History taking in respiratory system

1. RESPIRATORY MEDICINE
History taking in respiratory system
Dr .suresh kumar yogi
PG student
Dr. S. N. Medical Collage
Jodhpur

2.  History is a record of medical events that have taken
palace in patient’s life.
 Importance of good history lies in the fact that it provide
an insight into the exact nature of the patients problems
and the attitude of patient towards the illness.
 The examiner should first allow the patient to state the
nature of his complaints and narrate his problems in his
own language.
 Listening o the patient account helps not only in
establishing a rapport but also helps the examiner for
further enquiries into the history
 Leading questions must be avoided .
 End of history ,elicit and record negative history .
 In case the patient is unable to speak ,unconscious ,in
shock or a child ,the history should be taken from the
nearst relative/friend who is known as informant

3.  Examiners approch should be gentle ,
sympathetic and caring.
Particulars of the patients
 Name
 Age
 Sex
 Address
 Occupation
 Contect number
 Date of admission and date of examination

4. Presenting complaints;
 Complaints for which the patient has come
to the doctor.
 Define and record the main complaints and
the duration of the presence of complaints.
 Duration of complaints may be recorded in
days, weeks ,months or years.
 Complaints should be recorded In
chronological order.

5. History of presenting complaints;-
 Recording of details of each complaint
separately
 Mode of onset
 duration
 Location / site
 Severity
 Character
 Diurnal variation
 Aggravating and relieving factors
 Exacerbation or remission

6. The main respiratory symptoms are:
 Cough and sputum
 Haemoptysis
 Dyspnoea .
 Chest pain
 Wheeze .

7. Other associate symptums
 Fever ;-the persistent elevation of body
temperature above the normal levels
 Normal -37.0 to 37.5 c
 Type of fever-
 Continuous Fever-The temperature
remains above normal throughout the day
and does not fluctuate more than 1 degree
Celsius in 24 hours. This type of fever occurs
in lobar pneumonia, typhoid, urinary tract
infection, infective endocarditis, brucellosis,
typhus etc

8. Remittent Fever-The temperature remains above
normal throughout the day and fluctuates more than
2 degree Celsius in 24 hours. This type of fever is
usually seen patients of typhoid infection
and infective endocarditis. This type of fever is most
common in practice.
 Intermittent Fever-The temperature is present only
for some hours in a day and remains to normal for
the remaining hours. When the spike occurs daily, it
is quotidian, when every alternate day, it tertian and
when every third day, it is quartan. Intermittent fever
is seen in malaria, kala-azar, pyemia, septicemia etc.

9.  Anorexia –TB/Bronchogenic ca
 Headace-co2 narcosis
 Edema -corpulmonale
 Loss of appetite is a common feature
whenever people are unwell. It suggests
that the disease is having a significant
effect on well-being.
 Significant loss of weight may well be
indicative of serious illness - eg,
malignancy or tuberculosis.

10.  Upper gastrointestinal symptoms: gastro-
oesophageal reflux is a common cause of chronic
cough.
 Heart disease may cause respiratory symptoms.
Establish whether there are any indications of heart
failure or coronary heart disease.
 Severe anaemia may cause breathlessness.
 Rheumatoid arthritis and other connective tissue
diseases may cause respiratory symptoms.
 Neuromuscular diseases may cause respiratory
symptoms, particularly dyspnoea.

11. Cough
 Definition-forced expiration against
closed glottis ,which clears the tracheo-
bronchial tree of any foreign material or
secretion.
it is protective reflex
it can be voluntary or involuntary being
provoked by physical, chemical,or
mechanical stimuli irritating of any part
of the respiratory tract and even from
irritation of the pleura.

12. Analysis of cough
 Was the onset of the cough sudden or
insidious? What was its initiating event?
Did it start as an isolated symptom or occur
with or follow other symptoms?
 How long has the cough been present? Is it
persistent or episodic? Seasonal or
perennial?
 To determine the severity of the cough,
ask: How frequent is a coughing spell?
How long does each coughing spell last?
What is its effect on daily activity or rest?

