  • Amount: Assess whether the hemoptysis is scant (streaks of blood) or massive (more than 200–600 mL in 24 hours).
  • Associated symptoms: Fever, weight loss, or night sweats accompanying hemoptysis may suggest tuberculosis, while chronic cough and sputum production may indicate bronchiectasis.

Past Medical History

Understanding the patient’s past medical history provides crucial information for identifying potential respiratory risk factors and comorbidities:

  • Asthma: A history of asthma is important, particularly if the patient reports frequent exacerbations or poor symptom control.
  • Chronic Obstructive Pulmonary Disease (COPD): This includes both chronic bronchitis and emphysema. Smoking history is often linked to COPD development.
  • Pneumonia: Recurrent episodes of pneumonia suggest an underlying immunocompromised state or chronic lung disease.
  • Tuberculosis (TB): A history of TB increases the likelihood of lung scarring or bronchiectasis.
  • Pulmonary Embolism (PE): A personal or family history of PE or deep vein thrombosis is a major risk factor for future embolic events.
  • Lung Cancer: A history of smoking or previous cancer diagnoses increases the risk of lung malignancies.
  • Occupational exposures: Previous jobs that exposed the patient to asbestos, silica, or other harmful substances are important in assessing the risk for diseases like asbestosis, silicosis, or occupational asthma.

Family History

Family history can help uncover hereditary respiratory conditions. Important conditions to ask about include:

  • Asthma: Asthma often has a genetic component, and a family history increases the likelihood of diagnosis.
  • Cystic Fibrosis: This is a genetic condition causing chronic respiratory infections and pancreatic insufficiency.
  • Alpha-1 Antitrypsin Deficiency: A genetic condition that predisposes individuals to early-onset emphysema.

Social History

A detailed social history is crucial in identifying modifiable risk factors for respiratory diseases.

  • Smoking: Smoking is the leading cause of COPD and lung cancer. Assess the patient’s smoking history in pack-years (packs per day multiplied by years of smoking).
  • Secondhand smoke: Even non-smokers who are exposed to secondhand smoke have a higher risk of respiratory illnesses.
  • Occupational Hazards: Inquire about exposure to chemicals, dust, or asbestos, particularly in jobs like construction, mining, or manufacturing.
  • Pets and Allergens: Exposure to animals or environmental allergens can trigger asthma or other allergic respiratory conditions.
  • Substance Use: Recreational drug use, especially smoking crack or inhaling other toxic substances, can cause significant lung damage, including pneumonitis or chronic bronchitis.
  • Travel: Recent travel, particularly to areas endemic to certain infections such as tuberculosis or fungal diseases like histoplasmosis, may suggest specific diagnoses.

Environmental and Occupational Exposure

In addition to social history, environmental and occupational exposures can significantly impact respiratory health.

  • Home Environment: Poor ventilation, mold, or exposure to dust mites and other indoor allergens may exacerbate asthma and other chronic lung diseases.
  • Occupational Exposure: Jobs involving exposure to chemicals, fumes, or particulate matter increase the risk of occupational lung diseases like silicosis, asbestosis, and pneumoconiosis.

Pulmonary Examination

The pulmonary exam begins with positioning the patient appropriately and ensuring an environment conducive to a thorough examination. This includes maintaining privacy, ensuring good lighting, and using hygienic practices.

Positioning

  • The patient should be seated upright with arms resting at the side.
  • Perform all parts of the exam on an undressed patient while maintaining modesty, often with the use of a gown or sheet.
  • Always explain each step of the exam to the patient and obtain their consent.

Initial Steps

  • Ensure vital signs are measured, including respiratory rate, pulse oximetry, and blood pressure.
  • Ask the patient to point out any areas of tenderness to avoid causing additional pain during the exam.

Observation

Observation is the initial step of the pulmonary exam – focus on the patient’s posture, chest shape, respiratory patterns, and any signs of respiratory distress.

Posture and General Appearance

  • Posture: A forward-leaning posture, known as the tripod position, is commonly adopted by patients with conditions like COPD or asthma to reduce respiratory effort.
  • General appearance: Look for signs of respiratory distress, such as labored breathing, use of accessory muscles, or cyanosis (bluish discoloration of the skin).

Shape of the Chest

Evaluate the chest for any structural abnormalities

  • Pectus excavatum: Inward sunken appearance of the sternum.
  • Pectus carinatum: Protrusion of the sternum outward.
  • Barrel-shaped chest: Increased anterior-posterior diameter, often seen in patients with chronic obstructive pulmonary disease (COPD).

Respiratory Conditions

Observation of the respiratory system provides crucial insights into both localized and systemic health. Respiratory symptoms and signs can be manifestations of underlying systemic diseases, infections, allergic reactions, or environmental exposures.

