THE RESPIRATORY SYSTEM HISTORYDr. J.A. Coetser

Department of Internal Medicine

CoetserJA@ufs.ac.za

PRESENTING SYMPTOMS

Cough Sputum Haemoptysis Dyspnoea Wheeze Chest pain Fever Hoarseness Night sweats

SOCRATES

Site Onset Character Radiation Alleviating factors Timing Exacerbating factors Severity

COUGH

Cough clears airways from secretions or foreign bodies

ONSET Acute = e.g. bronchitis / pneumonia Chronic = e.g. asthma

CHARACTER Sound

Barking = croup Loud and brassy = compression of trachea Bovine (hollow) = recurrent laryngeal nerve palsy

Productive of sputum?

COUGH

ALLEVIATING FACTORS Asthma inhaler improves cough in asthma

TIMING Lying down = GERD or cardiac failure Coughing at work = occupational irritants Worse at night = asthma / cardiac failure Worse in morning = chronic bronchitis

EXACERBATING FACTORS Eating / drinking = incoordinate swallowing /

GERD / tracheo-oesophageal fistula SEVERITY

How does coughing influence daily functioning / work?

COUGH

Associated symptoms with coughing: Postnasal drip or sinus congestion = upper

airway cough syndrome Irritating dry cough = GERD / ACE-I / interstitial

lung disease

SPUTUM

Ask about type and amount Purulent (yellow or green) = pneumonia /

bronchiectasis Foul-smelling, dark-coloured = lung abscess Frothy pink = pulmonary oedema

HAEMOPTYSIS

Def: Coughing up of blood Mild <20mL/24h Massive >250mL/24h

Must distinguish haemoptysis from: Haematemesis Nasopharyngeal bleeding

How much blood was produced? Spotting in sputum / cup / bucket?

Most common causes: Carcinoma Tuberculosis Bronchiectasis

DYSPNOEA

Def: an awareness of effort required to breathe

ONSET Worsening slowly over weeks / months or years

= interstitial lung disease Rapid onset = acute infection / pulmonary

embolism / pneumothorax CLASSIFICATION

Class I – disease present but no dyspnoea / dyspnoea only with heavy exertion

Class II – dyspnoea on moderate exertion Class III – dyspnoea on minimal exertion Class IV – dyspnoea at rest

WHEEZE

Whistling noise coming from chest Usually maximal during expiration Causes

Asthma COPD Infections e.g. bronchiolitis Airway obstruction e.g. foreign body / tumor

Differentiate from stridor Loudest over trachea Occurs during inspiration

CHEST PAIN

Pleura and airways have abundant pain fibre innervation

Sudden onset of pleuritic pain Lobar pneumonia Pulmonary embolism and infarction Pneumothorax

OTHER PRESENTING SYMPTOMS

Flu-like viral prodome preceding viral pneumonia

Fever at night TB (also ask about night sweats) Pneumonia Lymphoma

Hoarseness (dysphonia) Laryngitis Vocal cord tumor Recurrent laryngeal nerve palsy

OTHER PRESENTING SYMPTOMS

Sleep apnoea Central = no respiratory effort for at least 10s Obstructive = respiratory effort present, but

airflow stops for at least 10s Typical presentation

Daytime somnolence Chronic fatigue Morning headaches Personality disturbances Loud snoring often present

Epworth sleepiness scale to quantify severity Hyperventilation

Often due to anxiety Development of alkalosis = parasthesiae, light-

headedness, chest pain

TREATMENT

Chronic drugs taken by patient Steroids (chronic lung disease, e.g. COPD,

sarcoidosis) Inhalers (COPD and asthma)

Pulmonary side-effects of drugs Oral contraceptives = pulmonary embolism Cytotoxic agents, e.g. MTX = interstitial lung

disease Beta-blockers = bronchospasm ACE-inhibitors = chronic dry coughing

PAST HISTORY

Previous respiratory illness? Previous respiratory investigations?

Bronchoscopy Lung biopsy Spirometry

OCCUPATIONAL HISTORY

Very, very important in the respiratory history

Ask about the occupation What patient does specifically at work Duration of exposure Use of protective devices Have other workers become ill?

Ask about exposure to Dusts in mines (e.g. asbestos, coal, silica) Industrial exposures (cotton, beryllium) Exposure to animals (psittacosis, Q-fever) Organic dusts, e.g. bird feathers, mould (allergic

alveolitis)

SOCIAL HISTORY

Smoking history Calculate the number of pack years

How does the condition interfere with work, daily activities and family life?

Alcohol intake Predisposes to pneumococcal and Klebsiella

infections IV drug users at risk for lung abscess

FAMILY HISTORY

Family history of asthma, cystic fibrosis, lung cancer or emphysema

Family members infected by tuberculosis

THANK YOU!