13.  Is the cough productive or dry? Lack of
expectoration does not necessarily
indicate that the cough is dry, as many
patients, particularly children and
women, tend to swallow their sputum
raised to the level of the pharynx. The
sound of the cough would help in
determining its productive or dry nature.

14.  Is the cough the only symptom, or is it
associated with other respiratory or
nonrespiratory symptoms? Inquiry should
be specifically made about conditions
known to cause the cough, particularly
when it is chronic and persistent.
 In addition to an accurate smoking history ,
ask: To what respiratory irritants is the
patient exposed at home or at work? Is
exposure accidental or intentional?

15.  What are the precipitating or aggravating
factors? What time of the day or night is
the cough or sputum production worse?
Does it happen in supine position, upon
arising in the morning, with drinking or
eating, with exercise, or with breathing cold
or dry air? Does the cough awaken the
patient from sleep?
 Is there a past history (recent or old) of
foreign body aspiration?

16.  Has the pattern of the cough and the
amount or other characteristics of the
sputum changed recently?
 Can the patient locate the site of origin of
the cough or the sputum, such as from the
throat or deeper in the chest?
 Has the patient had a similar problem with
coughing in the past?
 Does the cough have easily recognizable
characteristics, as in croup or whooping
cough?

17. Clinical Significance
 Onset;-
sudden –acute asthama ,massive pulmonary
embolism, Pneumothorax
Gradual-in chronic bronchitis
 Nature;-
( a) Dry cough- in pharyngitis ,allergic bronchitis
( b ) productive cough-in lower respiratory tract
infection like pneumonia , Bronchitis
,Bronchictasis, PTB

18.  Duration;-
short –in acute Bronchitis, pharyngitis
Long –COPD,PTB ,allergic
bronchitis,Fibrosing alveolits,
 Diurnal variation;
Early morning & night- chronic bronchitis,
Bronchictasis.
Cough disturbing patient sleep in night-
pulmonary oedema, asthma

19.  Postural variatons;-
Cough In bronchiectasis and lung absess
when the patient lies in the opposite side
of lesion ,this becouse the postural
drainge of the mucus into the healthy
bronchi stimulats cough reflex

20. sputum
 Sputum is mucus produced from
respiratory tract
 Normal lung produces about 100 ml of
clear sputum each day
 Enqury - amount , Appearance /colour,
type of sputum

21.  Patients with sputum production should be
asked about
 its frequency and description of the
physical characteristics of the sputum
including
Amount (with each coughing spell and
daily total),
color,
consistency,
ease of its expectoration,
taste, and smell.

22. Clinical Significance
 Bronchiectasis causes large volumes of
purulent sputum ,which varies with posture.
 Suddenly coughing up large amount of
purulent sputum on a single occasion
suggests rupture of a lung abscess or
empyema in to the bronchial tree.
 Large volumes of watery sputum with a
pink tinge in acutely breathless patient
suggest pulmonary oedema,
 But if occurring over weeks ,suggests
alveolar cell carcinoma

23. type appearance causes
serous Frothy,pink
Clear,watery/rarely
copious(bronchorrhea)
Acute pulmonary
oedema
Bronchioloalveolar
cancer
Mucoid Clear , grey
White,viscid
Chronic
bronchitis/COPD
asthma
purulent Yellow
Green
Acute
bronchopulmonary
infection
Asthma (eosinophil)
Longer –standing
infection
Pnemonia
Bronchiectasis,cystic
fibrosis,lung abscess
Rusty Rusty red Pnemococcal
pneumonia
Type of sputum

24. Appearance /colour;-
 Clear or mucoid sputum –in chronic bronchitis
and COPD with no infection
 Yellow sputum- in acute lower respiratory tract
infection(live neutrophils) and in
asthma(eosinophils).
 Green purulent –indicates chronic
infection(dead neutophils)e.g.in COPD or
bronchiectasis
 Rusty red sputum –early pneumococcal
pneumonia,as pneumonic inflammation
causes lysis of red cells.

