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1. History Taking in Respiratory System
“Always listen to
the patient they
might be telling
you the diagnosis”
Sir William Osler (1849-1919)
PREPARED BY DR. RUQAYA AL-KATHIRY
HEAD OF THE MEDICAL DEPARTMENT OF UST

2. *Careful Hx is more imp. than clinical examination.
*In many dis. the process may reach an advanced stage before any ABNL signs can be
detected e.g. B.A, chr. bronchitis and even Invx may be of limited use. Thus symp. are
promptly investigated otherwise serious delays in Dx and Rx.
HISTORY:
*Nature of the illness: ac., subac., chr.
*Narrative Hx.
*Specific inquiry about missing symp..
*D/D: 3-4.
*Leading Qs as evidence for/against each D/D.
Acute Respiratory Illness:
*Onset of illness: may help to differentiate between the cause.
Q.HOW TO DIFFERENTIATE B/W BACTERIAL &VIRAL PNEUMONIA?
In the former systemic manifestations (fever, rigors & malaise) may precede pleural pain by
a few hours while in the latter by a few days.
Chronic Respiratory Illness:
* Hx in chr. respiratory diseases is complex & time-consuming.
*Record major incidents in the illness.
*In ac. exacerbations of chr. bronchitis, inquire of preceding events & their effects on the
course of dis.

3. *Most chr. resp. dis. have predictable course. If new symp. develop→ think of another dis.
*The course of the dis. may be influenced by the Rx of coexisting dis. e.g. β-blockers for
HT & angina in pts. with B.A (Q.HOW?)
ASSIGNMENT: Q.WHAT DRUGS MAY EXACERBATE BRONCHIAL ASTHMA?
SYMPTOMS OF RESPIRATORY SYSTEM:
There are 6 principal resp. symptoms which may bring the pt. as his C/C:
1-COUGH
2-SPUTUM
3-HAEMOPTYSIS
4-CHEST PAIN
5-DYSPNOEA
6-WHEEZE
7-SYSTEMIC MANIFESTATIONS
N.B: of which most may occur in the absence of resp. dis. e.g.:
*central chest pain=cardiac, pericardial and oesophageal
*S.O.B=cardiac (pulmonary oedema 2ary to LVF)
*haemoptysis=cardiac(MS), haematologic (dis. of clotting)
1-COUGH:
*The most frequent symptom of resp. dis.
*Definition: “Cough is a forced expulsive maneuver against an initially closed glottis,
causing a characteristic sound.”

4. ASSIGNMENT: Q. DEFINE ACUTE, SUBACUTE & CHRONIC COUGH?
ASSIGNMENT: Q. WHAT IS THE MOST COMMON CAUSE OF ACUTE COUGH?
Q. WHAT ARE THE 5 MOST COMMON CAUSES OF CHRONIC COUGH?
*The frequency, severity & character are dependent on:
-site & nature of the lesion
-presence/absence of sputum
-coexisting ABNLity.
ASSIGNMENT: Q.WHAT ARE THE 'RED FLAG' SYMPTOMS ASSOCIATED WITH COUGH THAT
SHOULD PROMPT A CXR?
TYPES OF COUGH:
*The explosive quality of a NL cough can’t be achieved in pts with:
-severe airflow obstruction
-respiratory muscle paralysis
-unilateral vocal chord paralysis (Q.WHAT IS IT’S CHARACTERISTICS?)
ASSIGNMENT: Q.WHAT IS THE RESPIRATORY CAUSE OF LEFT VOCAL CORD PARALYSIS?
ASSIGNMENT: Q.WHAT IS 'COUGH SYNCOPE'?WHAT IS ITS MECHANISM?
ASSIGNMENT: Q.WHAT IS ‘SMOKER’S COUGH ‘?
ASSIGNMENT: Q.HOW IS SLEEP AFFECTED IN CHR. BRONCHITIS & B.A?
Q.WHERE DOES THE URT END & LRT START?

5. NATURE / CHARACTERISTICS
COMMON CAUSES
ORIGIN
Usu. persistent
Post-nasal drip
Pharynx
Harsh, barking, painful, persistent associated
with stridor (tumours)
Laryngitis
Tumour
Whooping cough
Croup
Larynx
dry, centrally painful
Tracheitis
Trachea
Productive/Dry; worse in mornings
Bronchitis (ac. & chr)
Bronchi
Dry/Productive; worse at night/dawn
Bronchial Asthma
Dry initially productive later
Pneumonia
Productive. Changes in posture induces sputum
production
Bronchiectasis
Dry, chr., irritant & distressing
ILD (e.g. IPF formerly known as
cryptogenic fibrosing alveolitis)
Productive; pink, frothy sputum; often at night
Pulmonary Oedema
Persistent (often with haemoptysis)
Bronchial CA
2-SPUTUM:
І)AMOUNT:
*Large or small (HOW TO ESTIMATE?)
ASSIGNMENT: Q.WHAT CAUSES LARGE AMOUNT SPUTUM PRODUCTION?

