HISTORY TAKING RESPIRATORY SYSTEM
OUTLINE PERSONAL INFO CHIEF COMPLAINTS PRESENT HISTORY REVIEW OF SYSTEMS PAST HISTORY PERSONAL HISTORY SOCIAL HISTORY FAMILY HISTORY DRUG HISTORY TRAVEL HISTORY
PERSONAL INFO NAME AGE SEX OCCUPATION MARITAL STATUS ADDRESS & PHONE NO.
CHIEF COMPLAINTS –What brought the patient to the hospital? COUGH SPUTUM HAEMOPTYSIS BREATHLESSNESS CHEST PAIN
COUGH DURATION – how long have you had this cough? –Acute (< 3 weeks) –Chronic (> 8 weeks)
ACUTE COUGH - CAUSES Viral URTI Acute bronchitis (bacterial) Inhaled foreign body Pneumonia
CHRONIC COUGH - CAUSES Asthma GORD Rhinitis-Sinusitis Smoking Drugs – ACE Inhibitors Lung malignancy TB Bronchiectasis Interstitial lung disease
Associated symptoms Do you have any of the following symptoms? Haemoptysis Breathlessness Fever Chest pain Weight loss Syncope
Cough - Character What is the nature of the cough? Wheezy cough – Asthma, COPD Bovine cough – lung malignancy with invasion of left Recurrent laryngeal N. Barking, Painful – Inflammation of trachea and larynx
Moist or dry Is the cough dry or moist? Moist cough Ac. Or Chr. Bronchitis Bronchiectasis Dry cough Tracheitis – painful Drug induced – ACEI Chronic dry cough Interstitial lung disease Malignancy
Timing Do you wake up coughing in the night? –Asthma Does your cough decrease on holidays? Occupational Does your cough increase during the day? GORD, chronic sinusitis
SPUTUM Do you bring out phlegm while coughing? Ask about amount, colour, taste/smell, solid material in sputum
Amount How much sputum do you cough out each day? – Spoonful or cupful Copious, purulent sputum – Bronchiectasis Sudden, large, purulent sputum – –Rupture of lung abscess into bronchi Large volume, watery, frothy pink sputum –Pulmonary oedema
Colour What is the colour of sputum? –Serous –Mucoid –Purulent –Rusty
Serous sputum Clear watery, frothy, pink –Acute pulmonary oedema –Malignancy
Mucoid Clear, grey, white, viscid –Chronic bronchitis –COPD –Asthma
Purulent sputum Is your sputum yellowish? –Acute infection –Greenish? Chronic infection –Pneumonia –Bronchiectasis –Cystic fibrosis –Lung abscess
Rusty sputum Is the sputum rusty red? –Pneumococcal pneumonia
Taste/Smell Foul smelling (anaerobic infection) –Anaerobic bacteria Bronchiectasis Lung abscess Empyema
Solid material Mucus plugs –Asthma –Bronchopulmonary aspergillosis
HAEMOPTYSIS Did you cough out blood? Differentiate from haemetemesis Ask about amount, appearance, duration and frequency
Haemoptysis - causes Malignancy Infection Vascular – PTE, infarction Vasculitis – Wegener’s, Goodpasture Trauma – FB, chest trauma, iatrogenic Cardiac – MS, Ac. LVF Coagulopathy
Amount and appearance Blood streaked clear sputum / blood clot –Lung carcinoma Blood streaked purulent sputum – infection Large amounts of blood – Lung carcinoma Bronchiectasis Tuberculosis
Duration & frequency Intermittent haemoptysis with infection for several years –Bronchiectasis Daily haemoptysis for more than a week - Carcinoma, TB, Lung abscess Single large haemoptysis episodes - Pulmonary Thromboembolism, infarction
BREATHLESSNESS Shortness of breath Undue awareness of breathing (dyspnoea) Normal during strenuous exercise
Mode of onset, duration & progression Did it occur suddenly and progress over minutes? –PTE –Pneumothorax –Acute LVF –Asthma –FB
Did it occur gradually and progress over hours to days? –Pneumonia, asthma, exacerbation of COPD Weeks to months? Anaemia, Pl. effusion Months to years? COPD, Pulm. Fibrosis, PTB
Associated symptoms Lightheadedness Dizziness, Tingling Chest tightness
Acute breathlessness Without chest pain –P. embolism –Pneumothorax –Met. Acidosis –Acute LVF
Acute breathlessness With Pleuritic pain –Pneumonia –Pneumothorax –P Embolism –Rib fracture
Acute breathlessness Central chest pain –MI –Massive p. embolism With wheeze and cough Asthma COPD
Severity Gr. 1 – when hurrying on level ground Gr. 2 – when walking with people of own age or on level ground Gr. 3 – has to stop when walking on level ground or with people of own age
Aggravating – relieving factors Orthopnoea –cardiac cause, severe lung disease Wakes up pt. from sleep –Acute LVF, asthma Worse on waking, improves with coughing - COPD
Chest pain Usually originates from pleura, chest wall or mediastinal structures
Pleural pain Sharp, stabbing, worsens on coughing/inspiration –P. embolism –Pneumonia –Pneumothorax –Rib fractures
Past history Known allergies – asthma Known patient of asthma Frequent episodes of infections –Bronchiectasis Known patient of tuberculosis? History of connective tissue disease? History of lung malignancy?
Drug history Drugs for asthma, route, dose ACE Inhibitor intake - cough
Family history Cystic fibrosis – inherited Alpha 1 antitrypsin deficiency – Emphysema History of Allergies TB
Social history Smoking (pack years) –COPD (> 20 pack year history) –Cancer Pets allergies - asthma
Occupational Exposure to asbestos (construction workers, metal miners) –Malignancy –P. fibrosis Allergens (animals, plant products, dusts, chemicals) - asthma