History taking in respiratory system

History taking in respiratory system

1. RESPIRATORY MEDICINE History taking in respiratory system Dr . suresh kumar yogi PG student Dr. S. N. Medical Collage Jodhpur

2. History is a record of medical events that have taken palace in patient’s life. Importance of good history lies in the fact that it provide an insight into the exact nature of the patients problems and the attitude of patient towards the illness. The examiner should first allow the patient to state the nature of his complaints and narrate his problems in his own language. Listening o the patient account helps not only in establishing a rapport but also helps the examiner for further enquiries into the history Leading questions must be avoided . End of history ,elicit and record negative history . In case the patient is unable to speak ,unconscious ,in shock or a child ,the history should be taken from the nearst relative/friend who is known as informant

3. Examiners approch should be gentle , sympathetic and caring. Particulars of the patients Name Age Sex Address Occupation Contect number Date of admission and date of examination

4. Presenting complaints; Complaints for which the patient has come to the doctor. Define and record the main complaints and the duration of the presence of complaints. Duration of complaints may be recorded in days, weeks ,months or years. Complaints should be recorded In chronological order.

5. History of presenting complaints;- Recording of details of each complaint separately Mode of onset duration Location / site Severity Character Diurnal variation Aggravating and relieving factors Exacerbation or remission

6. The main respiratory symptoms are: Cough and sputum Haemoptysis Dyspnoea . Chest pain Wheeze .

7. Other associate symptums Fever ;-the persistent elevation of body temperature above the normal levels Normal -37.0 to 37.5 c Type of fever- Continuous Fever- The temperature remains above normal throughout the day and does not fluctuate more than 1 degree Celsius in 24 hours. This type of fever occurs in  lobar pneumonia, typhoid, urinary tract infection, infective endocarditis , brucellosis, typhus etc

8. Remittent Fever- The temperature remains above normal throughout the day and fluctuates more than 2 degree Celsius in 24 hours. This type of fever is usually seen patients of typhoid infection and  infective endocarditis . This type of fever is most common in practice. Intermittent Fever- The temperature is present only for some hours in a day and remains to normal for the remaining hours. When the spike occurs daily, it is quotidian, when every alternate day, it tertian and when every third day, it is quartan . Intermittent fever is seen in malaria, kala-azar , pyemia , septicemia etc.

9. Anorexia –TB/ Bronchogenic ca Headace-co2 narcosis Edema - corpulmonale Loss of appetite is a common feature whenever people are unwell. It suggests that the disease is having a significant effect on well-being. Significant loss of weight may well be indicative of serious illness - eg , malignancy or tuberculosis.

10. Upper gastrointestinal symptoms: gastro- oesophageal reflux is a common cause of chronic cough. Heart disease may cause respiratory symptoms. Establish whether there are any indications of heart failure or coronary heart disease. Severe anaemia may cause breathlessness. Rheumatoid arthritis and other connective tissue diseases may cause respiratory symptoms. Neuromuscular diseases may cause respiratory symptoms, particularly dyspnoea .

11. Cough Definition-forced expiration against closed glottis ,which clears the tracheo -bronchial tree of any foreign material or secretion. it is protective reflex it can be voluntary or involuntary being provoked by physical, chemical,or mechanical stimuli irritating of any part of the respiratory tract and even from irritation of the pleura.

12. Analysis of cough Was the onset of the cough sudden or insidious? What was its initiating event? Did it start as an isolated symptom or occur with or follow other symptoms? How long has the cough been present? Is it persistent or episodic? Seasonal or perennial? To determine the severity of the cough, ask: How frequent is a coughing spell? How long does each coughing spell last? What is its effect on daily activity or rest?

13. Is the cough productive or dry? Lack of expectoration does not necessarily indicate that the cough is dry, as many patients, particularly children and women, tend to swallow their sputum raised to the level of the pharynx. The sound of the cough would help in determining its productive or dry nature.

14. Is the cough the only symptom, or is it associated with other respiratory or nonrespiratory symptoms? Inquiry should be specifically made about conditions known to cause the cough, particularly when it is chronic and persistent. In addition to an accurate smoking history , ask: To what respiratory irritants is the patient exposed at home or at work? Is exposure accidental or intentional?

15. What are the precipitating or aggravating factors? What time of the day or night is the cough or sputum production worse? Does it happen in supine position, upon arising in the morning, with drinking or eating, with exercise, or with breathing cold or dry air? Does the cough awaken the patient from sleep? Is there a past history (recent or old) of foreign body aspiration?

16. Has the pattern of the cough and the amount or other characteristics of the sputum changed recently? Can the patient locate the site of origin of the cough or the sputum, such as from the throat or deeper in the chest? Has the patient had a similar problem with coughing in the past? Does the cough have easily recognizable characteristics, as in croup or whooping cough?

