1. Respiratory System Focused history taking
Ishraq Elshamli
Respiratory Unit
Tripoli Medical Center

2. History Taking A history is the story of the patients illness.
It is the first step in determining the etiology of a patient’s problem
Let the patient describe his or her problem.
Be a medical detective to establish the diagnosis.

3. History Taking > 80% of diagnosis may be made from history alone.
Examination and investigations would either confirm or refute the history based diagnosis.

4. Skills Needed for history taking
The ability to :
Understand and be understood.
Obtain relevant information.
Interview logically
Interrupt when necessary without inhibiting patient.
Look for non verbal clues.
Establish good relationship with patients.
Be able to summarize the information.

5. The patient initiates this by describing a particular symptom which you would use for additional questioning that will help identify the cause of the problem.

6. Understanding the Pathophysiology of
disease ( Medical Knowledge) as well as Increased ExposureTo Patients and disease will improve the
skill of taking a good history.

7. The Most Important Symptoms are:
Cough.
Sputum.
Haemoptysis.
Breathlessness.
Wheeze.
Chest pain.

8. 1. Cough Origin cause charactiristic Pharynx Post. Nasal drip
Usualy persistent
Larynx
Laryngitis, tumour, whooping cough
Harsh barking painful persistent
Trachea
Tracheitis
Painful
Asthma
Dry or productive,worse at night, cold exp, or allergen
COPD
Worse in the morning , often productive
Bronchial carcinoma
Persistent, associated with hemoptysis
Pneumonia
Initialy dry the productive
Bronchiectasis
Productive, positional changes
Pulmonary edema
Often at night, frothy sputum
Pulmonary tuberculosis
Productive, wt. Loss, fever
Interstitial lung disease
Dry, irritant, distressing
Other
Drug induced
ACE, B- Blocker

9. How To Assess Cough ?
It is important to ask about :
Frequency: Intermittent OR Persistent
Severity : Diurnal variation
Character dry or productive
Associated symptoms e.g chest pain
What is responsible or Triggered by :
Sputum in the respiratory tract e.g. in acute infections or Bronchiectasis.
Cigarette smoke .
Pungent smell.
Cold air.

10. 2.SPUTUM TYPES: Mucoid as in Chronic Bronchitis.
Green or Yellow in Infection.
Bloody in bronchogenic carcinoma, T.B
Rusty colour in Pneumonia.
Pink and frothy in Pulmonary oedema.
Foul smelling suggest anaerobic infection.
Clear watery, large volume (Bronchorrhea ) in alveolar cell carcinoma.

11. How To Assess Sputum ? It is important to ask about: Colour.
Amount OR Volume, fill a teaspoon, tablespoon, eggcup, a sputum cup.
positional changes.
Taste or Smell.
Viscosity
Blood stained.

12. 3. HAEMOPTYSIS CAUSES : Common: Bronchial Carcinoma.
Pulmonary Infarction.
TB.
Bronchiectasis.
Lung Abscess.
Acute/chronis bronchitis.
Other:
Mitral stenosis.
Aspergilloma.
Connective tissue disease.
Goodpasteurs disease.
Forign body.
Anticoagulation
Chest trauma.

13. How to assess HAEMOPTYSIS?
It Is Important To Ask About:
Is it frank blood or associated with purulent sputum.
Is it frank blood or streaks of blood.
Amount ?
Is it coughed up or vomited.
Previous respiratory illnesses e.g.Tuberculosis, Bronchiectasis.
D.V.T, connective tissue disease.

14. 4. BREATHLESSNESS Undue awareness of breathing. Shortness of breath.
Unable to get enough air.

15. BREATHLESSNESS Pulmonary causes: COPD Pulmonary fibrosis.
Days- Weeks
Hours
Minutes
Pulmonary causes:
COPD
Pulmonary fibrosis.
Pulmonary collapse due to
obstructing bronchial carcinoma
Pneumonia
Asthma
Airway occlusion by FB, laryng. Edema
Sp. Pneumothorax.
Acute pulmonary embolism
Other:
Psychogenic.
Anemia
Pleural effusion
Pulmonary embolism
Acute pulmonary edema due to left heart failure, MI, arrhythmia.