25. Haemoptysis
 Coughing up blood ,ranging from blood
streak sputum to gross blood that
originates from the tracheobronchial tree
 Haemoptysis immediattely preceded by
cough indicates origin of bleeding at a
level lower than the larynx
 Most common cause of haemoptysis in
india is TB

26. Causes of haemoptysis;-
 Respiratory – TB, bronchogenic ca, pulmonary
embolism, lung abscess ,bronchiectasis,
bronchial adenoma, trauma
 Cardiac –mitral stenosis,aortic
aneurysm,primary pulmonary hypertension
 Immunological- good pasture’s syndrome,
wegener’s granulomatosis and PAN
 Itarogenic- lung biopsy, bronchoscopy
 Bleeding disorder-thrombocytopenic
purpura,hemophilia
 Spurious –trauma,ulcer in mouth

27. Amount and appearance
 Blood –streaked clear sputum or clots in
sputum for more than a week suggest lung
cancer
 Haemoptysis with purulent sputum suggests
infection
 Coughing up large amount of pure blood is
rare but potentially life threatening ;
causes –lung cancer, bronchiectasis , TB
,lung abscess ,mycetoma,Cystic fibrosis,
aortobronchial fistula, granulomatosis wth
polyangitis

28. Duration and frequency
 Single episodes of hemoptysis ,if
associated with symptoms e.g.pleuritic
chest pain and breathlessness, suggest
pulmonary thromboembolism and infarction
and need immediate investigation
 Bronchiectasis causes intermittent
hemoptysis associated with copious
sputum over years
 Daily hemoptysis for a week or more –in
lung cancer ,other TB and lung abscess.

29. Breathlessness(Dyspnoea)
Defination;-An abnormal, uncomfortable
subject awareness of once breathing
 Dyspnea (also SOB, air hunger)
 normal in heavy exertion
 pathological if it occurs in unexpected
situations.
 Breathlessness is common symtom of
cardiac disease. however it also present
in respiratory disease

30. Analysis of breathlessness-
 Occurrence
Rest
Exertion (quantify)
 Position
Orthopnea (dyspnea lying flat)
Trepopnea (dyspnea in lateral position)
Platypnea (dyspnea when upright)
Other precipitating factors
 Environment Emotional state

31.  Chronology
Duration
Progression
Diurnal and seasonal variations
Constant or intermittent
 Relieving factors
Rest
Medications (physician and self-
prescribed)

32.  Predisposing factors
Cigarette smoking
Occupational and environmental exposures
 Associated medical diseases and
symptoms
Pulmonary
Cardiac
Neuromuscular
Family history

33.  Breathlessness occurs as a symptom
most frequently in lung cancer, where it
might affect 75% of people with primary
disease of the lung, bronchus and
trachea (Muers & Round 1993).
 For patients with COPD, intractable
breathlessness develops late in the
course of the disease, gradually
increasing in severity over a period of
years in the majority of people.

34. Onset and durestion

36. Severity grading-

37. Clinical Significance
Causes of breathlessnss
1. Physiological ;–exercises, high altitude,etc
2. Pathological;-
(a) Cardiac –
acute-pulmonary edema, pulmonary embolism, CHD
in neonates
chronic-CCF, acyanotic CHD, chronic
thromoembolism.
(b) Respiratory –
acute- pneumothorax, acute severe asthma, inhaled
foreign body, acute exacerbation of COPD,
pneumonic consolidation, laryngeal edema etc
chronic-COPD, Asthma, pleural effusion(subacute),
bronchogenic Ca, PTB, ILD eg fibrosing alveolitis,
etc

38. 3.Pharmacological ; drugs beta-blockers,
busulfan etc
4.Psycological - hypervantilation
5.Miscellaneous ;-
acute- metabolic acidosis & respiratory
muscle paralysis
chronic-anemia ,ankylosing spondylitis

