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Respiratory System: Basic to Pro Level Case Taking

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PART 1 - PRESENTING COMPLAINTS (Chief Complaints) - Breathe Lene Se Pehle Suno

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PART 2 - HISTORY OF PRESENTING ILLNESS (HPI)

1. DYSPNEA (Sans phoolna) - Sab se Important

• Acute (<72 hrs): Pulmonary edema, PE (pulmonary embolism), pneumothorax, pneumonia, asthma attack
• Chronic/Progressive: COPD, interstitial lung disease, left heart failure, pulmonary HTN

• Orthopnea: Lait ke saans phoolna, uthne pe theek → Left heart failure, mitral stenosis - kitne taqiye chahiye raat ko?
• Paroxysmal Nocturnal Dyspnea (PND): Raat ko neend se uthna, sans ke liye tadapna → Left ventricular failure
• Platypnea: Khade hone pe saans phoolna, laitne pe theek → Hepatopulmonary syndrome, AVM
• Trepopnea: Ek karawat pe theek, doosri pe phoolna → Unilateral lung disease

• Exertional only: COPD, mild heart failure, anemia
• Rest pe bhi: Severe disease

• Progressive = COPD, ILD, malignancy
• Episodic/Recurrent = Asthma, cardiac dysfunction

• Wheeze ke saath = Asthma / COPD
• Chest pain ke saath = PE, pneumothorax, pleuritis
• Leg swelling ke saath = Cor pulmonale, DVT/PE
• Orthopnea + PND ke saath = Cardiac

• Exercise se badhe, rest se kahe = Cardiac / Pulmonary
• Allergens se badhe = Asthma
• Inhaler se theek ho = COPD / Asthma

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2. COUGH - Khansi

• Acute (<3 weeks): URTI, pneumonia, PE
• Subacute (3-8 weeks): Post-viral, whooping cough
• Chronic (>8 weeks): Top 3 causes - (1) Postnasal drip, (2) GERD, (3) Asthma

• Dry, non-productive = Interstitial lung disease, ACE inhibitor cough, viral
• Productive = Bronchitis, bronchiectasis, pneumonia, lung abscess
• "Barking" = Croup, tracheal compression
• Paroxysmal = Pertussis, foreign body

• Raat ko = Post-nasal drip, GERD, asthma
• Subah uthte hi = Chronic bronchitis (smoker's cough)
• Khana khane ke baad = GERD, aspiration

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3. HEMOPTYSIS - Khoon aana

• Scant: Thukk mein blood streaks = Bronchitis, bronchogenic Ca
• Frank hemoptysis = TB, bronchiectasis, lung abscess, PE
• Massive hemoptysis (>600 mL/24 hr) = Medical emergency - TB cavity, bronchiectasis, aspergilloma

• True hemoptysis hai ya pseudohemoptysis (nose/throat se)? - Bright red, frothy = True hemoptysis
• Bloody vomiting (hematemesis) se distinguish karo - dark red, acidic, food particles = Hematemesis
• TB history? Smoking? Weight loss? Fever?

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4. CHEST PAIN

• Pleuritic pain: Sharp, inspiration pe worse = Pleuritis, PE, pneumonia (pericarditis mein bhi)
• Dull aching: Tumor infiltration, rib involvement
• Central crushing: Cardiac (distinguish karna zaruri)

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PART 3 - PAST MEDICAL HISTORY (PMH)

• Prior respiratory illnesses (asthma, TB, pneumonia, pleural effusion)
• Childhood respiratory infections / frequent bronchitis
• Prior surgeries especially thoracic
• Prior hospitalizations / ICU admissions / intubations
• HIV status - pulmonary complications often first presentation of AIDS (Fishman's)
• Rheumatological disorders: Scleroderma (ILD + aspiration), SLE, RA - all cause lung disease
• Malignancies: Breast Ca, colon Ca - metastasize to lung; Pancreatic Ca - DVT/PE risk
• Chemotherapy: Drug-induced pulmonary toxicity (bleomycin, methotrexate)
• Cardiac history: LVF → cardiac dyspnea

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PART 4 - DRUG HISTORY

• ACE inhibitors (enalapril, lisinopril) = Dry chronic cough (very common - even after years of use, ethnic differences noted - Fishman's)
• Amiodarone = Pulmonary toxicity / fibrosis
• Bleomycin, Methotrexate, Cyclophosphamide = Drug-induced ILD
• Beta-blockers = Bronchospasm in asthmatics
• Aspirin/NSAIDs = Aspirin-exacerbated respiratory disease

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PART 5 - OCCUPATIONAL AND ENVIRONMENTAL HISTORY

• Naya humidifier ya air conditioning (stagnant water) = Legionella / hypersensitivity pneumonitis
• Mold exposure = Aspergillosis, HP

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PART 6 - TRAVEL AND GEOGRAPHIC HISTORY

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PART 7 - SMOKING HISTORY (VITAL!)