6. ІІ)CHARACTER:
*It should be assessed by the doctor by inspecting a specimen.
N.B: The term dirty spit may be misleading.
CAUSE
APPEARANCE
TYPE
Ac. Pulmonary Oedema
Bronchoalveolar Cell CA
Clear, watery, frothy, may be pink
Serous
Chr. Bronchitis
Chr. Asthma
Clear, grey, white, may be frothy or
black (soot)
Mucoid
All bronchopulmonary bact. infection
B.A
Yellow, Green, Brown(ASSIGNMENT
Q.WHAT DOES IT INDICATE?)
Mucopurulent
/Purulent (?)
Pneumococcal pneumonia
Red, golden, yellow
Rusty
ІІІ)VISCOSITY:
*Viscous: mucoid (more difficult to cough up→ 'worm-like' struct. that are casts of the
bronchi ) e.g. B.A, chr. bronchitis (if no active infection) & early stages of pneumococcal
pneumonia.
*Serous: watery
ІV)TASTE OR ODOUR:
N.B: It should be assessed by the doctor.
*Foul (vile) tasting/smelling sputum: ASSIGNMENT: Q.WHAT DOES IT SUGGEST?
-bronchiectasis -lung abscess -empyema
ASSIGNMENT: Q. A CHANGE OF SPUTUM IN BRONCHIECTASIS INDICATES WHAT?

7. 3-HAEMOPTYSIS:
*Definition: “coughing of blood from the LRT”
not vomited (UGIT) (Q. DIFFERENTIATE B/W HAEMOPTYSIS & HAEMATEMESIS?)
nor suddenly appeared in the mouth without coughing (nasopharyngeal).
N.B: Always investigate haemoptysis.
*Most important causes:-PI -Lung CA -T.B
*Most common causes of frank/massive (HOW MUCH?) haemoptysis, although it is rare:
-PI -Lung CA -Bronchiectasis
*After excluding other causes: Ac. & Chr bronchitis.
N.B: When no cause is found the oropharynx should be examined.
*Ask about: -Type: BRIGHT RED OR DARK? (WHY?)
-Degree: amount (blood stained/clots, streaks, frank/pure)
-Frequency:-single, large or ass.with symp., e.g. pleuritic pain & S.O.B; D/D:
PE & PI→ immediate invx.
-days/week or early morning=Lung CA. D/D:*T.B *lung abscess
-recurrent over years=Bronchiectasis
-Duration: days=pneumonia; years=bronchiectasis.
ASSIGNMENT: Q.WHAT ARE THE CAUSES OF HAEMOPTYSIS?

8. 4-CHEST PAIN:
-It may be central (retrosternal) or lateral.
-Most common medical cause of non-central pain is pleural disease (pleurisy /pleuritis).
ASSIGNMENT: Q.WHAT ARE THE COMMON CAUSES OF PLEURITIC CHEST PAIN?.
N.B: when pleural pain occurs spontaneously, pulmonary TE must always be considered.
*SITE: lateral
*SEVERITY: variable
*ONSET: variable
*CHARACTER: sharp, stabbing
*RADIATION: may refer to the abdomen & lumbar areas
*RELIEVING FACTORS: analgesics, shallow breathing & suppression of cough.
*AGGRAVATING FACTORS: deep breathing, coughing
*ASSOCIATED SYMPTOMS: variable.
*TIME: variable.
ASSIGNMENT:
I) IRRITATION OF THE PARIETAL PLEURA OF THE UPPER 6 RIBS CAUSES __________.
II) IRRITATION OF THE PARIETAL PLEURA OF THE CENTRAL DIAPHRAGM IS
REFERRED TO THE________________.
III) IRRITATION OF THE PARIETAL PLEURA OF THE LOWER 6 RIBS AND OUTER
DIAPHRAGM IS REFERRED TO THE _______________.
IV) PANCOAST'S TUMOUR OF THE LUNG APEX ERODING THE 1ST RIB AND THE
BRACHIAL PLEXUS CAUSES REFERRED PAIN DOWN THE_________SIDE OF THE ARM.