17. Clinical Significance Onset;- sudden –acute asthama ,massive pulmonary embolism, Pneumothorax Gradual-in chronic bronchitis Nature;- ( a) Dry cough- in pharyngitis ,allergic bronchitis ( b ) productive cough-in lower respiratory tract infection like pneumonia , Bronchitis , Bronchictasis , PTB

18. Duration;- short –in acute Bronchitis, pharyngitis Long –COPD,PTB ,allergic bronchitis,Fibrosing alveolits , Diurnal variation; Early morning & night- chronic bronchitis, Bronchictasis . Cough disturbing patient sleep in night- pulmonary oedema , asthma

19. Postural variatons ;- Cough In bronchiectasis and lung absess when the patient lies in the opposite side of lesion ,this becouse the postural drainge of the mucus into the healthy bronchi stimulats cough reflex

20. sputum Sputum is mucus produced from respiratory tract Normal lung produces about 100 ml of clear sputum each day Enqury - amount , Appearance / colour , type of sputum

21. Patients with sputum production should be asked about its frequency and description of the physical characteristics of the sputum including Amount (with each coughing spell and daily total), color, consistency, ease of its expectoration, taste, and smell.

22. Clinical Significance Bronchiectasis causes large volumes of purulent sputum ,which varies with posture. Suddenly coughing up large amount of purulent sputum on a single occasion suggests rupture of a lung abscess or empyema in to the bronchial tree. Large volumes of watery sputum with a pink tinge in acutely breathless patient suggest pulmonary oedema , But if occurring over weeks ,suggests alveolar cell carcinoma

23. type appearance causes serous Frothy,pink Clear,watery /rarely copious( bronchorrhea ) Acute pulmonary oedema Bronchioloalveolar cancer Mucoid Clear , grey White,viscid Chronic bronchitis/COPD asthma purulent Yellow Green Acute bronchopulmonary infection Asthma ( eosinophil ) Longer –standing infection Pnemonia Bronchiectasis,cystic fibrosis,lung abscess Rusty Rusty red Pnemococcal pneumonia Type of sputum

24. Appearance / colour ;- Clear or mucoid sputum –in chronic bronchitis and COPD with no infection Yellow sputum- in acute lower respiratory tract infection(live neutrophils ) and in asthma( eosinophils ). Green purulent –indicates chronic infection(dead neutophils )e.g.in COPD or bronchiectasis Rusty red sputum –early pneumococcal pneumonia,as pneumonic inflammation causes lysis of red cells.

25. Haemoptysis Coughing up blood ,ranging from blood streak sputum to gross blood that originates from the tracheobronchial tree Haemoptysis immediattely preceded by cough indicates origin of bleeding at a level lower than the larynx Most common cause of haemoptysis in india is TB

26. Causes of haemoptysis ;- Respiratory – TB, bronchogenic ca, pulmonary embolism, lung abscess , bronchiectasis , bronchial adenoma, trauma Cardiac –mitral stenosis,aortic aneurysm,primary pulmonary hypertension Immunological- good pasture’s syndrome, wegener’s granulomatosis and PAN Itarogenic - lung biopsy, bronchoscopy Bleeding disorder-thrombocytopenic purpura,hemophilia Spurious – trauma,ulcer in mouth

27. Amount and appearance Blood –streaked clear sputum or clots in sputum for more than a week suggest lung cancer Haemoptysis with purulent sputum suggests infection Coughing up large amount of pure blood is rare but potentially life threatening ; causes –lung cancer, bronchiectasis , TB ,lung abscess , mycetoma,Cystic fibrosis, aortobronchial fistula, granulomatosis wth polyangitis

28. Duration and frequency Single episodes of hemoptysis ,if associated with symptoms e.g.pleuritic chest pain and breathlessness, suggest pulmonary thromboembolism and infarction and need immediate investigation Bronchiectasis causes intermittent hemoptysis associated with copious sputum over years Daily hemoptysis for a week or more –in lung cancer ,other TB and lung abscess.

29. Breathlessness( Dyspnoea ) Defination ;-An abnormal, uncomfortable subject awareness of once breathing Dyspnea (also SOB, air hunger ) normal in heavy exertion pathological if it occurs in unexpected situations. Breathlessness is common symtom of cardiac disease. however it also present in respiratory disease

30. Analysis of breathlessness- Occurrence   Rest  Exertion (quantify)  Position   Orthopnea ( dyspnea lying flat)   Trepopnea ( dyspnea in lateral position)    Platypnea ( dyspnea when upright)  Other precipitating factors   Environment  Emotional state

31. Chronology Duration  Progression  Diurnal and seasonal variations  Constant or intermittent Relieving factors Rest  Medications (physician and self-prescribed)

32. Predisposing factors   Cigarette smoking  Occupational and environmental exposures Associated medical diseases and symptoms  Pulmonary  Cardiac  Neuromuscular Family history

33. Breathlessness occurs as a symptom most frequently in lung cancer, where it might affect 75% of people with primary disease of the lung, bronchus and trachea ( Muers & Round 1993). For patients with COPD, intractable breathlessness develops late in the course of the disease, gradually increasing in severity over a period of years in the majority of people.

