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Respiratory - History Taking
Related Subjects:
|Assessing Breathlessness
Core symptoms
- Breathlessness, Reduced Exercise tolerance
- Chest pain, Orthopnoea, Cough, Wheeze
- Sputum, Haemoptysis, Fever, Weight loss
- Smoking, Allergies/Atopy, Asbestos and dust and animals
- Social - Manage ADLS
Introduction
- There is a great deal of overlap in the symptomatology of respiratory and cardiac disease. Patients often have both.
- Get a good history of the current presenting complaints and try to get quantitative estimates e.g. amounts of sputum/haemoptysis, distance walked, cigarettes smoked, weight lost.
- Always establish a timeline - patients can be very imprecise but push "A little while", "Ask. Is that a day, a week, a month, a year..." "about 6 weeks doctor"
- Smoking, animal exposure and occupational history play a major role in chest disease in many patients and should not be neglected.
- Don't forget to ask how their disease impacts their life, can they do stairs at home, are they too breathless to do housework or to even wash and dress, do they need help...
Breathlessness
- When did it start and how did it start - sudden or gradual, episodic or chronic, getting better or worse or static
- Get quantitative evidence e.g. could walk 500 m and now can only do 20 m. Ask about stairs, exercise tolerance
- Rate of onset is useful as is clinical context and past medical history
Timing - Rapid within minutes
- Asthma ? younger (not always) patient, known history, wheeze, nocturnal cough, atopy
- Left ventricular failure ? known impaired LV function from previous MI or other cause
- Pulmonary embolism? post-op, immobility, pregnancy, past history of VTE
- Respiratory obstruction e.g. peanut, meat bolus
- Laryngeal oedema ? anaphylaxis, ingested corrosives
- Inhaled foreign body ? usually a child
- Pneumothorax
- Panic attacks/anxiety ? alcohol, young
Rapid over several hours
- Acute Asthma attack
- Exacerbation of COPD ? smoker, middle aged
- Pulmonary oedema (improves sitting up), Pneumonia- fever, sputum
- ARDS ? post op, sepsis, trauma
- Pulmonary embolism
- Allergic alveolitis ? exposure to allergens
- Pleural effusion ? smoker, asbestos
- Metabolic acidosis ? Diabetic ketoacidosis
Gradual over weeks
- Progressive massive fibrosis
- Hamman Rich syndrome
- Congestive cardiac failure
Gradual over months/years
- COPD ? smoker, middle aged
- Idiopathic pulmonary fibrosis, Sarcoidosis
- Bronchiectasis, Cystic fibrosis
- Congestive cardiac failure
- Lymphangitis carcinomatosis
- Hypoventilation - neuromuscular disease
Episodic breathlessness
- Asthma
- LVF, Angina equivalent
- Pulmonary embolism
- Hypersensitivity pneumonitis
- Hyperventilation,
- Panic attack
Cough
Most often due to infection but always exclude malignancy when the cough persists (> 6 weeks) especially in a smoker. A CXR at the minimum should be performed and a further opinion sought if it continues and cancer is a differential
Causes
- Tracheitis (cough is painful), Bronchitis
- Asthma ? usually nocturnal
- Pneumonia ? fever, rusty or green sputum
- Bronchiectasis ? copious foul sputum
- Post nasal drip ? often nocturnal. Worse with hayfever
- Bovine cough with Recurrent laryngeal nerve damage with lung tumour
- ACE Inhibitors (bradykinin mediated)
Nocturnal Cough
- Asthma in bed at night
- Post nasal drip
- Gastro- oesophageal reflux
- Pulmonary oedema
- Investigations: CXR, Serial PEFR measurements, Spirometry, HRCT chest, Bronchoscopy, ENT exam in some
Stridor
- Stridor is an Inspiratory noise
- Causes
- Acute epiglottis in a child? a paediatric emergency
- Laryngospasm or oedema due to anaphylaxis or local burn
- Laryngeal obstruction - foreign body or tumour
- Diphtheria
- Croup in an infant
Wheeze
- Expiratory noise seen with bronchoconstriction
- Causes
- Asthma, COPD, Pulmonary oedema
Haemoptysis
- Causes
- Infection - Pneumonia, Bronchitis? fever, rigors
- Pulmonary embolism ? new sudden onset breathlessness
- Lung cancer ? smoker, lung mass
- Tuberculosis? fever, weight loss, immunosuppressed
- Pulmonary oedema? oedema on CXR
Sputum production
- Purulent - green/yellow (From neutrophil myeloperoxidase)
- Bloody - pneumonia, PE, cancer.
- Rusty - Pneumococcal pneumonia
- Mucoid, Copious, thick, tenacious - Bronchiectasis, Cystic fibrosis
Causes
- Chest infection? Pneumonia, bronchitis, tracheitis
- Chronic bronchitis
- Bronchiectasis
- Lung Tumour
Fever (temperature > 38C)
- Infection - pneumonia, TB
- Lymphoma or other malignancy
- Connective tissue disease
- Extrinsic allergic alveolitis.
Unexpected weight loss: Chest Causes
- Malignancy
- Tuberculosis
- Idiopathic pulmonary fibrosis
- COPD
Smoking history
- A significant smoking history immediately focuses the diagnosis
- Is there a lung malignancy, is there COPD
- Is the patient clubbed? Recent weight loss? A mass on CXR
- Assess pack years i.e. how many packets of 20/day for how many years
Occupational history and animal exposure
- Occupational history should always be asked about. Get a complete working history e.g. A job lagging pipes for 6 months 50 years ago might be the source of the asbestos causing the mesothelioma
- Ask about Pets and exposure to organic and other allergens both at home and at work
- Enquire after Asbestos exposure, Passive smoking (e.g. bar workers)
Chest pain
- Pulmonary embolism and infarction? usually pleuritic
- Localised infection - pneumonia with pleurisy
- Pneumothorax
- Tumour e.g. mesothelioma, rib metastases? localised pain
- Rib fractures from trauma or destructive malignancy? localised pain
- Acute coronary syndrome should always be considered if symptom suggestive
- Oesophagitis
- Pericarditis
Miscellaneous
- Sexual/IV drug history where HIV considered presenting as PCP pneumonia
- Recent travel history - hotels etc - Legionnaire's disease
- Travel to certain parts of the world can bring back chest disease - TB, Coccidioidomycosis from Californian Deserts, Anthrax from hides or terrorist plot