Download History taking OF Respiratory System in Adult Prayudi

History taking OF Respiratory System in Adult
Prayudi Santoso, Arto Y. Soeroto
Pulmonary Division
Dept. of Internal Medicine,
School of Medicine Padjadjaran University
BANDUNG
Objectives
• After this session, you will be able to recognize and
describe the following:
– Useful techniques for interviewing the patient with
respiratory symptoms
– The common symptoms of respiratory disease and the
significant characteristics of each to identify in the interview
Categories of the Medical History
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Patient identification
Chief complaints
History of present illness
Past Medical History
Family history
Occupational history
Smoking history
Review of systems
History of Present Illness
• Describes the current medical problems and the
circumstances surrounding each problem
• For example: dyspnea:
– When it started
– How severe it was
– What made it worse or better
– Various other details that may be important (e.g. wheezing)
Past Medical History
• Describes important medical problems the patient has
had in the past.
• For example: if the patient has a history of asthma,
COPD, heart disease. Cancer or stroke it will be reported
in the Past Medical History
Review of Systems
• Determine whether the disease is confined to the
pulmonary complaints are a manifestation of illness
elsewhere (e.g. conjunctivitis and rhinitis in asthma,
sinusitis in bronchiectasis)
• Aspiration of postnasal drip or GERD can cause
exacerbate chronic bronchitis and asthma
COUGH
• A COUGH 1S THE COMMONEST MANIFESTATION OF
LOWER RESPIRATORY TRACT DISEASE
• A PERSON MAY COUGH VOLUNTARILY, BUT MORE
TYPICALLY COUGH IS A REFLEX RESPONSE TO STIMULLI
→ IRRITATE RECEPTORS → LARYNX, TRACHEA, LARGE
BRONCHE
COUGH
1.
2.
3.
•
DO YOU HAVE A COUGH ?
ITS QUALITY DRY OR PRODUCTIVE COUGH
ITS QUANTITY OR SEVERITY :
VOLUME → amount is it?
»
»
•
•
•
INTERMITTENT
PERSISTENT CHRONIC BRONCHITIS
COLOR
ODOR
CONSISTENCY
4.
5.
6.
7.
ITS TIMING : NEW SYMPTOM OR MORE CHRONIC
THE SETTING IS WHICH OCCURS WORSE AT NIGHT ? WORSE IN
THE MORNING
FACTORS THAT MAKE A BETTER OR WORSE
ASSOCIATED MANIFESTATION : (TABLE 1,2,3)
SYMPTOMS ASSOCIATED WITH THE COUGH LEAD
YOU ITS CAUSE
Patterns of cough in asthma and chronic bronchitis
Parameter
Asthma
Chronic bronchitis
Timing
Worse at night
Worse in the morning
Chronicity
Dry(may be green sputum) Productive
Nature
Intermittent
Persisten
Respon to
treatment
Associated wheeze is
reversible
Associated wheeze is
irreversible
Types of sputum
Character
Cause
Pink/frothy
Pulmonary oedema
Yellow/green
Infections/eosinophils in asthma
Rusty
Pneumococcal pneumonia
Fouly smell
anerobic
Viscous,difficult to cough up
Asthma/infections
Large volumes
Bronchiectasis
Black
Cavitating lesions in coal miners
Blood-stained
TB,Ca,pneumonia,bronchitis,bronchiectasis,e
tc
Common Respiratory Causes Of Cough
Cause
Nature
Asthma
Worse at night; dry orproductive
COPD
Worse in morning; often productive
Bronchiectasis
Related to posture
Post nasal drip
Persistent
Tracheitis
Painful
Croup
Harsh
Interstitial fibrosis
dry
OVERLAP BETWEEN COPD AND ASTHMA
COPD
ASTHMA
~10%
Cough and Hemoptysis
Problem
Cough and Sputum
(1
Associated Symptoms and Setting
Acute Inflammation
Laryngitis
Dry cough (without sputum), may become
productive of variable amounts of sputum
An acute, fairly minor illness with
hoarseness. Often associated with
viral nasopharyngitis
Tracheobronchitis
Dry cough, may become productive (as
above)
An acute, often viral illness, with
burning retrosternal discomfort
Mycoplasma and Viral
Pneumonias
Dry hacking cough, often becoming
productive of mucoid sputum
An acute febrile illness, often with
malaise, headache, and possibly
dyspnea
Bacterial Pneumonias
Pneumococcal: sputum mucoid or purulent;
may be blood-streaked, diffusely pinkish, or
rusty
An acute illness with chills, high
fever, dyspnea, and chest pain.
Often is preceded by
acute upper respiratory
infection.
