t he r espiratory s ystem h istory dr. j.a. coetser department of internal medicine...
TRANSCRIPT
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THE RESPIRATORY SYSTEM HISTORYDr. J.A. Coetser
Department of Internal Medicine
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PRESENTING SYMPTOMS
Cough Sputum Haemoptysis Dyspnoea Wheeze Chest pain Fever Hoarseness Night sweats
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SOCRATES
Site Onset Character Radiation Alleviating factors Timing Exacerbating factors Severity
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COUGH
Cough clears airways from secretions or foreign bodies
ONSET Acute = e.g. bronchitis / pneumonia Chronic = e.g. asthma
CHARACTER Sound
Barking = croup Loud and brassy = compression of trachea Bovine (hollow) = recurrent laryngeal nerve palsy
Productive of sputum?
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COUGH
ALLEVIATING FACTORS Asthma inhaler improves cough in asthma
TIMING Lying down = GERD or cardiac failure Coughing at work = occupational irritants Worse at night = asthma / cardiac failure Worse in morning = chronic bronchitis
EXACERBATING FACTORS Eating / drinking = incoordinate swallowing /
GERD / tracheo-oesophageal fistula SEVERITY
How does coughing influence daily functioning / work?
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COUGH
Associated symptoms with coughing: Postnasal drip or sinus congestion = upper
airway cough syndrome Irritating dry cough = GERD / ACE-I / interstitial
lung disease
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SPUTUM
Ask about type and amount Purulent (yellow or green) = pneumonia /
bronchiectasis Foul-smelling, dark-coloured = lung abscess Frothy pink = pulmonary oedema
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HAEMOPTYSIS
Def: Coughing up of blood Mild <20mL/24h Massive >250mL/24h
Must distinguish haemoptysis from: Haematemesis Nasopharyngeal bleeding
How much blood was produced? Spotting in sputum / cup / bucket?
Most common causes: Carcinoma Tuberculosis Bronchiectasis
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DYSPNOEA
Def: an awareness of effort required to breathe
ONSET Worsening slowly over weeks / months or years
= interstitial lung disease Rapid onset = acute infection / pulmonary
embolism / pneumothorax CLASSIFICATION
Class I – disease present but no dyspnoea / dyspnoea only with heavy exertion
Class II – dyspnoea on moderate exertion Class III – dyspnoea on minimal exertion Class IV – dyspnoea at rest
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WHEEZE
Whistling noise coming from chest Usually maximal during expiration Causes
Asthma COPD Infections e.g. bronchiolitis Airway obstruction e.g. foreign body / tumor
Differentiate from stridor Loudest over trachea Occurs during inspiration
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CHEST PAIN
Pleura and airways have abundant pain fibre innervation
Sudden onset of pleuritic pain Lobar pneumonia Pulmonary embolism and infarction Pneumothorax
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OTHER PRESENTING SYMPTOMS
Flu-like viral prodome preceding viral pneumonia
Fever at night TB (also ask about night sweats) Pneumonia Lymphoma
Hoarseness (dysphonia) Laryngitis Vocal cord tumor Recurrent laryngeal nerve palsy
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OTHER PRESENTING SYMPTOMS
Sleep apnoea Central = no respiratory effort for at least 10s Obstructive = respiratory effort present, but
airflow stops for at least 10s Typical presentation
Daytime somnolence Chronic fatigue Morning headaches Personality disturbances Loud snoring often present
Epworth sleepiness scale to quantify severity Hyperventilation
Often due to anxiety Development of alkalosis = parasthesiae, light-
headedness, chest pain
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TREATMENT
Chronic drugs taken by patient Steroids (chronic lung disease, e.g. COPD,
sarcoidosis) Inhalers (COPD and asthma)
Pulmonary side-effects of drugs Oral contraceptives = pulmonary embolism Cytotoxic agents, e.g. MTX = interstitial lung
disease Beta-blockers = bronchospasm ACE-inhibitors = chronic dry coughing
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PAST HISTORY
Previous respiratory illness? Previous respiratory investigations?
Bronchoscopy Lung biopsy Spirometry
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OCCUPATIONAL HISTORY
Very, very important in the respiratory history
Ask about the occupation What patient does specifically at work Duration of exposure Use of protective devices Have other workers become ill?
Ask about exposure to Dusts in mines (e.g. asbestos, coal, silica) Industrial exposures (cotton, beryllium) Exposure to animals (psittacosis, Q-fever) Organic dusts, e.g. bird feathers, mould (allergic
alveolitis)
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SOCIAL HISTORY
Smoking history Calculate the number of pack years
How does the condition interfere with work, daily activities and family life?
Alcohol intake Predisposes to pneumococcal and Klebsiella
infections IV drug users at risk for lung abscess
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FAMILY HISTORY
Family history of asthma, cystic fibrosis, lung cancer or emphysema
Family members infected by tuberculosis
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THANK YOU!