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

2. History Taking in Respiratory Diseases

3. History and Physical Exam are Skills

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

5. Patient Centered Interviewing NOT Clinician Centered

6. 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

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

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

9. Major Symptoms
Upper respiratory tract
Lower respiratory tract

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

12. Major Symptoms
Lower respiratory tract symptoms cough sputum hemoptysis chest pain dyspnea wheeze

13. 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

15. Cough
Onset
Duration
Diurnal variation
Dry or productive

16. Sputum Amount Character serous mucoid purulent rusty Viscosity
Taste and odour

17. Hemoptysis
Amount
Type
Duration

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

19. Dyspnea Unpleasant and unexpected awareness of breathing
Factors contributing to dyspnea increased work of breathing increased ventilatory drive impaired respiratory muscle function

20. 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

21. 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

22. 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

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

24. Family history Atopy Cystic fibrosis Tuberculosis
Chronic obstructive lung disease

25. Occupational history Chemicals Organic dust Animal proteins
Non-organic dust

26. Social history
Smoking
Alcohol
Keeping pets (birds or animals)