Taking history of presenting complaint
Focus on in why the patient has come to see you
Let them speak, language they can understand, prompt but no leading
6 symptoms of respiratory disease
- Cough
- Sputum production
- Haemoptysis
- Shortness of breath (dyspnoea)
- Unusual breathing (wheeze)
- Chest pain
Describe cough
- Rhinitis, colds
- Patients are consistent in the way they describe coughs
- Persistent or recurrent (disruptive at night, in front of others= distressing)
Common respiratory disorders that present as cough
- Asthma
- Chronic bronchitis
- Bronchial carcinoma
- Bronchiectasis (less common)
- Gaud
- Gastro-oesophageal reflux disease
- Drugs (ACE inhibitors)
- Chronic sinusitis= post nasal drip of secretions that cough up
Features of asthma cough
- Asthma= dry, irritating cough, can be productive of small sputum, at worst in small hours of morning= inadequately controlled- occupational? Environmental?
- Intermittent
Features of chronic bronchitis cough
- Chronic bronchitis (spectrum of COPD)= mucus hypersecretion and inflammation, increased risk of bacterial infection.
- Sputum production most days of the week for 3 consecutive months in 2 successive years
- More persistent than asthma, productive, not disturbed at night
- Do you usually bring up flehm in the winter months?
- Does this go on for a period of several months each year
- Do you have repeated chest infections during the year/ winter?
Features of lung cancer cough
- Difficult to notice as already may have COPD
- Persistent, blood stained if encroaching airway, haemoptysis= slight to significant
- Central tumours in left lung invade left recurrent laryngeal nerve that hooks around the left main bronchus= bovine sounding cough, hoarseness of voice
Describe sputum
- Amount, character, colour, viscosity, smells, taste
- Large amounts= bronchiectasis
What does mucopurulent mean?
Mucus that is infected
Colour of sputum
clear, whitish/grey (smokers), yellow, green (invasion of neutrophils or eosinophils infiltrating airway), red/ brown sputum= pneumococcal pneumonia
Thickness of sputum
watery (acute pulmonary oedema, bronchio-alveolar cell carcinoma= rare), mucoid (chronic bronchitis, chronic asthma), thick
Taste and smell of sputum
-Taste and smell= anaerobic infections of lung
Describe haemoptysis
Coughing up blood
Malignancy- tumour within airways/ chest infection that doesn’t go away
Pulmonary infarction and embolism- tissue destruction, bright red blood initially then darkens, severe pleuritic chest pain, breathlessness and hypoxia
-Infections= cavitation (TB, fungal like aspergillosis, chronic bronchiectasis)
Sudden shortness of breath
Duration- hyper acute to gradual
-Sudden shortness= pneumothorax (puncture in lung surface leading to deflation), pulmonary embolism (pleuritic pain), PND (Paroxysmal nocturnal dyspnoea, acute left ventricular failure), acute myocardial infarction?
Shortness of breath- hours
Pneumonia, acute asthma, acute left ventricular failure, COPD (can be acute deterioration with infection), acute alveolitis environmental exposure
Shortness of breath- days to weeks
Pleural effusion (weeks to occupy hemithorax), carcinoma (collapse of major lobe), sub acute alveolitis, heart failure, congestive cardiac failure, anaemia as gradual onset shortness
Shortness of breath- chronic
COPD, parenchymal lung diseases (fibrotic), congestive heart failure (ankle swelling), anaemia, anxiety and panic attacks
How to talk about breathlessness
MRC dyspnoea scale- Grade 1 (normal) to Grade 5 (breathless on minimal exertion)
Describe chest pain
- Inflamed pleura (pleuritic chest pain)
- Bony structure= crush, fractures, tumour invasion of vertebral bodies, chronic and persistent pain
- Inflammation of the costochondral joints Tietze’s syndrome (benign)
- Neuralgic pain in thorax= intercostal nerve compression by vertebral collapse, herpes zoster
- Oesophagus and heart= chest pain
Describe wheeze
- Musical sound produced by the passage of air through narrowed airways
- Expiration over inspiration
- Pitch reflection of diameter of airway
- Asthma and bronchitis= polyphonic wheeze
- Monophonic wheeze, loud in one area= fixed lesion (tumour/ inhaled foreign body)
What is stridor?
Sound worse on inspiration, caused by partial obstruction of a major airway such as the trachea/ one of two main bronchi
Often tumour, foreign body
Audible over trachea
Other history taking in adults
-Airways disease- *asthma as child/ atopic diseases (eczema, hay fever) = common clinical trajectory to recur in middle age
=Asthma more clinically responsive than COPD
-Chronic bronchiectasis, COPD= childhood infections (pneumonia, measles, TB, whooping cough)
-Pulmonary embolism= extensive foreign travel, surgery
What is involved in a systematic enquiry?
Underlying tumour/ COPD= appetite, weight loss
- Morning headaches= respiratory failure, CO2 retention
- Nasal polyps in asthma
- Post nasal drip in chronic cough
- Ankle swelling- cor pulmonale, right sided failure of chronic lung disease
- Anorexia and weight loss
- Recurrent pneumonia, aspiration of stomach and oesophageal content
Family and social history
- Smoking= person themselves, passive smoking, occupational and environmental exposure
- How old when started smoking
- Still smoking? Given up? When?
- How many cigarettes a day at peak and how long that continued for
- Quantify in pack years, 1 pack year= 20 cigarettes a day for a year
- COPD= 10 pack year smoking history or more (not including passive smoke or occupational exposure)
- Family history of asthma= can happen later on in life
- Pets- dogs and cats
- Hobbies- soldiering and paint
- Pigeon fanciers
- Abroad= TB, legionella (bacterial pneumonia)
- Social circumstances= quality of living, bungalow/ flat, stairs, bathroom same floor as bedroom, living alone, support network, nursing services