16. How To Assess A Patient With Breathlessness?
Onset & progession:
ACUTE , sudden OR Gradual over a prolonged period or time.
Progression the time period over which breathlessness developed.
Timing
Early morning→ severe asthma and LVF
During the week→ occupational asthma
Winter→ bronchitis
Spring→ atopic asthma

17. 3.Severity or Grade:
How far the patient can walk on the flat without
stopping.
How many steps can be climbed without stopping.
Do you feel breathless when washing or dressing.
Do you feel breathless at rest.
Variability:
Episodic ( intermittent) or persistent.
worse at night and early morning (morning dippers in
asthma)
lying flat (orthopnea) in heart failure and severe airway
obstruction.
AGGREVATING&RELIEVING FACTORS
Exercise, cold exposure, Excitement, Drugs.

18. SEVERE LEFT HEART FAILURE
5. WHEEZE
Musical sound best heard on expiration
A common in patients with airways obstruction caused by Asthma or COPD.
May be present only:
At night or early morning, On exposure to cold air or Allergen and On Exercise.
Diffuse expiratory wheezes may occur in
SEVERE LEFT HEART FAILURE

19. STRIDOR Noisy respiration, always inspiratory.
Indicates central large airway obstruction.
Causes:
Carcinoma Larynx
Tracheal stenosis
extrinsic compression

20. 6. CHEST PAIN Causes Of Central Chest Pain
Tracheitis and bronchitis.
Angina.
Massive pulmonary embolism.
Pericarditis.
Acute aortic dissection.
Oesophagitis.
Large central tumour.

21. Causes Of Lateral Chest Pain
Pleural Pain:
Sharp and stabbing in character.
Localized or referred to shoulder tip if diaphragmatic pleura is involved.
Worse on deep inspiration or cough, if severe, shallow breathing, avoidance of movement, and cough suppression.
Results from inflammatory or malignant involvement of the parietal pleura.
e.g. Pneumonia, Pulmonary infarction, Malignancy, Lung abscess, Rheumatoid arthritis

22. SUMMARY CAUSES OF CHEST PAIN
STRUCTURE
Possible CAUSE of pain
Pleura
Inflammation, infarction
Muscle
Strain from coughing
Bone
Rib fracture or Tumour
Costochondral junction
Tietze’s syndrome
nerves
Herp. zoster,Pancoast tumour
Heart and great vessels
Cardiac ischemia, Infarction, aortic dissection, aneurysm
Oesophagus
Spasm reflux

23. How To Assess A Patient With Chest Pain
Enquire about:
Site.
Mode of onset.
Character.
Radiation.
Intensity.
Precipitating
Aggravating and relieving factors.
Relationship to breathing, coughing or movement

24. Co-existing Symptoms Fever. Hoarseness of voice. Ankle swelling.
Poor appetite and weight loss.
Snoring and day time sleepiness.

25. OSCE Objective Structured Clinical Examination
The curriculum tells the staff what to teach.... 
The OSCEs tells the students what to learn

26. But you will make it if you prepare for it and
It is a stressful exam?!..
But you will make it if you prepare for it
and
practice, practice, practice..!

27. WHAT IS OSCE OSCE is objective structured clinical examinations
It is standards in clinical exam in Europe and states

28. The OSCE increase the fairness by:
1.Increase the range of skills that the students are tested for
2. Increase the numbers of examiners by whom the students are assessed
3. asking the students the same questions over the same period of time

29. Most of exam will get the patients with abnormal finding
But we can get normal ..
We can get volunteers…

30. It consist of 6 stations over (80 ) minutes
4 Physical examination skills station.
History taking skills station.
Oral exam station ( Management of common cases, Emergency, Radiology, Instruments).
All are patients oriented

