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and microbiology may be indicated, depending on the circumstances. The most important causes of haemoptysis are bronchial carcinoma, lung infections (pneumonia, bronchiectasis, tuberculosis), chronic bronchitis, pulmonary infarction, pulmonary vasculitis and pulmonary oedema (pink frothy sputum) (Table 2.2). In some cases, no cause is found, and the origin of the blood may have been in the upper airway (e.g. nose [epistaxis], pharynx or gums).

      Chest pain

      Pain that is aggravated by inspiration or coughing is described as pleuritic pain, and the patient can often be seen to wince when breathing in, as the pain ‘catches’. Irritation of the pleura may result from inflammation (pleurisy), infection (pneumonia in adjacent lung), infarction of underlying lung (pulmonary embolism) or tumour (malignant pleural effusion). Chest wall pain resulting from injury to the intercostal muscles or fractured ribs, for example, is also aggravated by inspiration or coughing and is associated with tenderness at the point of injury. Whatever the cause of pleuritic pain, adequate analgesia is an essential component of treatment. If a patient is unable to take a deep breath or cough, pneumonia often follows.

Table 2.2 Major causes of haemoptysis

TumoursBronchial carcinomaLaryngeal carcinoma

InfectionsTuberculosisPneumoniaBronchiectasis

InfarctionPulmonary embolism (though haemoptysis is unusual)

Pulmonary oedema (sputum usually pink and frothy)Left ventricular failureMitral stenosis

Pulmonary vasculitisGoodpasture syndromegranulomatosis with polyangiitis (GPA)

      Associated symptoms

      In addition to these major respiratory symptoms, it is important to consider other associated symptoms. For example, anorexia and weight loss are features of malignancy or chronic lung infections (e.g. lung abscess). Pyrexia and sweating are features of acute (e.g. pneumonia) and chronic (e.g. tuberculosis) infections. Lethargy, malaise and confusion may be features of hypoxaemia. Headaches, particularly on awakening in the morning, may be a symptom of hypercapnia. Oedema may indicate cor pulmonale. Snoring and daytime somnolence may indicate obstructive sleep apnoea syndrome. Hoarseness of the voice may indicate damage to the recurrent laryngeal nerve by a tumour.

      Many respiratory diseases have their roots in previous childhood lung disease or in the patient’s environment, so that it is crucial to make specific enquiries concerning these points during history taking.

History

      Past medical history

      Did the patient suffer any major illness in childhood? Did the patient have frequent absences from school? Was the patient able to play games at school? Did any abnormalities declare themselves at a preemployment medical examination or on chest X‐ray? Has the patient ever been admitted to hospital with chest disease? A long history of childhood ‘bronchitis’ or ‘chestiness’ may in fact indicate asthma that was undiagnosed at the time. Severe whooping cough or measles in childhood may cause bronchiectasis. Tuberculosis acquired early in life may reactivate many years later.

      General medical history

      Has the patient any systemic illness that may involve the lungs (e.g. rheumatoid arthritis)? Is the patient taking any medications that might affect the lungs (e.g. amiodarone or nitrofurantoin), which can cause interstitial lung disease, or β‐blockers (e.g. bisoprolol), which may provoke bronchospasm? What effect will the patient’s lung disease have on other illnesses (e.g. fitness for surgery?).

      Family history

Is there any history of lung disease in the family? An increased prevalence of lung disease in a family may result from ‘shared genes’ (inherited traits such as cystic fibrosis, α₁‐antitrypsin deficiency or asthmatic tendency) or ‘shared environment’ (e.g. tuberculosis).

Figure 2.1 Which man has airway obstruction?

      Answer to question in Fig. 2.1: (b) has airway obstruction – note the high position of the shoulders.

      Social history

      Does the patient smoke, or have they ever smoked? It is important to obtain a clear account of total smoking exposure over the years so as to assess the patient’s risk for diseases such as lung cancer or COPD. Pack‐year history should be calculated as follows: smoking one pack (20 cigarettes) per day for 1 year equates to 1 pack‐year. Does the patient keep any pets or participate in any sports (e.g. diving) or hobbies (e.g. pigeon racing) that might be important in assessing the lung disease?

      Occupational history

      What occupations has the patient had over the years, what tasks were performed and what materials were used? Do symptoms show a direct relationship to the work environment, as in the case of occupational asthma improving away from work and deteriorating on return to work? Has the patient been exposed to substances that might give rise to disease many years later, as in the case of mesothelioma arising from exposure to asbestos 20–40 years previously (see Chapter 14)?

Examination

      Some physical signs in medicine are difficult to assess, and examination skills may take years to refine (e.g. identifying the nature of a heart murmur). By contrast, most of the signs in respiratory disease are easy to elicit and interpret. Despite this, evidence of respiratory disease is often entirely overlooked.

Answer to question in Fig. 2.1: (b) has airway obstruction – note the high position of the shoulders.

      The expertise in respiratory examination lies in knowing what to look for. Read the following and you will become expert. You will discover the insightful experience that is respiratory examination; ordinary doctors will be in awe of your deductive abilities.

      General examination

      Be alert to clues to respiratory disease that may be evident from the moment the patient is first seen (Fig. 2.1) or that become apparent during history taking. These include the rate and character of breathing, signs of respiratory distress such as use of accessory muscles of respiration (e.g. sternocleidomastoids), the shape of the chest, spine and shoulders and the character of any cough. Hoarseness of the voice may be a clue to recurrent laryngeal nerve damage by a carcinoma. Wheeze may be audible. Stridor is most commonly picked up during history taking, rather than examination.

      Avoid proceeding directly to examination of the chest; first pause and ask the patient to cough.

      Cough

      A

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