9. -Most common D/D of pleural dis. pain is a fractured (#) rib. Q.HOW TO DIFFERENTIATE
B/W THEM CLINICALLY & PARACLINICAL?
*Other causes of lateral chest pain is chest wall dis.:
-ribs: #, mets., infection (costochondritis=Tietze's syndrome )
-muscles: I.C.S m. injury (sprains/tears), direct invasion by lung CA, infection (Bornholm's
disease=Coxsackie B infection)
-nerves: infection (Prevesicular HZV) or T spinal N. root compression (vertebral collapse)
ASSIGNMENT: Q.DESCRIBE THE PAIN OF A MALIGNANT CHEST WALL?SOCRAT.
5-DYSPNOEA:
Definition: “A subjective experience of breathing discomfort”. Other definitions: S.O.B,
difficulty in breathing or getting enough air in, disordered or inadequate breathing,
uncomfortable awareness of breathing and breathlessness.
*TACHYPNOEA: rapid, shallow breathing (less energy consuming).
*HYPERPNOEA: ↑ in both depth & rate.
*APNOEA: “cessation of breathing” e.g.
-voluntary breath holding for short periods
-apnoea alternating with overventillation: Cheyne-Stokes breathing
-apnoea during sleep is of 2 types: Obstructive & Central Sleep Apnoea
*Clinical analysis:-Assess the severity of S.O.B (GRADES)
-Identify the cause (BELOW)

10. MONTHS-YEARS
WEEKS-MONTHS
HOURS-DAYS
MINUTES-HOURS
T.B
Bronchial CA
Pneumonia
PnTx
COPD
Pleural effusion
Asthma
Ac. Asthma
Pulmonary Fibrosis
Guillian-Barré Syndrome-GBS
(neuromuscular dis.)
Ac. Exacerbation
of COPD
Pulmonary Oedema
PE
Spondyloarthritis
Anaemia
Inhaled F.B
N.B: Acute dyspnea → urgent Rx; an error in Dx of PnTx, B.A, LVF may be fatal.
ASSIGNMENT: Q.WHAT ARE THE CAUSES OF ACUTE BREATHLESSNESS?
CLINICAL PATTERNS:
I)MODE OF ONSET, DURATION & PROGRESSION:
Onset occurred *sudden & progressed rapidly over a few mins.
*gradual & progressed over hrs or ds, or over wks, ms or ys.
II)VARIABILITY, AGGRAVATING AND RELIEVING FACTORS:
*Diurnal & d-d variation ch.ch. in:
-B.A -Extrinsic allergic alveolitis.
*S.O.B which awakes the pt. from sleep:
-Severe COPD -Pulmonary Oedema(PND) -B.A
*S.O.B which occurs when the pt. lies flat (Orthopnoea):
-HF -Respiratory muscle weakness -Severe lung dis. e.g. Emphysema
*Postural Dyspnoea is ↑ in bilateral diaphragmatic paralysis.

11. III)ASSOCIATED SYMPTOMS:
ACUTE BREATHLESSNESS : DIAGNOSTIC VALUE OF ASSOCIATED SYMPTOMS
Without chest pain but with cough & wheeze
B.A
COPD
Pulmonary Oedema with ac. LVF
PnTx
With lateralised & pleuritic chest pain
Pneumonia
PE/PI
PnTx
Rib #
Without chest pain, cough or wheeze
PE
Tension PnTx
Hypovolaemic Shock
Metabolic Acidosis
With central & non-pleuritic chest pain
MI with LVF
Massive PE/PI
IV)SEVERITY:
*Assess the severity of breathlessness in terms of daily activities.
Q.IS SLEEP DISTURBED BY BREATHLESSNESS?
Q.DOES BREATHLESSNESS OCCUR AT REST?
Q.DOES BREATHLESSNESS INTERFERE WITH NORMAL CONVERSATION?
Q.DRESSING OR WASHING PRODUCE BREATHLESSNESS?
Q.HOW FAR CAN THE PT. WALK ON THE FLAT WITHOUT STOPPING?
Q.HOW MANY STAIRS CAN THE PT. CLIMB WITHOUT STOPPING?
Q.WHAT DOES BREATHLESSSNESS PREVENT THE PT. FROM DOING?

12. ASSIGNMENT: Q. HOW TO DIFFERENTIATE PSYCHOGENIC BREATHLESSNESS FROM
OTHER CAUSES OF DYSPNOEA?WHAT ARE ITS ASSOCIATED SYMPTOMS?
6-WHEEZING:
*It is a musical, whistling sound produced by the passage of air through narrowed bronchi.
*Typically, it is limited to expiration. It is louder during expiration.
*Pts. may mean noisy, laboured breathing with rattling of secretions in the URT thus it must
be differentiated from STRIDOR. (Q.HOW?)
ASSIGNMENT: Q.PROLONGED WHEEZY COUGHING ORWHEEZE ON EXERCISE IS A
COMMON SYMPTOM OF WHICH RESPIRATORY DISEASES?HOW TO DIFFERENTIATE
B/W THEM?