39. Wheeze and
stridor
 High pitched whistling sound
 Mainly expiratory
 Usually indicative of bronchospasm
 Wheeze on exercise is common in
asthma and COPD
 Night wakening with wheeze suggestive
of asthma or PND
 But wheeze after wakening in the
morning suggests COPD

40. Stridor ;-high pitched ,often harsh noise
produced by airflow turbulence through a
partial obstruction of the upper airway.
 Most commonly on inspiration but also on
expiration or biphasically
 Inspiratory-narrowing at vocal cords
 Biphasic –s/o tracheal obstraction
 Expiratory-trachiobronchial obstruction
 Usually accompanied by dyspnoea
 Stridor is serious condition always need
investigation

41. Analysis of wheeze
 Onset
 Duration and periodicity of wheeze
 Diurnal and seasonal variations

42.  Duration ;-short duration suggests obstraction
by foreign,functional disturbance of larynx or
inflammatory disease
 Onset ;-
(a) instantaneous onset of dypnoea and stridor
suggests foreigne body impaction or
neuromuscular disturbance of larynx
(b)Acute onset is typical of laryngitis, laryngismus
stridulus, measles, whooping cough or
diphtheria
(c)Slow and gradual onset suggests papilloma or
recurrnt laryngeal nerve

43. Chest pain
if pain is a symptom, clarify the details of the pain
using SOCRATES
 Site – where is the pain ?
To differentiate from cardic,gastrointestinal. Respiratory
chest pain is usually laterlized
 Onset – when did it start?
sudden -spontaneous pneumothorax
gradual-pluerisy
 Character/type –
sharp /stabing-related to deep breathing and coughing in
pleuritis ,usually subsides after pleural effusion develops
dull ache –lateral/low down in spontaneous pneumothorax
 Radiation – does the pain move anywhere else?

44.  Associations – other symptoms associated with the
pain
 Time course – worsening / improving / fluctuating /
time of day dependent
 Exacerbating / Relieving factors – does anything
make the pain worse or better?
Costo chondial pain is aggravated by movement
To differentiate from cardiac causes angina is
aggravated by stress and relieved by rest while
pleural pain is aggravated on deep breathing and
coughing.
 Severity – on a scale of 0-10, how severe is the
pain?

45.  Common respiratory causes of chest pain-
Pleurisy
Pneumothorax
Acute pulmonary embolism
Pneumonia
Massive collapse
Lung absess
Ca lung
Tracheitis
Pneumomediastinum

46. Past history;-
 H/O PTB and treatment ATT ,DM, HTN, Asthama,blood
transfusion,
 H/o previous hospital admission
 In case of COPD /ASTHMA number of episode of acute
exacerbation
 Use of inhalers (assess compliance and technique).
 Use of steroids (some measure of severity in asthma).
 Other drugs which may have relevance in respiratory
disease - eg, angiotensin-converting enzyme (ACE)
inhibitors (cough).
 Allergies
 Ask about all allergies including, for example, food,
inhaled allergens and drugs.

47. Occupational and social history
 An occupational history may be very important in
respiratory disease. Occupational Asthma , Industrial
Dust Diseases,Asbestos-related Diseases,Extrinsic
Allergic Alveolitis and Sick Building Syndrome
 Hobbies and pets may also be responsible for respiratory
disease like extrinsic allergic alveolitis .
 Lifestyle and alcohol consumption are also very relevant
to respiratory diseases. Ask about illicit drugs.
 Smoking history should detail, for example, the type and
number of cigarettes smoked currently and in the past.
Ask also about passive smoking.
 Sexual history may be relevant to risk of HIV and AIDS.

48. Family history;-
 Respiratory diseases with a genetic
component - eg, cystic fibrosis,
emphysema (alpha-1-antitrypsin
deficiency).
 Infectious diseases such as tuberculosis
(remember high-risk groups).
 Atopic diseases such as asthma, hay
fever and eczema.

49. Thank
you