Makindo Medical Notes

Related Subjects: | Assessing Breathlessness

Core Symptoms for OSCE

• Breathlessness; reduced exercise tolerance
• Chest pain; orthopnoea; cough; wheeze
• Sputum production; haemoptysis; fever; weight loss
• History of smoking, allergies/atopy, exposure to asbestos, dust, and animals
• Impact on social activities and ability to manage activities of daily living (ADLs)

Introduction

• Respiratory and cardiac symptoms often overlap. Many patients present with a mix of both.
• Gather a detailed history. Include quantitative aspects (e.g., sputum volume, haemoptysis amount, walking distance, cigarettes smoked, weight loss).
• Establish a clear timeline. Clarify vague durations like “a little while” by asking for specifics (days/weeks/months/years).
• Explore smoking status, animal exposure, and occupational history—important factors in respiratory disease.
• Assess functional impact: ability to climb stairs, manage housework, personal care, and any aids used.

Breathlessness

• Frequency of episodes and speed of onset
• Trigger: exertion, rest, or sleep (orthopnoea, paroxysmal nocturnal dyspnoea [PND])
• Pattern of exacerbation and relief: Does it get better or worse with any specific measures?
• Onset: sudden or gradual? How long does it last?
• Actions taken during an episode
• Smoking, vaping, or drug use history
• Night-time episodes waking the patient from sleep (PND)
• Episodic wheeze (asthma/COPD); any occupational or environmental triggers?
• Medication history (e.g., amiodarone), history of cancer, hobbies
• Exposure to pets or birds; do episodes correlate with workplace vs. holiday?
• Progression over time: is it getting worse or better?
• Quantify exercise tolerance: “How far can you walk now compared to 2, 3, or 6 months ago?”

Timing of Breathlessness

• Rapid Onset (within minutes):
  • Asthma (often younger patients, nocturnal cough/wheeze, atopy)
  • Left Ventricular Failure (LVF): known cardiac impairment or previous MI
  • Pulmonary Embolism (PE): risk factors include recent surgery, immobility, pregnancy, prior VTE
  • Respiratory obstruction (e.g., foreign body) especially in children
  • Anaphylaxis or laryngeal oedema (allergic triggers/corrosives)
  • Pneumothorax; panic or anxiety attacks
• Rapid Onset over Several Hours:
  • Acute asthma attack or COPD exacerbation (typically in smokers)
  • Pulmonary oedema (may improve on sitting up), pneumonia (fever, sputum), ARDS (post-op, sepsis, trauma)
  • PE, pleural effusion, allergic alveolitis, metabolic acidosis (DKA)
• Gradual Onset over Weeks: Progressive massive fibrosis, Hamman–Rich syndrome, congestive cardiac failure
• Gradual Onset over Months/Years:
  • COPD (common in middle-aged smokers)
  • Idiopathic Pulmonary Fibrosis, Sarcoidosis, bronchiectasis, cystic fibrosis
  • Congestive cardiac failure, lymphangitis carcinomatosis
  • Hypoventilation (e.g., neuromuscular disease)
• Episodic Breathlessness:
  • Asthma, LVF, angina equivalent
  • PE, hypersensitivity pneumonitis
  • Hyperventilation or panic attacks

Cough

• Onset: “When did it first start?”
• Frequency: daily, weekly, or less?
• Timing: worse at night (suggests asthma, post-nasal drip), lying down (reflux)?
• Triggers: eating/drinking (possible reflux, neurological cause), is it improving or worsening?
• Associated symptoms: haemoptysis, weight loss, fever, night sweats (TB, lymphoma?)
• Character of sputum: quantity, color, consistency, presence of blood
• Smoking or exposure history (pets, job, hobbies), hoarseness or voice changes
• Medications (e.g., ACE inhibitors linked to cough)

Causes of Cough

• Tracheitis (painful cough), bronchitis
• Asthma (often nocturnal), pneumonia (fever, rust/green sputum)
• Bronchiectasis (copious, foul sputum), post-nasal drip (worse at night/allergies)
• Bovine cough (recurrent laryngeal nerve palsy due to lung tumours)
• ACE inhibitors (bradykinin-mediated)
• Nocturnal Cough: asthma, post-nasal drip, reflux, pulmonary oedema

Investigations

• FBC, CRP, CXR, serial PEFR measurements, spirometry
• High-resolution CT (HRCT), bronchoscopy if indicated
• ENT examination (e.g., post-nasal drip, laryngeal pathology) if necessary

Other Symptoms to Explore

• Stridor (Inspiratory Noise): Suggests upper airway obstruction.
  • Acute epiglottitis (childhood emergency)
  • Laryngospasm or oedema (anaphylaxis, burns)
  • Laryngeal obstruction (foreign body, tumour)
  • Diphtheria, croup (infants)
• Wheeze (Expiratory Noise): Often due to bronchoconstriction.
  • Asthma, COPD, pulmonary oedema
• Haemoptysis:
  • Infections: pneumonia, bronchitis (often fever/rigors)
  • Pulmonary embolism (new breathlessness)
  • Lung cancer (particularly in older smokers)
  • Tuberculosis (weight loss, immunosuppression)
  • Pulmonary oedema (CXR findings)

Sputum

• Purulent (green/yellow): often bacterial infection (neutrophil myeloperoxidase)
• Bloody: pneumonia, PE, malignancy
• Rusty: classic for pneumococcal pneumonia
• Mucoid, copious, thick, tenacious: seen in bronchiectasis, cystic fibrosis

Causes of Sputum Production

• Chest infections: pneumonia, bronchitis, tracheitis
• Chronic bronchitis, bronchiectasis, lung tumours

Fever (Temperature >38°C)

• Infections (pneumonia, tuberculosis)
• Lymphoma or other malignancies
• Connective tissue disease
• Extrinsic allergic alveolitis

Unexpected Weight Loss (Chest Causes)

• Malignancy or tuberculosis
• Idiopathic pulmonary fibrosis, COPD

Smoking History

• Heavy smoking suggests COPD or lung cancer
• Look for clubbing, weight loss, suspicious CXR lesions
• Calculate pack-years (packs/day × years smoking)

Occupational History and Animal Exposure

• Obtain full job history; even remote asbestos exposure can lead to mesothelioma
• Ask about pets, farm animals, or other allergens (home/workplace)
• Consider second-hand smoke exposure (e.g., bar workers), industrial inhalants

Chest Pain

• Pulmonary embolism or infarction (often pleuritic)
• Pneumonia with pleurisy, pneumothorax
• Tumours (mesothelioma, rib metastases)
• Rib fractures (trauma or pathological)
• Acute coronary syndrome (rule out if suspected)
• Oesophagitis, pericarditis

Miscellaneous Considerations

• Sexual/IV drug history (possible HIV-related pneumonia like PCP)
• Recent travel or hotel stay (risk of Legionnaire’s disease)
• Travel to endemic areas (TB, coccidioidomycosis), or unusual exposures (anthrax)