History taking in pulmonary medicine

Smoking

• An attempt should be made to quantify the exposure. When did it begin? When did it stop? How many cigarettes per day (expressed in number of pack-years)?

• The smoking history should include the number of years of smoking, the intensity (i.e., number of packs per day), and, if the patient no longer smokes, the interval since smoking cessation.

• The risk of lung cancer falls progressively in the decade following discontinuation of smoking, and loss of lung function above the expected age-related decline ceases with the discontinuation of smoking.

• Even though chronic obstructive lung disease and neoplasia are the two most important respiratory complications of smoking, other respiratory disorders (e.g., spontaneous pneumothorax, respiratory bronchiolitis–interstitial lung disease, pulmonary Langerhans cell histiocytosis, and pulmonary hemorrhage with Goodpasture's syndrome) are also associated with smoking.

• . A history of significant secondhand (passive) exposure to smoke, whether in the home or at the workplace, should also be sought as it may be a risk factor for neoplasia or an exacerbating factor for airways disease.

Occupational history

• An almost forgotten exposure to a toxic inhalant 20 years ago can explain certain types of pulmonary or pleural diseases.

• Symptoms that appear to improve during weekends or other periods away from work may be a clue to an occupational exposure that causes a respiratory ailment.

• Important agents include the inorganic dusts associated with pneumoconiosis (especially asbestos and silica dusts) and organic antigens associated with hypersensitivity pneumonitis (especially antigens from molds and animal proteins).

• Asthma is often exacerbated by exposure to environmental allergens (dust mites, pet dander in the home or allergens in the outdoor environment such as pollen or may be caused by occupational exposures (diisocyanates)

Past Medical History

• Rheumatologic disorders such as systemic sclerosis (scleroderma) may be associated with interstitial lung disease, aspiration pneu-monia due to the involvement of the esophagus, or pulmonary vascular disease. Certain malignancies often metastasize to the lung (e.g., breast or colon carcinoma), or predispose to the development of venous thromboembolism (e.g., pancreatic carcinoma).

• Infection with the human immunodeficiency virus (HIV) should not be overlooked since pulmonary complications are often the initial presentation of acquired immunodeficiency syndrome (AIDS).

• impaired host defense mechanisms and secondary infection, which occur in the case of immunoglobulin deficiency or with hematologic and lymph node malignancies.

Drug History

• Almost every class of drug can produce lung toxicity. Examples include pulmonary embolism from use of the oral contraceptive pill, interstitial lung disease from cytotoxic agents (e.g. methotrexate, cyclophosphamide, bleomycin), bronchospasm from beta-blockers or non-steroidal anti-inflammatory drugs, and cough from ACE inhibitors.

• Treatment of nonrespiratory disease can be associated with respiratory complications, either because of effects on host defense mechanisms (immunosuppressive agents, cancer chemotherapy) with resulting infection or because of direct effects on the pulmonary parenchyma (cancer chemotherapy, radiation therapy, or treatment with other agents, such as amiodarone) or on the airways (beta-blocking agents causing airflow obstruction, angiotensin-converting enzyme inhibitors causing cough).

Personal habits

• Smoking• IVDU• hobbies

Family history

• This history can be particularly helpful in uncovering heritable diseases of the lungs (e.g., cystic fibrosis, α1-antitrypsin deficiency, alveolar microlithiasis, and hereditary telangiectasia). The unraveling of a familial history of asthma, a common disease, or of familial pulmonary arterial hypertension, a rare disease, can be much more difficult.

Travel History

• A brief residence in an area where either cryptococcosis (southwestern United States) or histoplasmosis (southern and midwestern United States) is endemic may help to clarify the nature of an illness that mimics tuberculosis. A recent visit to a South or Central American country may bring into focus a more remote possibility (e.g., South American blastomycosis)

• Exposure to particular infectious agents can be suggested by contacts with individuals with known respiratory infections (especially tuberculosis) or by residence in an area with endemic pathogens (histoplasmosis, coccidioidomycosis, blastomycosis).

Presenting symptoms• Major symptoms • Cough • Sputum • Haemoptysis • Dyspnoea (acute, progressive or paroxysmal) • Wheeze • Chest pain • Fever • Hoarseness • Night sweats

COUGH

Cough

• The duration of a cough is important. A cough of recent origin, particularly if associated with fever and other symptoms of respiratory tract infection, may be due to acute bronchitis or pneumonia.

Cough

• A chronic cough associated with wheezing may be due to asthma; sometimes asthma can present with just cough alone. An irritating chronic dry cough can result from oesophageal reflux and acid irritation of the lungs.

Cough

• It may be a feature of late interstitial pulmonary fibrosis. A similar cough is not uncommonly associated with the use of the angiotensin-converting enzyme (ACE) inhibitors-drugs used in the treatment of hypertension and cardiac failure.

Cough

• Cough that wakes a patient from sleep may be a symptom of cardiac failure or of the reflux of acid from the oesophagus into the lungs that can occur when a person lies down.

• A chronic cough that is productive of large volumes of purulent sputum may be due to bronchiectasis.

• A change in the character of a chronic cough may indicate the development of a new and serious underlying problem (e.g. infection or lung cancer).

• A cough that is worse at night is suggestive of asthma or heart failure, while coughing that comes on immediately after eating or drinking may be due to a tracheo-oesophageal fistula or oesophageal reflux.

• It is an important (though perhaps a somewhat unpleasant task) to inquire about the type of sputum produced and then to look at it, if it is available.

• A large volume of purulent (yellow or green) sputum suggests the diagnosis of bronchiectasis or lobar pneumonia.

• Foul-smelling dark-coloured sputum may indicate the presence of a lung abscess with anaerobic organisms.

• Pink frothy secretions from the trachea, which occur in pulmonary oedema, should not be confused with sputum.

• Haemoptysis (coughing up of blood) .

Causes of haemoptysis

Respiratory• Bronchitis • Bronchial carcinoma• Bronchiectasis• Pneumonia (The above

four account for about 80% of cases)

• Pulmonary infarction• Cystic fibrosis

• Lung abscess • Tuberculosis• Foreign body• Goodpasture's syndrome Cardiovascular • Mitral stenosis (severe)• Acute left ventricular

failure Bleeding diatheses

BREATHLESSNESS (DYSPNOEA)

• The awareness that an abnormal amount of work is required for breathing is called dyspnoea. It can be due to respiratory or cardiac disease

• Careful questioning about the timing of onset, severity and pattern of dyspnoea is helpful in making the diagnosis.

The New York Heart Association classification

• Class I-disease present but no dyspnoea or dyspnoea only on heavy exertion

• Class II-dyspnoea on moderate exertion • Class III-dyspnoea on minimal exertion • Class IV-dyspnoea at rest .

• It is more useful, however, to determine the amount of exertion that actually causes dyspnoea-that is, the distance walked or the number of steps climbed.

• The duration and variability of the dyspnoea are important.

• Dyspnoea that worsens progressively over a period of weeks, months or years may be due to pulmonary fibrosis.

• Dyspnoea of more rapid onset may be due to an acute respiratory infection (including bronchopneumonia or lobar pneumonia) or to pneumonitis (which may be infective or secondary to a hypersensitivity reaction).

• Dyspnoea that varies from day to day or even from hour to hour suggests a diagnosis of asthma.

• Dyspnoea of very rapid onset associated with sharp chest pain suggests a pneumothorax.

• Dyspnoea that is described by the patient as inability to take a breath big enough to fill the lungs and associated with sighing suggests anxiety.

• Dyspnoea that occurs on moderate exertion may be due to the combination of obesity and a lack of physical fitness (a not uncommon occurrence).