Patient History: Pulmonary Examination

1. Clinical history helps to distinguish the potential causes of abnormal lung sounds.
2. Look for symptoms of infection or cardiac decompensation.

The major symptom that raises suspicion of pulmonary disease is dyspnea.

In asking patients about dyspnea, the following types of questions are helpful:

• When do you feel short of breath?
• What activities bring on shortness of breath? (Be specific: Walking up 2 flights of stairs, walking ½ mile level ground, mowing lawn)
• Could you do these same activities without symptoms 3m ago? 6 m ago?
• What is your usual level of activity?
• Do certain positions make you feel more comfortable?

In addition to dyspnea, other features may be a clue to etiology:

History suggestive of asthma or chronic airway obstruction:

• Previous diagnosis of obstructive airways disease
• Allergen-induced (being outside; cold air, dust, tobacco, pet exposure)
• Audible wheezing detected when dyspneic
• Cough
• Note: in a variant of asthma, cough is presenting feature without wheezing
• Orthopnea ("straight up breathing")
• Paroxysmal Nocturnal Dyspnea (PND)

History suggestive of lower respiratory infection:

• Short duration of symptoms
• Fever
• Cough
• Increased sputum production, change in character or color of sputum, purulence
• Hemoptysis
• Pleuritic chest pain

History suggestive of cardiac ischemia/heart failure:

• History of coronary artery disease
• Associated chest pain
• Diaphoresis
• Dizziness
• Fluid overload
• edema, weight gain
• Orthopnea, paroxysmal nocturnal dyspnea

History suggestive of pulmonary embolism:

• Pleuritic chest pain
• Scant hemoptysis
• Symptoms of lower extremity clot
• Unilaterla leg swelling
• Leg tenderness in calf or higher
• Recent immobility or long-distance travel
• Treatment with oral contraceptives
• Pregnancy or postpartum
• Underlying malignancy

(Source: fishman, Shapira)

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