1. History Taking in Respiratory Diseases
Suleiman Momany, MBBS, FCCP

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

3. Patient Centered NOT Clinician Centered

4. 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

5. 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.

6. 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

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

8. Major Symptoms
Upper respiratory tract
Lower respiratory tract

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

11. Lower respiratory tract symptoms
Cough
Sputum
Hemoptysis
Chest pain
Dyspnea
Wheeze

12. 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

14. Cough
Onset
Duration
Diurnal variation
Dry or productive

15. Causes of Cough

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

17. Types of Sputum

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

19. Causes of Hemoptysis

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

21. Causes of Non-Central Chest Pain

22. Causes of Central Chest Pain

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

24. 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

25. Causes of Dyspnea

26. Causes of Dyspnea

27. Dyspnea: onset, duration and progression

28. 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

29. MRC Dyspnea Scale

30. Variants of Dyspnea Orthopnea PND: Paroxysmal nocturnal dyspnea
Platypnea

31. 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

32. Causes of wheezes

33. 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

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

38. Drug Induced Lung Disease

39. Family history Atopy Cystic fibrosis Tuberculosis
Chronic obstructive lung disease
Cancer

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

42. The Spectrum of Occupational Lung Disease

43. 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

49. 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

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

56. 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

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

58. 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

59. Occupational History

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