Klebsiella: similar; or sticky, red, and
jellylike
Typically occurs in older alcoholic
men
Cough and Hemoptysis
Problem
Cough and Sputum
(2
Associated Symptoms and Setting
Chronic Inflammation
Postnatal Drip
Chronic cough; sputum mucoid or
mucopurulent
Repeated attempts to clear the throat. Postnasal
discharge may be sensed by patient or seen in
posterior pharynx. Associated with chronic rhinitis, with
or without sinusitis
Chronic Bronchitis
Chronic cough; sputum mucoid to purulent,
may be blood-streaked or even bloody
Often longstanding cigarette smoking. Recurrent
superimposed infections. Wheezing and dyspnea may
develop.
Bronchiectasis
Chronic cough; sputum purulent, often copious
and fouls-smelling; may be blood-streaked or
bloody
Recurrent bronchopulmonary infections common;
sinusitis may coexist
Pulmonary Tuberculosis
Cough dry or sputum that is mucoid or
purulent; may be blood-streaked or bloody
Early, no symptoms. Later, anorexia, weight loss,
fatigue, fever, and night sweats
Lung Abscess
Sputum purulent and foul-smelling; may be
bloody
A febrile illness. Often poor dental hygiene and a prior
episode of impaired consciousness
Asthma
Cough, with thick mucoid sputum, especially
near end of an attack
Episodic wheezing and dyspnea, but cough may occur
alone. Often a history of allergy
Gastroesophageal Reflux
Chronic cough, especially at night or early in
the morning
Wheezing, especially at night (often mistaken for
asthma), early morning hoarseness, and repeated
attempts to clear the throat. Often a history of
heartburn and regurgitation
Cough and Hemoptysis
Problem
Cough and Sputum
(3
Associated Symptoms and Setting
Neoplasm
Cancer of the Lung
Cough dry to productive; sputum may be
blood-streaked or bloody
Usually a long history of cigarette
smoking. Associated manifestations
are numerous
Left Ventricular Failure or
Mitral Stenosis
Often dry, especially on exertion or at
night; may progress to the pink frothy
sputum of pulmonary edema or to frank
hemoptysis
Dyspnea, orthopnea, paroxysmal
nocturnal dyspnea
Pulmonary Emboli
Dry to productive; may be dark, bright red,
or mixed with blood
Dyspnea, anxiety, chest pain, fever;
factors that predispose to deep
venous thrombosis
Irritating Particles,
Chemicals, or Gases
Variable. There may be a latent period
between exposure and symptoms
Exposure to irritants. Eyes, nose,
and throat may be affected
Cardiovascular Disorders
Chest Pain
Problem
Cardiovascular
Angina Pectoris
(1
Process
Location
Quality
Severity
Temporary myocardial
ischemia, usually
secondary to coronary
atherosclerosis
Retrosternal or across
the anterior chest,
sometimes radiating to
the shoulders, arms,
neck, lower jaw, or
upper abdomen
Pressing, squeezing,
tight, heavy,
occasionally burning
Mild to moderate,
sometimes
perceived as
discomfort rather
than pain
Myocardial
Infarction
Prolonged myocardial
ischemia resulting in
irreversible muscle
damage or necrosis
Same as in angina
Same as in angina
Often but not
always a severe
pain
Pericarditis
 Irritation
Predordial, may
radiate to the tip of
the shoulder and to
the neck
Retrosternal
Sharp, knifelike
Often severe
Crushing
Severe
Anterior chest,
radiating to the neck,
back, or abdomen
Ripping, tearing
Very severe
of parietal
pleura adjacent to
pericardium
 Mechanism
Dissecting Aortic
Aneurysm
unclear
A splitting within the
layers of the aortic wall,
allowing passage of blood
to dissect a channel
Chest Pain
(2
Problem
Process
Location
Quality
Severity
Pulmonary
Tracheobronchitis
Inflammation of
trachea and large
bronchi
Upper sternal or on
either side of the
sternum
Burning
Mild to
moderate
Pleural Pain
Inflammation of the
parietal pleura, as from
pleurisy, pneumonia,
pulmo-nary infarction,
or neoplasm
Chest wall overlying the
process
Sharp, knifelife
Often severe
Retrosternal, may
radiate to the back
Burning, may be
squeezing
Mild to
severe
Retrosternal, may
radiate to the back,
arms, and jaw
Often below the left
breast or along the costal
cartilages; also
elsewhere
Usually squeezing
Mild to
severe
Chest Wall Pain
Inflammation of
the esophageal
mucosa by reflux
of gastric acid
Motor dysfunction of
the esophageal
muscle
Variable, often unclear
Stabbing, sticking, or
dull, aching
