Dr Musa Malkawi MBChB (Baghdad) FRCP (London) Consultant Chest Physician

History Taking in Respiratory Diseases

History and Physical Exam are Skills

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

Patient Centered Interviewing 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

Basic Requirements for History Taking Satisfactory approach to the patient Give patient adequate time to tell and express himself 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

Major Symptoms Upper respiratory tract symptoms nasal obstruction nasal discharge sneezing epistaxis sore throat hoarseness stridor cough

Major Symptoms 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 300mmHg and expiratory velocity 500 miles/h

Cough Onset Duration Diurnal variation Dry or productive

Sputum Amount Character serous mucoid purulent rusty Viscosity Taste and odour

Hemoptysis Amount Type Duration

Chest pain Central trachea heart vessels esophagus Lateral pleuritic H. zooster root compression

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 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

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 (considerable): dyspnea on doing less than ordinary effort Grade IV: dyspnea at rest

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 flow limitation. Rhonchi are low pitched sounds (200Hz) Invariably louder during expiration and may be confined to expiration Stridor is a high-pitched wheezing sound resulting from turbulent airflow in upper airways

Past history Previous x-rays Tuberculosis Pneumonia Childhood illnesses; measles and whooping cough Chest trauma Recent anaesthesia or loss of consciousness

Family history Atopy Cystic fibrosis Tuberculosis Chronic obstructive lung disease

Occupational history Chemicals Organic dust Animal proteins Non-organic dust

Social history Smoking Alcohol Keeping pets (birds or animals)