34. Onset and durestion

35. Severity grading-

36. Clinical Significance Causes of breathlessnss Physiological ;–exercises, high altitude,etc Pathological;- Cardiac – acute-pulmonary edema, pulmonary embolism, CHD in neonates chronic-CCF, acyanotic CHD, chronic thromoembolism . (b) Respiratory – acute- pneumothorax , acute severe asthma, inhaled foreign body, acute exacerbation of COPD, pneumonic consolidation, laryngeal edema etc chronic-COPD, Asthma, pleural effusion( subacute ), bronchogenic Ca, PTB, ILD eg fibrosing alveolitis , etc

37. 3.Pharmacological ; drugs beta-blockers, busulfan etc 4.Psycological - hypervantilation 5.Miscellaneous ;- acute- metabolic acidosis & respiratory muscle paralysis chronic-anemia , ankylosing spondylitis

38. Wheeze and stridor High pitched whistling sound Mainly expiratory Usually indicative of bronchospasm Wheeze on exercise is common in asthma and COPD Night wakening with wheeze suggestive of asthma or PND But wheeze after wakening in the morning suggests COPD

39. Stridor ;-high pitched ,often harsh noise produced by airflow turbulence through a partial obstruction of the upper airway. Most commonly on inspiration but also on expiration or biphasically Inspiratory -narrowing at vocal cords Biphasic –s/o tracheal obstraction Expiratory- trachiobronchial obstruction Usually accompanied by dyspnoea Stridor is serious condition always need investigation

40. Analysis of wheeze Onset Duration and periodicity of wheeze Diurnal and seasonal variations

41. Duration ;-short duration suggests obstraction by foreign,functional disturbance of larynx or inflammatory disease Onset ;- (a) instantaneous onset of dypnoea and stridor suggests foreigne body impaction or neuromuscular disturbance of larynx (b)Acute onset is typical of laryngitis, laryngismus stridulus , measles, whooping cough or diphtheria (c)Slow and gradual onset suggests papilloma or recurrnt laryngeal nerve

42. Chest pain   if pain is a symptom, clarify the details of the pain using  SOCRATES S ite – where is the pain ? To differentiate from cardic,gastrointestinal . Respiratory chest pain is usually laterlized O nset – when did it start? sudden -spontaneous pneumothorax gradual- pluerisy C haracter/type –  sharp / stabing -related to deep breathing and coughing in pleuritis ,usually subsides after pleural effusion develops dull ache –lateral/low down in spontaneous pneumothorax R adiation – does the pain move anywhere else? 

43. A ssociations –  other symptoms associated with the pain  T ime course – worsening / improving / fluctuating / time of day dependent E xacerbating / Relieving factors – does   anything make the pain worse or better? Costo chondial pain is aggravated by movement To differentiate from cardiac causes angina is aggravated by stress and relieved by rest while pleural pain is aggravated on deep breathing and coughing. S everity –  on a scale of 0-10, how severe is the pain?

44. Common respiratory causes of chest pain- Pleurisy Pneumothorax Acute pulmonary embolism Pneumonia Massive collapse Lung absess Ca lung Tracheitis Pneumomediastinum

45. Past history;- H/O PTB and treatment ATT ,DM, HTN, Asthama,blood transfusion, H/o previous hospital admission In case of COPD /ASTHMA number of episode of acute exacerbation Use of inhalers (assess compliance and technique). Use of steroids (some measure of severity in asthma). Other drugs which may have relevance in respiratory disease - eg , angiotensin -converting enzyme (ACE) inhibitors (cough). Allergies Ask about all allergies including, for example, food, inhaled allergens and drugs.

46. Occupational and social history An occupational history may be very important in respiratory disease. Occupational Asthma , Industrial Dust Diseases,Asbestos -related Diseases,Extrinsic Allergic Alveolitis and Sick Building Syndrome Hobbies and pets may also be responsible for respiratory disease like extrinsic allergic alveolitis . Lifestyle and alcohol consumption are also very relevant to respiratory diseases. Ask about illicit drugs. Smoking history should detail, for example, the type and number of cigarettes smoked currently and in the past. Ask also about passive smoking. Sexual history may be relevant to risk of HIV and AIDS.

47. Family history;- Respiratory diseases with a genetic component - eg , cystic fibrosis, emphysema (alpha-1-antitrypsin deficiency). Infectious diseases such as tuberculosis (remember high-risk groups). Atopic diseases such as asthma, hay fever and eczema.