  • Dyspnea (Shortness of Breath): Dyspnea is a common indicator of respiratory distress. It may be acute or chronic and is seen in conditions like asthma, chronic obstructive pulmonary disease (COPD), pneumonia, and heart failure. Acute dyspnea often suggests infections, pulmonary embolism, or pneumothorax, while chronic dyspnea is typical of conditions like COPD or interstitial lung disease.
  • Cough: A persistent or acute cough can reflect various respiratory conditions. A productive cough, characterized by sputum production, is often seen in infections such as pneumonia or bronchitis, while a dry cough may indicate asthma, viral infections, or gastroesophageal reflux. Hemoptysis (coughing up blood) suggests more serious conditions like tuberculosis, lung cancer, or pulmonary embolism.
  • Wheezing: Wheezing is a high-pitched sound caused by narrowing of the airways, commonly associated with asthma, COPD, or bronchitis. It often indicates obstruction or inflammation in the lower airways and may be triggered by allergens, infections, or irritants.
  • Chest Pain: Respiratory-related chest pain often stems from pleuritic causes, such as pleurisy, pulmonary embolism, or pneumonia, and is exacerbated by breathing or coughing. It is crucial to differentiate respiratory chest pain from cardiac or musculoskeletal sources.
  • Cyanosis: Bluish discoloration of the skin or mucous membranes indicates hypoxemia (low blood oxygen levels) and is often a sign of severe respiratory distress, seen in conditions like COPD, asthma, or severe pneumonia. Central cyanosis (around the lips and tongue) usually reflects more severe oxygen deprivation than peripheral cyanosis (fingers and toes).
  • Clubbing: Clubbing of the fingers or toes is a sign of chronic hypoxia and is often seen in respiratory conditions such as lung cancer, interstitial lung disease, or bronchiectasis. It is characterized by the rounding and enlargement of the nail beds.
  • Use of Accessory Muscles: In patients with respiratory distress, the use of accessory muscles (neck and shoulder muscles) during breathing is often observed. This indicates increased work of breathing, commonly seen in severe asthma, COPD exacerbations, or respiratory failure.
  • Tachypnea (Rapid Breathing): Tachypnea is an abnormally rapid breathing rate and is a non-specific sign of respiratory or metabolic distress. It is observed in a wide range of conditions, including pneumonia, sepsis, or pulmonary embolism.

Breathing Patterns

  • Abdominal breathing: Diaphragmatic involvement where abdominal muscles are more engaged.
  • Thoracic breathing: More involvement of chest muscles with limited diaphragmatic movement.
  • Mixed breathing: A combination of both abdominal and thoracic breathing patterns.

Respiratory Rate and Rhythm

  • Respiratory rate: Normal is 12–20 breaths per minute in adults. Note any bradypnea (rate < 12) or tachypnea (rate > 20).
  • Rhythm: Evaluate for irregularities:
    1. Kussmaul breathing: Deep and rapid breathing, often seen in diabetic ketoacidosis or metabolic acidosis.
    2. Cheyne-Stokes respiration: Cyclic pattern of gradual increase and decrease in breathing, followed by periods of apnea, often seen in stroke or heart failure.
    3. Biot’s breathing: Irregular breathing with periods of apnea, typically associated with severe brain injury.

Types of breathing

Type of BreathingDescriptionAssociated Conditions
EupneaNormal, unlabored breathing at a regular rate.Normal condition
DyspneaDifficulty breathing or shortness of breath.Heart failure, pulmonary embolism, anxiety
HyperpneaIncreased depth of breathing to meet metabolic demands.Exercise, anemia
TachypneaRapid, shallow breathing.Pneumonia, fever, heart failure
BradypneaAbnormally slow breathing rate.Narcotic overdose, brain injury
ApneaAbsence of breathing.Sleep apnea, cardiac arrest

Signs of Respiratory Distress

  • Dyspnea: Difficulty breathing, often associated with labored, shallow breathing.
  • Cyanosis: A bluish tint to the skin or nails, indicating inadequate oxygenation.
  • Pursed-lip breathing: A breathing technique commonly seen in patients with COPD, allowing them to control the rate of exhalation and maintain open airways.
  • Use of accessory muscles: Recruitment of neck and intercostal muscles indicates increased respiratory effort, often seen in severe respiratory distress.

Palpation

Palpation helps assess the movement of the chest wall and identify abnormalities that may not be visible on inspection.

Chest Expansion

  • Place your hands on the patient’s back with your thumbs touching at the midline.
  • Ask the patient to take a deep breath and observe the symmetry of chest expansion. Asymmetry may suggest conditions like atelectasis, pleural effusion, or lung collapse.