31. Physical examination skills General History taking skills station
Physical examination skills Dermatology
Physical examination skills Cardio/Neur
Oral exam station
Physical examination skills Resp/Abd

32. What are examiners looking for ?
1. A confident approach 2. A good skill performance 3. Good applied knowledge 4. Clear answers 5. Good communications

33. 1. History taking Skills Introduction:
Good morning Miss. N.J I am Dr. XYZ, senior house officer in the department of (?) I would like to have a small chat with you regarding your ( ) is that all right with you?
Introduce yourself
Reason
Permission

34. Focused history taking OSCEs (Data gathering station)
Here you will show your medical knowledge concerning the current specific patient and case. Include:
The chief complaint.
History of present illness.
Past medical and surgical history.
Medications and allergies.
Family history and social history.
Occupational history.

35. The examiner will ask you 2-4 standard questions which are usually:
What is your Provisional diagnosis for this patient?
What is your three most relevant differential diagnosis?
What are the risk factors of this patient?
What is your only / three investigation you are going to order for this patient and why?

36. What is your initial / short term plan of management?
What is your long term plan of management?
Interpret this lab findings / imaging...etc.
Prognosis? If this patient came back in .. days / weeks with .. what will be your explanation.

37. 1. History taking Skills N
1. History taking Skills N.J is a 29 year old woman who has been diagnosed with asthma recently
Introduction:
Good morning Miss. N.J I am Dr. XYZ, senior house officer in the department of (?) I would like to have a small chat with you regarding your asthma, is that all right with you?

38. Questions to be asked in history taking
Wheeze, dyspnoea or cough? Disturbed sleep?
Exercise (quantify distance to breathlessness).
Days per week off work or school.
Diurnal variation?
Precipitating factors: emotion, exercise, infection, allergens and drugs.
Any other atopic diseases like eczema, hay fever, allergy.
Any Family history of asthma?

39. Any Acid reflux? Occupational history?
Drugs , inhalers, NSAID, Corticosteroids.
Past medical history:
Hospitalizations, emergency Rx, ICU admissions, intubation.
Social history
Smoking duration and amount, alcohol, living conditions, number of children, animals.

40. Questions:
Investigations
Management

41. 2. History taking Skills N
2. History taking Skills N.S is a 50 ys old employee presented to the Medical OPD complaining of Chest pain, take a focused history.
timing

42. Introduce yourself and make the patient comfortable in the bed.
Onset: when did the pain start? Sudden, gradual?
Is this the first time? Have you felt similar symptoms before?
Site& Radiation of pain to the jaw, arm or to the back ?
Precipitating .What were you doing when pain came on?
Palliation .What make pain less? antacids, rest, positional

43. Cont’ Chest Pain Provocation: What make pain worse?
Exercise, food, emotion, deep breaths
Character : sharp, dull, heavy, squeezing, tearing
Duration of the pain? Describe the course of the pain. (Worsening, intermittent, better),timing of day.
Associated features like nausea, vomiting,sweating and breathlessness?

44. Objective -PMHx-
Previous similar episodes? (past therapy, investigations)
Hx: MI, documented CAD, angioplasty, CABG
Important historical risk factors
Smoking
Hypertension
Diabetes mellitus
hypercholesterolemia
positive family history

45. D/D
Acute myocardial infarction, angina, pericarditis, myocarditis, aortic dissection.
PE, pleurisy, pneumothorax.
Oesophagitis + spasm, acid peptic disease, cholecystitis and pancreatitis.
Costochondritis, rib fracture.
Herpes zoster.

46. Hemoptysis
J.T is a 66 year old man who comes to your office complaining of coughing up blood. In the next 10 minutes take focused history.

47. COPD exacerbation
N.C is  65 year old man known case of COPD who comes to the emergency complaining of shortness of breath for two days. In the next 10 minutes, take a focused history.

48. Cough
A.H is a 62 year old man who comes to your office with cough for three months. In the next 10 minutes take focused history.

49. THANK YOU