Introduction

80% of clinical information comes from the history.

Shortness of breath

Onset – when? How (was it sudden / prolonged)?  – Rapid, slow, subacute (inbetween acute and slow (chronic))

Sudden

Long term onset of shortness of breath

  • COPD (obstructive lung disease)
  • Asthma
  • Lung cancer
  • Heart failure –   Ask about exercise tolerance
  • Pulmonary hypertension
  • Fibrotic lung disease
  • Pneumonia caused by TB
  • Pneumocytis (in immunosupressed people – HIV)
  • Pseudomonas – secretes film around itself that makes it very resistant to loads of AB’s! Amoxicillin is normally used in chest infection because it is effective against pneumococcus (strep) – however this is useless against pseudomonas, and thus you have to use anti-pseudomonals (amino-glycosides). Very common in CF (cystic fibrosis)

Sub-acute presentations

  • Infection – bacterial/viral – pneumonia!

Diurnal variation

This is present in

  • Asthma
  • Sleep apnoea – people with big necks!
    • Positional variation – Orthopnia – shortness of breath when lying down – this is associated with cardiac complaints. (‘How many pillows do you use at night?’ PND? More than two pillows is abnormal                                          

Medication

Inhalers – the inhalers they are on give you an indication of the severity / type of disease they have.
Nebulisers
O2 at home – this means they have a pretty chronic condition! Continuous oxygen? Spurts during the day? Who is their respiratory physician?
Prednisolone / long term AB’s will show the severity of the COPD.
Montoleucast – called ‘singular’ – used for severe asthma
ALLERGIES!

 

Coughing

Asthma – ask about job – could be occupational asthma.
COPD (productive sputum) – chronic
Infection (productive sputum) – acute
What is the sputum like?

  • Green – infection
  • Brown – can be bad infection, can contain blood
  • Haemoptysis – CANCER! – if this is present, ask about weight loss. Ask about family history – ask about pack years. Ask about job history – industry; asbestos, fungi (aspergillus), cotton mill, coal miners!
  • Pink frothy sputum – orthopnia – cardiac issue
  • Frequency
  • Volume – quantify in terms of teaspoons / cups / mug fulls?
  • Haemoptysis
  • Dry cough – is it bovine cough / barking cough? Whooping cough (pertussis?)

 

Wheeze

  • Is it inspiratory? Called stridor– obstructive disease! – asthma (reversible) and COPD (irreversible). Can also be caused by cancer or other blockage. It is generally a sign of an obstruction of the large airways.
  • Is it expiratory? – Generally a sign of smaller airway obstruction.

 

Pain

Chest pain – this is a very big topic! Ask SOCRATES! Learn Socrates! Can be respiratory, cardiac, musculoskeletal or GI in
origin

Respiratory pain, can be – pneumonia (usually occurs post-pneumonia), cancerous, or very often can just be musculoskeletal pain from coughing.
Radiation – only usually occurs in cardiac causes (radiates to arm, jaw neck). Radiates to the back in dissecting aortic aneurysmcheck the blood pressures in both arms – the dissection can be at any point in the aorta – the blood pressures can be different in the two arms if the aneurysm is in a particular place – so if there are different BP’s in the arms, and there is back pain you pretty much have a diagnosis! However, often the pressures will be the same.
Alleviating factors – e.g. leaning forwards can alleviate pericarditis.
Exaggerating factors – eg. Cold air, coughing, breathing can make chest pain worse.
Cardiac type pain

  • Nature of the pain (i.e. ‘brick on the chest’) – Mi
  • MI – radiates to the arms. Also will be clammy, and have nausea/vomiting, may have lost consciousness, and may have a ‘band type pain’ across the chest.
  • If the patient responds to GTN, then you know the cause is cardiac.

Other symptoms to ask about (constitutional symptoms)

  • Fatigue
  • A bit of a general symptom, but can be useful, e.g PE is unlikely to cause fatigue.
  • Weight loss
  • Anorexia
  • Sleep
  • Sweats
  • Sleep apnoea
    • During REM sleep, all your muscles relax, except the diaphragm and the heart. This means that airway muscle can relax, and airway architecture is lost. This can lead to apnoea and hypoxia. This can will arouse the patient from REM – sometimes patients will wake up, or sometimes just to a higher level of sleep – but then they will drop straight back to REM sleep again. There will also be a compensatory rise in HR.
    • Treatment is either weight loss, or CPAP (Continuous positive airway pressure)- a mask blowing air into the mouth, or a device that lifts the jaw forwards.
  • Dizziness / pins + needles
    • This is mainly due to CO2 retention.
    • Carpopedal spasm – spasm in the hands – the patient is stuck in a position – seen in anxious patients / hypoventilation.
  • Fever
    •   Checking for infection – ask about sweats – night sweats are a big sign of TB! On a CXR you will see a ‘cavitating lesion’ – basically a lesion with air in it. They are found especially in the upper lobes. You would have to send sputum for smears for acid fast bacilli.
    • Also look for rigors – these are particularly present in pneumonia.
  • Management of SOB and fever:
    • Fluids
    • Oxygen
    • CURB 65 score! – the higher the curb score the more likely it is to be pneumonia.
    • White count + Hb + CRP
  • Hoarseness / vocal changes?
  • Stridor
    • Can have swelling of upper airways, so could be anaphylaxis
    • Could also be foreign bodies (these are more likely to lodge on the right due to the steepness of the bronchi (steeper on the right)
  • General stuff
    • Appetite (and weight loss)
    • Sleep (is it a nocturnal problem?)
    • Pets at home – BIRDS particularly carry pathogens. Also for asthma.

 

Past medical history

  • Asthma / allergies – atopic type things – high IGE levels
  • Cardiac history
  • Diabetes (more prone to infection)
  • Hypertension
  • Heart disease / MI
  • Neurological disorders
  • Epilepsy
  • Had TB before
  • Stroke / DVT?
  • Psychological history – you can blunt this question by asking if they are under any other consultants / go to any clinics? Have they ever been to clinics?
  • Surgical history – in examination you need to look for scars on the chest – e.g. from lobectomy.

 

Drug history

  • Allergies
  • Cardiac drugs
  • Don’t forget to ask about OTC or complementary therapies – St. John’s wart.
  • Fruit juices – grapefruit juice!
  • Drug interactions! Beware warfarin! Also many people are on atenolol (β blocker) and salbutamol (β agonist!)
    • Theophyline – this can interact with ciprofloxacin! Theophyline is also found in tea – but in too smaller amounts to cause any harm.

 

Social history

  • Occupation – what age did they leave school – then work through all their jobs!
  • Smoking!
  • Drinking
  •  Who lives with them at home / looking after them – lots of respiratory patients are really debilitated and so may have carers/family at home.

 

Systems Review

Consider a full systems review but focus particularly on…

Genitourinary

  • Frequency (particularly at night)
  • Dyuria
  • Ployuria
  • Haematuria

Gastro-intestinal

  • Frequency – change
  • Pain
  • Vomiting
  • Dysphagia
  • Odinophagia

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