Respiratory System

history taking
DR. AIMAN AL SHAREI
ANATOMY
 Therespiratory system comprises the
upper airway; the nose, mouth,
oropharynx and larynx, and the lower
airway; the trachea and lungs .
 The airways (bronchi) transport air to
the alveoli on inspiration and carry
waste gases, e.g. carbon dioxide,
away on expiration.
History Taking
 A history is the story of the patients illness.

 It is the first step in determining the etiology of a

patient’s problem

 Let the patient describe his or her problem.

 > 80% of diagnosis may be made from history
alone.
 Examination and investigations would either
confirm or disprove the history based diagnosis
The Most Important Symptoms
are:
• Cough.
• Sputum.
• Haemoptysis.
• Dyspnoea (breathlessness)
• Wheeze / Stridor
• Chest pain.
1. Cough
 Cough is a characteristic sound caused by a forced
expulsion against an initially closed glottis.
 Acute cough is one lasting less than 3 weeks;
chronic cough lasts more than 8 weeks.
 The most common cause of acute cough is acute
upper respiratory tract viral infection.
Other causes : Pneumonia , Inhaled foreign body
 Chronic cough causes : Gastro-oesophageal reflux
disease (GERD), Asthma, Rhinitis/sinusitis,
Cigarette smoking (chronic obstructive
pulmonarydisease (COPD)) , Drugs, especially
angiotensin-converting enzyme inhibitors (ACEI),
Lung tumour, Tuberculosis, Interstitial lung disease
.
How To Assess Cough ?

It is important to ask about :

1. Frequency: Intermittent or Persistent
2. Severity : Diurnal variation
3. Character : dry or productive
4. Associated symptoms : e.g chest pain
2. SPUTUM TYPES:
 There are four main types of sputum :

 1) Clear or ‘mucoid’ as in Chronic Bronchitis.

 2) Purulent ( Green or Yellow) as in Pneumonia.
 3) Serous as in Pulmonary oedema
 4) Rusty colour as in Pneumococcal pneumonia

 Foul-tasting or smelling sputum suggests anaerobic

bacterial infection .
How To Assess Sputum ?
It is important to ask about:
• Colour.
• Amount or Volume , fill a teaspoon, tablespoon .
• positional changes.
• Taste or Smell.
• Blood stained.
3. HAEMOPTYSIS CAUSES :
Haemoptysis is coughing up blood from the respiratory
tract and always requires investigation

Common: Other:
 Bronchial Carcinoma.  Mitral stenosis.
 Pulmonary Infarction.  Forign body.
 TB.  Anticoagulation
 Bronchiectasis.  Chest trauma.
How to assess HAEMOPTYSIS?
It Is Important To Ask About:

• Is it frank blood or associated with purulent sputum.

• Is it frank blood or streaks of blood.

• Amount .

• Is it coughed up or vomited.

• Previous respiratory illnesses e.g. Tuberculosis ,

Bronchiectasis.
4. Dyspnoea (Breathlessness)

• Undue ( excessive ) awareness of breathing and is normal

with strenuous physical exercise.
• Patients use terms such as ‘shortness of breath’, ‘difficulty
getting enough air in’ .
 BREATHLESSNESS : modes of onset, duration
and progression
Days- Weeks

 COPD
 Pulmonary fibrosis.
 Pleural effusion
.
 Anemia
Hours

 Pneumonia

 Asthma
 Inhaled foreign body
Minutes

 Pneumothorax.
 Acute pulmonary embolism
 Acute left ventricular failure
How To Assess A Patient With
Breathlessness?
1. Onset & progession:
• Sudden or Gradual over a prolonged period of time.
• Progression : the time period over which
breathlessness developed.
2. Timing / Variability
 when lying flat (orthopnoea) is usually associated with left
ventricular failure
 Breathlessness that wakes the patient from sleep is typical of
asthma and left ventricular failure (paroxysmal nocturnal
dyspnoea).
3.Severity or Grade:

 Grade 1 : Breathless when hurrying on the level or walking up a slight hill

 Grade 2 : Breathlessness when walking with people of own age or on level ground
 Grade 3 : Walks slower than peers, or stops when walking on the flat at own pace
 Grade 4 : Stops after walking 100 metres, or a few minutes, on the level
 Grade 5 : Too breathless to leave the house
 (Grade 5b) : Too breathless to wash or dress

4 . Aggravating & Relieving factors :

• Exercise, cold exposure , Drugs.
5. WHEEZE
 high-pitched whistling sound produced by air passing through
narrowed small airways. It occurs with expiration.

 Wheeze on exercise is common in asthma and COPD. Night

wakening with wheeze suggests asthma or paroxysmal nocturnal
dyspnea , but wheeze after wakening in the morning suggests
COPD.
STRIDOR
 high-pitched, often harsh noise, It occurs most
commonly on inspiration.

 Stridor always needs investigation.

 Common causes include infection/inflammation,

e.g. acute epiglottitis in children and young adults,
and tumours of the trachea and main bronchi or
extrinsic compression .
6. CHEST PAIN :
Causes Of Central Chest Pain
 Tracheal :  Great vessels :

 • Infection  • Aortic dissection

 Cardiac :  Mediastinal :

 • Massive pulmonary  • Lung cancer

thromboembolism  • Thymoma
 • Acute myocardial infarction/  • Lymphadenopathy
 • Metastases
 Oesophageal :  • Mediastinitis
 • Oesophagitis
 • Rupture
Causes Of Non-central Chest
Pain :
 Pleural (sharp, stabbing and intensified by
inspiration or coughing ) :
 • Infection: pneumonia, bronchiectasis,
tuberculosis
 • Malignancy: lung cancer .
 • Pneumothorax
 • Pulmonary infarction
 • Connective tissue disease: rheumatoid arthritis, SLE
How To Assess A Patient With
Chest Pain
 SOCRATES
 Site – where is the pain
 Onset – when did it start ? / sudden vs gradual ?
 Character – sharp / dull ache / burning
 Radiation – does the pain move anywhere else?
 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?
 Severity – on a scale of 0-10, how severe is the pain?