Vocal Fremitus

  • Place your hands on the patient’s chest or back and ask them to repeat a phrase such as “ninety-nine”, “blue balloons” or “czterdzieści cztery”.
  • Feel for the vibrations transmitted through the chest wall. Increased fremitus may indicate consolidation (as in pneumonia), while decreased fremitus suggests effusion, pneumothorax, or obstructive lung disease.

Tracheal Deviation

  • Palpate the trachea to assess its position. A deviation from the midline may suggest a tension pneumothorax or large pleural effusion.

Percussion

Percussion in lung examination involves rhythmically tapping the chest wall using the middle finger of one hand to strike the distal interphalangeal joint of the opposite hand. This technique is applied systematically across the anterior, posterior, and lateral lung fields to assess resonance. Abnormal sounds, such as dullness or hyper-resonance, can indicate lung pathologies like consolidation, pleural effusion, or pneumothorax.

Comparative Percussion

  • Systematically percuss the anterior, posterior, and lateral chest to compare resonance across both lung fields.
  • Normal lung tissue produces a resonant sound, while dullness suggests consolidation, effusion, or atelectasis.
  • Hyper-resonance indicates air trapping, as seen in pneumothorax or emphysema.

Detailed Percussion

  • Lung apices: Percussion over the upper lung areas to evaluate for pneumothorax or upper lung disease.
  • Lower lung boundaries: Percuss to define the lower margins of the lung fields and assess for pleural effusion or other abnormalities.
  • Respiratory mobility: Evaluate the movement of the lungs during inhalation and exhalation by percussing the lung borders and noting their shift with breathing.

Auscultation

Preparation: Ensure a quiet environment and ask the patient to sit comfortably with their chest exposed for clear stethoscope placement.

Stethoscope Placement: Place the diaphragm of the stethoscope firmly on the chest wall, systematically covering anterior and posterior regions, as well as upper, middle, and lower lung fields, for a thorough respiratory assessment.

Normal Breath Sounds

SoundDescriptionNormal Location
Tracheal BreathingLoud and high-pitchedHeard over the neck
Bronchial BreathingLoud and high-pitched. Expiratory sounds last longer.Heard over large airways (sternum)
BronchovesicularIntermediate intensity and pitch. Inspiratory and expiratory sounds are equal.Heard over 1st and 2nd intercostal spaces
Vesicular BreathingLower-pitched, rustling sounds. Inspiratory sounds last longer than expiratory.Heard over both lung fields

Note: In clinical practice, we primarily focus on bronchial breathing and vesicular breathing. These two types of breath sounds are the most clinically significant when distinguishing between normal and pathological respiratory states.

Pathological Breath Sounds

Type of SoundSubtypeDescriptionAssociated Conditions
Crackles (Rales)1. Fine CracklesDiscontinuous, intermittent. High-pitched. Heard during inspiration.Pneumonia, pulmonary fibrosis, pulmonary edema
2. Coarse CracklesLow-pitched, louder, and heard during both inspiration and expiration.Bronchiectasis, chronic bronchitis
Wheezes1. Inspiratory WheezesHigh-pitched sound due to airway narrowing outside the chest wall.Vocal cord dysfunction, tracheal inflammation, foreign body
2. Expiratory WheezesHigh-pitched sound due to airway narrowing within the chest wall. Heard during expiration.Asthma, COPD, chronic bronchitis
Stridor1. Inspiratory StridorHigh-pitched, musical sound from turbulent airflow during inspiration.Epiglottitis, retropharyngeal abscess
2. Expiratory StridorHigh-pitched, musical sound during expiration, usually due to lower airway obstruction.Asthma, COPD
3. Biphasic StridorHigh-pitched sound during both inspiration and expiration, suggesting glottic obstruction.Foreign body, vocal cord palsy
Sonorous Wheezes (Rhonchi)Low-pitched, snoring sounds, often associated with crackles.Bronchitis, pneumonia, or other conditions with mucus accumulation
Pleural Friction RubDiscontinuous, low-pitched sound. Heard in both inspiration and expiration.Pleuritis, fibrosis, or neoplasm
Muffled or Absent SoundsContinuous, musical sound. Wheezing louder during expiration.Emphysema, pneumothorax, pleural effusion, tumor

Diagnostic Tests and Procedures

Pulmonary Function Tests (PFTs)

Pulmonary function tests (PFTs) measure lung capacity and airflow. They are often used to diagnose and monitor conditions like asthma, chronic obstructive pulmonary disease (COPD), and restrictive lung diseases.

