T HE R ESPIRATORY S YSTEM H ISTORY Dr. J.A. Coetser Department of Internal Medicine

P RESENTING SYMPTOMS Cough Sputum Haemoptysis Dyspnoea Wheeze Chest pain Fever Hoarseness Night sweats

SOCRATES Site Onset Character Radiation Alleviating factors Timing Exacerbating factors Severity

C OUGH 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?

C OUGH 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?

C OUGH Associated symptoms with coughing: Postnasal drip or sinus congestion = upper airway cough syndrome Irritating dry cough = GERD / ACE-I / interstitial lung disease

S PUTUM 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

W HEEZE 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

C HEST PAIN Pleura and airways have abundant pain fibre innervation Sudden onset of pleuritic pain Lobar pneumonia Pulmonary embolism and infarction Pneumothorax

O THER 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

O THER 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

P AST HISTORY Previous respiratory illness? Previous respiratory investigations? Bronchoscopy Lung biopsy Spirometry

O CCUPATIONAL 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)

S OCIAL 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

F AMILY HISTORY Family history of asthma, cystic fibrosis, lung cancer or emphysema Family members infected by tuberculosis

T HANK YOU !