Variable
Anxiety
Unclear
Precordial, below the left
breast, or across the
anterior chest
Stabbing, sticking, or
dull, aching
Variable
Gastrointestinal and
other
Reflex Esophagitis
Diffuse Esopha-geal
Spasm
Chest Pain
Problem
Cardiovascular
Angina Pectoris
(3
Timing
Usually 1-3 min but up to
10 min. prolonged
episodes up to 20 min
Factors That Aggravate
Exertion, especially in the
cold; meals; emotional
stress. May occur at rest
Myocardial
Infarction
20 min to several hr
Pericarditis
Persistent
Breathing, changing
position, coughing, lying
down, some-times
swallowing
Dissecting
Aortic
Aneurysm
Abrupt onset, early peak,
persistent for hours or
more
Hypertension
Factors That Relieve
Rest, nitroglycerin
Associated
Symptoms
Sometimes
dyspnea, nause,
sweating
Nausea, vomiting,
sweating,
weakness
Sitting forward may
relieve it
Of the underlying
illness
Syncope,
hemiplegia,
paraplegia
Dyspnea
(1
Problem
Process
Left-Sided Heart Failure (left
Elevated pressure in pulmonary
capillary bed with transudation of
fluid into interstitial spaces and
alveoli, decreased compliance
(increase stiffness) of the lungs,
increased work of breathing
Dyspnea may progress slowly,
or suddenly as in acute
pulmonary edema
Exertion, lying down
Chronic Bronchitis
Excessive mucus production in
bronchi, followed by chronic
obstruction of airways
Chronic productive cough
followed by slowly progressive
dyspnea
Exertion, inhaled irritants,
respiratory infections
Chronic Obstrucitve
Pulmonary Disease (COPD)
Overdistention of air spaces distal
to terminal bronchioles, with
destruction of alveolar septa and
chronic obstruction of the airways
Slowly progressive dyspnea;
relatively mild cough later
Exertion
Asthma
Bronchial hyperresponsive-ness
involving releasse of
inflammatory mediators,
increased airway secretion, and
bronchoconstriction
Acute episodes, separated by
symptom-free period.
Nocturnal episodes are
common
Variable, including allergens,
irritants, respiratory infections,
exercise, and emotion
ventricular failure or mitral
stenosis)
Timing
Factor that Aggravate
Dyspnea
(2
Problem
Process
Diffuse Interstitial Lung
Diseases (such as
Bronchial hyperresponsiveness
involving release of inflamma-tory
mediators, increased airway
secretions, and bronchoconstriction
Acute episodes, separated by
symptom-free period.
Nocturnal episodes are
common
Pneumonia
Inflammation of lung paren-chyma
from the respiratory bronchioles to
the alveoli
An acute illness, timing varies
with the causative agent
Spontaneous
Pneumothorax
Leakage of air into pleural space
through blebs on visceral pleura,
with resulting partial or complete
collapse of the lung
Sudden onset of dyspnea
Acute Pulmonary
Embolism
Sudden occlusion of all or part of
pulmonary arterial tree by a blood
clot that usually originates in deep
veins of legs or pelvis
Sudden onset of dyspnea
Anxiety with
Hyperventilation
Overbreathing, with resultant
respiratory alkalosis and fall in the
partial pressure of carbon dioxide in
the blood
Episodic, often recurrent
sarcoi-dosis, widespread
neoplas-ms, asbestosis,
and idiopathic pulmonary fibrosis)
Timing
Factor that Aggravate
Variable, including allergens,
irritants, respiratory
infections, exercise, and
emotion
More often occurs at rest
than after exercise. An
upsetting event may not be
evident
Dyspnea
Problem
(3
Factors that Relieve
Associated Symptoms
Setting
Left-Sided Heart Failure (left
Rest, sitting up, though
Often cough, orthopnea,
History of heart disease or its
ventricular failure or mitral
stenosis)
dyspnea may become
paroxysmal nocturnal
predisposing factors
persistent
dyspnea; sometimes
wheezing
Chronic Bronchitis
Expectoration; rest, though
Chronic productive cough,
History of smoking, air
dyspnea may become
recurrent respiratory
pollutants, recurrent
persistent
infections; wheezing may
respiratory infections
develop
Chronic Obstrucitve
Rest though dyspnea may
Cough, with scant mucoid
History of smoking, air
Pulmonary Disease (COPD)
become persistent
sputum
pollutants, sometimes a
familial deficiency in alpha1antitrypsin
Asthma
Separation from aggravat-ing
Wheezing, cough, tightness in
Environmental and emotional
factors
chest
conditions
HASAN SADIKIN GENERAL HOSPITAL