THE RESPIRATORY SYSTEM HISTORYDr. J.A. CoetserDepartment of Internal MedicineCoetserJA@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!