History Taking in Respiratory Diseases Suleiman Momany, MBBS, FCCP

Why to Take History? 70% of medical problems can be diagnosed by proper history taking 20% can be diagnosed after physical exam

Patient Centered NOT Clinician Centered

5 – Step Model of Interviewing Set the stage for interview Elicit the chief complaint Open the history of present illness Continue the patient centered history of present illness Transition to clinician centered process

A 29-year old woman presented to pulmonary clinic complaining of dry cough for the last three months. She noticed that her cough is worse at night and after exposure to cold air and household chemicals. She also has associated wheezes and chest tightness. She feels short of breath when going upstairs. Has seasonal running nose and sneezing and watery eyes. She visited ER twice for this complaint. She smokes ½ pack per day and works as hair dresser. Had childhood ? Asthma Family history of allergic rhinitis She is currently taking occasional antihistamine and received nebulized treatment in the ER.

Basic Requirements for History Taking Satisfactory approach to the patient Give patient adequate time to tell and express himself/herself Competent interrogation and skillful communication

History Taking in Respiratory Diseases Major symptoms Past history Family history Occupational history Social history

Major Symptoms Upper respiratory tract Lower respiratory tract

Upper respiratory tract symptoms Nasal obstruction Nasal discharge Sneezing Epistaxis Sore throat Hoarseness Stridor Cough

Lower respiratory tract symptoms Cough Sputum Hemoptysis Chest pain Dyspnea Wheeze

Cough The 5th most common symptom seen in outpatient clinics An explosive expiration that clears the tracheobronchial tree from secretions and foreign materials Intrathoracic pressure may reach 300 mmHg and expiratory velocity 800 km/h

Cough Onset Duration Diurnal variation Dry or productive

Causes of Cough

Sputum Amount Character Viscosity Taste and odor Serous Mucoid Purulent Rusty Viscosity Taste and odor

Types of Sputum

Hemoptysis Amount: massive Type: frank, streaks, clots Duration

Causes of Hemoptysis

Chest pain Central Lateral Trachea Heart Vessels Esophagus Pleuritic Herpes zoster Root compression

Causes of Non-Central Chest Pain

Causes of Central Chest Pain

Dyspnea Unpleasant and unexpected awareness of breathing Factors contributing to dyspnea Increased work of breathing Increased ventilatory drive Impaired respiratory muscle function

Increased work of breathing Airflow limitation Decreased compliance Restricted expansion Increased pulmonary ventilation Increased dead space Metabolic acidosis Severe hypoxia Hysterical Weakness of respiratory muscles Poliomyelitis Myasthenia gravis Spinal cord injury

Causes of Dyspnea

Causes of Dyspnea

Dyspnea: onset, duration and progression

NYHA Severity Grading of Dyspnea Grade I (minimal): dyspnea on running or on doing more than ordinary effort Grade II : dyspnea on ordinary effort Grade III: dyspnea on doing less than ordinary effort Grade IV: dyspnea at rest

MRC Dyspnea Scale

Variants of Dyspnea Orthopnea PND: Paroxysmal nocturnal dyspnea Platypnea

Wheeze Wheezes are continuous high pitched (400Hz) musical sounds produced by oscillations of airway walls. The oscillations begins when the airflow velocity reaches a critical value called flutter velocity. Wheezes always accompanied by air flow limitation Invariably louder during expiration and may be confined to expiration Rhonchi are low pitched sounds (200Hz) Stridor is a high-pitched wheezing sound resulting from turbulent airflow in upper airways

Causes of wheezes

Past history Childhood illnesses; measles and whooping cough Tuberculosis Pneumonia Chest trauma Chest (or other surgeries) Previous x-rays Recent anaesthesia or loss of consciousness Previous Hospitalization; Ward Vs ICU Admission Previous Mechanical Ventilation

Medication History Follow up of disease severity ( SABA Calendar) Response to treatment Proper Device use Side effects Drug Induced Lung Disease

Drug Induced Lung Disease

Family history Atopy Cystic fibrosis Tuberculosis Chronic obstructive lung disease Cancer

Occupational and Environmental history Chemicals Organic dust Animal proteins Non-organic dust

The Spectrum of Occupational Lung Disease

Hypersensitivity pneumonitis / (Extrinsic Allergic Alveolitis) A spectrum of granulomatous, interstitial, and alveolar-filling lung diseases Result from repeated inhalation of and sensitization to a wide variety of organic dusts

Pneumoconioses Group of interstitial lung diseases caused by the inhalation of certain dusts and the lung tissue’s reaction to the dust Primary pneumoconiosis are asbestosis, silicosis, and coal dust Other forms aluminum, antimony, barium, graphite, iron, kaolin, mica, talc, among other dusts. There is also a form called mixed-dust pneumoconiosis. Typically many years Some cases – silicosis, particularly – rapidly progressive forms can occur after only short periods of intense exposure

Asbestos exposure Asbestosis = parenchymal disease interstitial fibrosis Pleural Calcification Malignant mesothelioma Lung cancer: all types

Lung Cancer Occupational Exposure Several occupational carcinogens Environmental exposures Outdoor particulate matter Residential radon exposure (attributable risk 7% in US) Environmental tobacco smoke Enviromental exposure to occupational carcinogens low dietary intake; other factors Sources: Samet J. J Natl Cancer Inst 1989 and Steenland K et al. Am J Ind Med 1996

Occupational lung cancer occupations Aluminium production Coal gasification Coke production Hematite mining Iron and steel founders Painting Rubber production Source :IARC

Occupational lung cancer agents Arsenic Asbestos BCME Beryllium Cadmium Chromium 6 Silica dust Nickel Ionizing radiation Occupational exposure to strong inorganic acids Sulfur mustard Polycyclic aromatic hydrocarbons Soot Coal tar pitch Diesel exhaust

Occupational History

Social history Smoking (Pack-Year) Alcohol Keeping pets (birds or animals)