Pack years = (cigarettes per day ÷ 20) × years smoked

• 20 pack years = High COPD/lung cancer risk

• Current/Ex-smoker? Kab choda?
• Passive smoking bhi puchho (children mein especially)
• Hookah / Bidi bhi include karo

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PART 8 - FAMILY HISTORY

• Alpha-1 antitrypsin deficiency (young COPD patient mein sochho)
• Cystic fibrosis
• Familial pulmonary fibrosis
• Atopy / Asthma / Allergic diseases

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PART 9 - SOCIAL HISTORY

• Alcohol abuse = Aspiration pneumonia risk
• IV drug use = Septic emboli, pneumococcal pneumonia
• Immunocompromised state (HIV, steroids, chemotherapy) = Opportunistic infections (PCP, CMV pneumonitis)
• Homeless/crowded living = TB risk

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PART 10 - REVIEW OF SYSTEMS (Associated Symptoms)

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PART 11 - PHYSICAL EXAMINATION (Basic to Pro)

GENERAL INSPECTION (Bedside se shuru karo)

• Patient ki position: Tripod position (leaning forward on arms) = severe COPD
• Accessory muscle use (sternomastoid, scalene)
• Pursed lip breathing = COPD
• Nasal flaring = Respiratory distress
• Cyanosis: Central (tongue/lips) vs Peripheral (fingertips)
• Cachexia = Malignancy, advanced COPD/TB

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HANDS

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FACE

• Central cyanosis (tongue, lips) = SaO2 <85% generally
• Horner's syndrome (ptosis + miosis + anhidrosis) = Pancoast tumor (apex lung Ca)
• Plethoric face + JVD = SVC syndrome (central lung Ca)
• Cushingoid face = Long-term steroid use (asthma/COPD)

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NECK

• JVP: Raised = Cor pulmonale, tension pneumothorax, cardiac tamponade
• Tracheal position: Central normally
  • Shifted TOWARDS lesion: Collapse, fibrosis
  • Shifted AWAY from lesion: Pleural effusion (large), tension pneumothorax
• Lymphadenopathy = TB, sarcoidosis, lymphoma, malignancy

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CHEST EXAMINATION - THE CORE

Inspection

• Chest shape:
  • Barrel chest (AP:Lateral ratio increased) = COPD emphysema
  • Kyphoscoliosis = Restrictive lung disease
  • Pectus excavatum/carinatum = Rarely cause restriction
• Symmetry of movement: Reduced unilaterally = Pneumonia, effusion, pneumothorax
• Intercostal indrawing = Increased negative inspiratory pressure (obstruction)
• Scars: Thoracotomy, VATS, drain sites

Palpation

• Chest expansion:
  • Reduced bilateral = COPD, severe asthma, diffuse fibrosis
  • Reduced unilateral = Collapse, effusion, pneumothorax, consolidation
• Tactile Vocal Fremitus (TVF):

• Tracheal tug = Severe airflow obstruction
• Tenderness = Pleuritis, rib fracture, costochondritis

Percussion

Auscultation - PRO LEVEL

• Normal vesicular = Soft, rustling (insp > exp)
• Bronchial breathing = Harsh, tubular (insp = exp or exp > insp) = Consolidation, large effusion (at top margin), fibrosis
• Diminished/Absent = Effusion, pneumothorax, severe obstruction, obesity

• Whispered pectoriloquy: Whispered words clearly heard = Consolidation
• Bronchophony: "99" clearly heard = Consolidation
• Aegophony: "ee" sounds like "aa" = Top of effusion

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LOWER LIMBS

• Pitting edema = Cor pulmonale, DVT
• DVT signs (calf tenderness, swelling, warmth) = PE source

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VITALS - Jab Bhi Patient Dekho

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PRO-LEVEL CLUES: Classic Exam Patterns

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Summary Approach - Case Taking ka Flow

1. Chief Complaint (4 main symptoms)
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2. HPI - Onset, duration, character, severity (MRC scale),
   positional, progression, relieving/aggravating
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3. Associated symptoms (systemic review)
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4. PMH - Prior lung disease, cardiac, rheumatological, malignancy
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5. Drug history (ACE-i, amiodarone, bleomycin)
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6. Smoking history (pack-years)
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7. Occupational/Environmental/Travel history
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8. Family + Social history
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9. Physical Examination:
   General → Hands → Face → Neck → Chest (IPPA) → Legs → Vitals
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10. Synthesize → Working Diagnosis → Investigations

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