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MD3001 > History Taking: The Respiratory System > Flashcards

History Taking: The Respiratory System Flashcards

1
Q

What is the history taking structure?

A 
Presenting complaint (PC)
History of presenting complaint (HPC)
Past medical history (PMH)
Medication/allergies (DH)
Family history (FH)
Social history (SH)
Systems enquiry/review (SE)
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2
Q

What symptoms should you ask the patient about/ whether they have had any of the said symptoms?

A
  • Chest pain - Dyspnoea - Cough
  • Sputum
  • Haemoptysis
  • Wheeze
  • Systemic upset
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3
Q

If yes to chest pain, what ‘clarifying’ questions need to be asked?

A 
SOCRATES
Site
Onset
Character
Radiation
Associated symptoms 
Timing
Exacerbators / relievers 
Severity (1-10 rating scale)
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4
Q

If central chest pain, what can be potential causes?

A 
Tracheitis
Angina/ MI
Aortic dissection
Massive PE
Oesophagitis
Lung tumour / metastases 
Mediastinal tumour/ mediastinitis
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5
Q

If pleural chest pain, what can be potential causes?

A

Pneumonia / Bronchiectasis / TB
Lung tumour/ metastases/ mesothelioma
PE
Pneumothorax

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6
Q

If chest wall chest pain, what can be potential causes?

A

Muscular / rib injury
Costochondritis
Lung tumour / bony metastases/ mesothelioma
Shingles (herpes zoster)

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7
Q

What questions should be asked if patient is experiencing dyspnoea?

A

 Is there anything that brings it on?
 Does anything make it better or worse?
 Are you always breathless? Is it when you walk/ exercise?
 Do you get breathless lying down?
– Orthopnoea/ PND (cardiac causes)
 How far can you walk normally? How far can you walk now? i.e. exercise tolerance
 How do you manage walking uphill / up stairs?
 Is there anything it stops you from doing?
 Have you noticed any other symptoms?
– Consider – cough, sputum, chest pain, palpitations, wheeze, stridor

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8
Q

If dyspnoea onset is in minutes, what could be potential diagnoses?

A 
PE
Pneumothorax 
Acute LVF
Acute asthma 
Inhaled foreign body
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9
Q

If dyspnoea onset is in hours to days, what could be potential diagnoses?

A

Pneumonia
Asthma
Exacerbation of COPD

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10
Q

If dyspnoea onset is in weeks to months, what could be potential diagnoses?

A

Anaemia
Pleural effusion
Respiratory neuromuscular disorders

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11
Q

If dyspnoea onset is in months to years, what could be potential diagnoses?

A

COPD
Pulmonary fibrosis
Pulmonary TB

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12
Q

What questions should be asked of a patient suffering with a cough?

A

 How long have you had it?
 Is it a new problem?
 When does it occur?
 Is there anything that makes it better or worse?
 Is it a dry cough? Do you cough anything up?
 Do you smoke?
 Has your medication changed recently?
 Do you experience any other symptoms?
– Consider - dyspnoea, weight loss, stridor, pain, syncope, vomiting

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13
Q

If the cough is productive, what could be potential diagnoses?

A

Infection

Bronchiectasis

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14
Q

If the patient is presented with a persistent ‘moist’ cough worst in morning, what could be potential diagnoses?

A

COPD

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15
Q

If the cough is associated with wheeze, what could be potential diagnoses?

A

Asthma / COPD

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16
Q

If the cough is painful, what could be potential diagnoses?

A

Tracheitis

17
Q

If the cough is harsh or barking, what could be potential diagnoses?

A

Laryngitis/ laryngeal tumour

18
Q

If the cough is chronic and dry, what could be potential diagnoses?

A

Interstitial lung disease

19
Q

If the cough is Bovine (non-explosive), what could be potential diagnoses?

A

Left recurrent laryngeal nerve invasion (secondary to malignancy) Neuromuscular disorders

20
Q

If the cough is persistent with haemoptysis, what could be potential diagnoses?

A

Bronchial carcinoma

21
Q

If the patient has been producing sputum, what questions do you need to ask?

A

 How often do you produce sputum when you cough?
 How much sputum do you cough up? Has this changed?
 What colour is it? Has the colour changed?
 Is there any blood?
 Is it frothy or thick?
Is there any abnormal smell or taste?
Have you been experiencing any other symptoms?
E.g. fever, dyspnoea, pain

22
Q

If serous sputum is produced, what could be some potential diagnoses?

A

Acute pulmonary oedema

23
Q

If mucoid sputum is produced, what could be some potential diagnoses?

A

COPD/ asthma

24
Q

If purulent sputum is produced, what could be some potential diagnoses?

A

Infection

25
Q

If rusty sputum is produced, what could be some potential diagnoses?

A

Pneumococcal pneumonia

26
Q

If the patient is presented with haemoptysis (coughing up blood), what questions do you need to ask?

A

 When did you first notice blood in your sputum?
 How many times has it happened?
 How much blood is there?
 Are there any other colours in the sputum apart from the blood?
 Have you noticed bleeding or bruising anywhere else?
 Are you taking any medication to thin the blood?
 Have you noticed any other symptoms?
– E.g. breathlessness / chest pain / cough / weight loss (pleuritic chest pain and hemoptysis is a red flag)

27
Q

If the cause of haemoptysis is malignant, what potential diagnosises can be reached?

A

Bronchial carcinoma Metastatic lung disease

28
Q

If the cause of haemoptysis is infective, what potential diagnosises can be reached?

A

Acute infection
Bronchiectasis
TB

29
Q

If the cause of haemoptysis is vascular, what potential diagnosises can be reached?

A

Pulmonary infarction or pulmonary embolus

30
Q

If the cause of haemoptysis is cardiac, what potential diagnosises can be reached?

A

Mitral valve disease

Acute LVF

31
Q

If the cause of haemoptysis is vasculitis, what potential diagnosises can be reached?

A

Wegener’s granulomatosis

Good pasture’s syndrome

32
Q

If the cause of haemoptysis is of other origin, what potential diagnosises can be reached?

A

Trauma
Anticoagulation (consider warfarin)
Clotting disorder

33
Q

What are some other question that should be asked in a taking a pulmonary system history?

A

Change in appetite
Weight loss
Fever
Tiredness / lethargy

MD3001 (63 decks)

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