Types of PFTs

  • Spirometry: The most common PFT, spirometry measures how much air a person can inhale and exhale, as well as how fast they can exhale. It provides data on two important values:
    1. Forced Vital Capacity (FVC): The total amount of air exhaled forcefully after a deep breath.
    2. Forced Expiratory Volume in 1 second (FEV1): The amount of air exhaled in the first second during a forced exhalation.
  • Lung Volume Measurement (Plethysmography): This test measures the total volume of air in the lungs, including the air remaining after a complete exhalation (residual volume). It helps differentiate between restrictive and obstructive lung diseases.
  • Diffusion Capacity (DLCO): This measures how well oxygen passes from the lungs into the blood. It is used to diagnose conditions affecting the alveoli, such as pulmonary fibrosis.

How is it Performed?

The patient breathes into a mouthpiece connected to a machine that records various lung volumes and flow rates. The test is non-invasive and typically takes 20-30 minutes.

Diagnoses:

  • Asthma
  • COPD
  • Pulmonary fibrosis
  • Restrictive lung disease (e.g., sarcoidosis, interstitial lung disease)

Chest X-ray (CXR)

A chest X-ray is a basic imaging test used to visualize the lungs, airways, heart, and chest wall. It helps detect abnormalities like infections, tumors, or fluid buildup.

How is it Performed?

The patient stands in front of an X-ray machine, which takes an image of the chest using a small amount of ionizing radiation.

Diagnoses:

  • Pneumonia
  • Lung tumors
  • Tuberculosis
  • Pleural effusion (fluid in the pleural space)
  • Pneumothorax (collapsed lung)
  • Heart failure (indirectly, through signs like pulmonary edema)

Computed Tomography (CT) Scan

A CT scan provides a more detailed cross-sectional view of the lungs and surrounding structures. It is often used when abnormalities are detected on a chest X-ray or when more detailed imaging is needed.

How is it Performed?

 The patient lies on a table that moves through a circular X-ray machine, which takes multiple images from different angles. Sometimes, a contrast dye is used to highlight blood vessels and tissues.

Diagnoses:

  • Lung cancer
  • Pulmonary embolism (PE)
  • Interstitial lung disease
  • Bronchiectasis
  • Emphysema
  • Advanced infections (e.g., fungal infections)

Bronchoscopy

Bronchoscopy allows direct visualization of the airways, making it useful for diagnosing airway diseases, infections, or tumors, and for collecting biopsy samples.

How is it Performed?

A bronchoscope (a thin, flexible tube with a light and camera) is inserted through the nose or mouth and advanced into the trachea and bronchi. This procedure can be performed under local anesthesia with sedation or general anesthesia, depending on the case.

Diagnoses:

  • Lung cancer (biopsies can be taken)
  • Foreign body aspiration
  • Airway inflammation
  • Infection (bronchoalveolar lavage can collect fluid samples for culture)
  • Chronic cough or hemoptysis (coughing up blood)

Arterial Blood Gas (ABG) Analysis

Purpose: An arterial blood gas (ABG) test measures the levels of oxygen (O2), carbon dioxide (CO2), and the pH of arterial blood. It helps evaluate how well the lungs are able to move oxygen into the blood and remove carbon dioxide.

How is it Performed?

A small sample of blood is taken from an artery, usually in the wrist, and analyzed for oxygenation, carbon dioxide removal, and acid-base balance.

Diagnoses:

  • Respiratory failure
  • COPD exacerbation
  • Severe asthma attack
  • Metabolic acidosis or alkalosis
  • Conditions causing hypoxemia (low oxygen levels)

Sputum Culture and Cytology

Sputum tests examine mucus produced from the lungs, identifying infections or cancer cells. Sputum culture is used to diagnose bacterial, fungal, or viral infections, while cytology screens for cancer.

How is it Performed?

The patient is asked to cough deeply to produce a sample of sputum, which is then sent to the laboratory for culture or microscopic examination.

Diagnoses:

  • Pneumonia
  • Tuberculosis
  • Fungal lung infections
  • Lung cancer (via cytology)

Thoracentesis

Thoracentesis is a procedure used to remove fluid from the pleural space (the area between the lungs and the chest wall) for diagnostic or therapeutic purposes.

How is it Performed?

A needle is inserted through the chest wall into the pleural space under local anesthesia, and fluid is aspirated. The fluid is analyzed for infections, cancer, or other conditions.

Diagnoses:

  • Pleural effusion (to determine cause)
  • Infections such as empyema
  • Cancer metastasis to the pleura

Pulse Oximetry

Pulse oximetry is a non-invasive test that estimates the oxygen saturation (SpO2) in the blood, indicating how well oxygen is being transported through the bloodstream.

How is it Performed?

A small sensor is placed on the patient’s fingertip or earlobe. It uses light to measure oxygen saturation levels.

Diagnoses:

  • Hypoxemia
  • Monitoring of oxygen levels in patients with lung diseases (e.g., COPD, asthma, pneumonia)