13. PAST Hx:
Information about previous resp. & non-resp. illnesses can help with the Dx of the condition.
CONSEQUENCES
HISTORY
Allergic tendency relevant to B.A
ECZEMA, HAYFEVER
Relapse; Bronchiectasis; Aspergilloma
T.B
Bronchiectasis; Bronchial CA
Aspiration of vomit or alcohol
Hypoglobulinaemia; Multiple Myeloma (MM)
PNEUMONIA & PLEURISY
Pneumonia →bronchiectasis
MEASLES & WHOOPING COUGH
Recurrence of childhood B.A in adult
RECURRENT CHILDHOOD BRONCHITIS
/WHEEZY BRONCHITIS
Traumatic haemothorax → pleural thickening → frozen chest
CHEST INJURIES
Aspiration of oropharyngeal secretions
F.B → aspiration pneumonia
Lung abscess
RECENT GENERAL ANAESTHETIC FOR
SURGERY/LOSS OF CONCIOUSNESS
Compare old X-rays with the current ones
CXR
Lung dis. e.g. pleurisy, pulm. fibrosis, effusions, bronchiectasis
CTD= E.G. R.A, SLE
Recurrence, metastatic/pleural disease
Chemotherapeutic agents & radiotherapy cause pulm. fibrosis
PREVIOUS MALIGNANCY
Pulm. thromboembolism
RECENT TRAVEL, IMMOBILITY, CA
Respiratory failure; Aspiration
NEUROMUSCULAR DISORDERS

14. FAMILY Hx:
*T.B: infected person.
*B.A: Ask about other allergies.(e.g.?)
ASSIGNMENT: Q.WHAT DOES 'ATOPY' SIGNIFY IN THE FAMILY HX?
N.B: 'Asthma' in parents or grandparents who were smokers may have been mis-Dx COPD
*Chronic bronchitis: environmental factors & habits. (e.g.?)
ASSIGNMENT: Q.GIVE 2 IMPORTANT INHERITED AUTOSOMAL RECESSIVE(AR)
DISEASES THAT MAY CAUSE RESPIRATORY DISEASE? other dis. e.g. pulm. HT, pulm.
fibrosis.
SOCIAL Hx:
*If you suspect B.A: Ask about exposure to allergens as=
house dust mite (shaking bedding, hoovering), grass pollens (mowing the lawn, the 'hay-
fever season') and tree pollens, smoke, perfumes, fumes, cold air or drugs.
*Inquire about pets (animals e.g. cats, dogs, rodents, horses= B.A; birds=allergic
alveolitis) (ASSIGNMENT: Q.PARROTS CAUSE WHICH PNEUMONIA?)
*Physical effort involved in an employment.
*Cigarette smoking: A Hx of current & past smoking. ASSIGNMENT: Q.WHAT ARE THE 2
IMPORTANT RESPIRATORY DISEASES THAT ARE AFFECTED BY SMOKING?
smoking index:(?) -mild -moderate -heavy
*Other respiratory dis. associated with smoking : spontaneous PnTx, ILD, pulm.
haemorrhage with Goodpasture’s synd.)

15. OCCUPATIONAL Hx:
*Record all occupations, full- and part-time, held since the pt. left school & the no. of years
spent in each job.
*Find out exactly what the job entailed & the length of any exposure.
*Exposure to a recognized hazard helps Dx, prevention & may be the basis for compensation
in the case of occupational lung dis.
*ORGANIC PARTICLES: organic dust animal protein, moulds, chemicals.
*NON-ORGANIC PARTICLES: stone cutters, silica, coal dust & asbestos =pneumoconiosis
& malignant disease.
ASSIGNMENT: Q. GIVE EXAMPLES OF RESPIRATORY DISEASES THAT ARE WORSE AT
THE BEGINNING OF THE WORKING WEEK.
ASSIGNMENT: Q. GIVE EXAMPLES OF RESPIRATORY DISEASES THAT ARE WORSE AT
THE END OF THE WORKING WEEK AND GETS BETTER ON HOLIDAYS.
DRUG Hx:
*Detail the type of inhaler, dose in micrograms (not puffs) and frequency.
*Note the effectiveness of previously prescribed medications, e.g. corticosteroids & inhalers.
*Enquire about current & previous medications, if drug-induced respiratory dis. is suspected.

16. “Medicine is learned at
the bedside
and not in the
classroom”
Sir William Osler (1849-1919)
THANK YOU FOR YOUR ATTENDANCE