Respiratory history Flashcards
6 main questions?
- cough
- sputum
- haemoptysis
- chest pain
- SOB
- wheeze
(+/-
• fever
• weight loss
• apnoea)
Hx: patient presents with feeble non-explosive “bovine” cough, hoarseness, weight loss?
ΔΔ
• lung CA invading left recurrent laryngeal nerve (vocal cord paralysis)
• NMD
Hx: patient with harsh barking cough, pain upon coughing, and stridor?
ΔΔ
• laryngeal inflammation
• infection (epiglottitis)
• laryngeal tumour
Hx: patient presents with a chronic (>3 month) history of moist “smoker’s cough” first thing in the morning, coughing up sputum?
ΔΔ
• chronic bronchitis
• bronchiectasis
Hx: patient presents with nocturnal cough disrupting sleep?
• asthma
Hx: patient who works in a bakery notices that they have a chronic cough and SOB that lessens during weekends and holidays?
ΔΔ
• occupational asthma
• extrinsic allergic alveolitis
Hx: patient presents with daytime cough?
- GORD
* chronic sinus disease + postnasal drip
Hx: hypertensive patient presents with a dry cough?
• ACEi
Hx: chronic dry cough?
• ILD/PF
Hx: centrally painful cough, dry, non-productive?
- tracheitis
* pneumonia
RED FLAGS to ask with cough?
- heamoptysis
- fever
- weight loss
- chest pain
- SOB
Qs to ask about sputum?
• amount - tsp or teacupful? • colour • taste/smell • solid material (in allergic aspergillosis secretions can accumulate and be coughed up as worm-like structures which are bronchial casts, also solid material in necrotic tumour and inhaled FB)
Hx: patient with wet cough, producing large volumes of purulent green sputum which varies with posture?
bronchiectasis
Hx: sudden production of large amounts of purulent green sputum on a single occasion?
- ruptured lung abscess
* epmyema into bronchial tree
Hx: large volumes of serous, watery sputum with a pink tinge, acutely SOB?
if occurring over weeks (bronchorrhoea)?
- pulmonary oedema
* alveolar cell cancer
Hx: purulent yellow sputum vs green?
- yellow = acute LRTI (neutrophils), or asthma (eosinophils)
* green = longer-standing - dead neutrophils (pneumonia, bronchiectasis, CF, lung abscess, COPD)
Hx: patient coughing up rusty red sputum?
• pneumococcal pneumonia (lysis of rbcs)
Hx: patient coughing up clear/white mucoid sputum, for over 3 months?
- COPD (can be green in the morning)
* chronic bronchitis
Hx: patient presents with vile-tasting , smelly sputum?
anaerobic bacterial infection:
• bronchiectasis
• lung abscess
• empyema
Qs to ask about haemoptysis?
- coughed up or V?
- suddenly appeared in the mouth? (nasopharyngeal)
- amount
- appearance
Hx: patient presents with daily coughing up of blood-streaked CLEAR sputum/blood clots in sputum, for >1 week?
• lung CA
also consider TB, and lung abscess
Hx: patient presents with blood in purulent sputum?
infective cause
Hx: patient presents with coughing up large volumes of pure blood?
- lung CA
- bronchiectasis
- TB
rarely: • lung abscess • mycetoma • CF • aorto-bronchial fistula • Wegener's granulomatosis
Hx: patient has intermittent haemoptysis with respiratory tract infections over years?
bronchiectasis
Hx: patient presents with a single episode of coughing up blood, with pleuritic chest pain and breathlessness?
PE and infarction
Ix!!!
Hx: pt presents with sharp, stabbing chest pain, intensified by coughing or breathing in?
ΔΔ • PE • pneumonia • pneumothorax • #ribs
rarely:
• infection - bronchiectasis, TB
• CA - mesothelioma, mets
• connective tissue disease (RA, SLE)
where does pain refer to from the pleura overlying the central diaphragm?
- innervated by the phrenic nerve
* referred to neck or shoulder tip
Hx: pt presents with chest wall pain in a dermatomal distribution?
- prevesicular herpes zoster
* intercostal nerve root compression
Hx: pt describes dull, aching/gnawing pain in the chest wall, unrelated to respiration, progressively worsening and disrupting sleep?
• CA invading the chest wall
- lung CA
- mesothelioma
- rib mets
Hx: patient presents with weight loss, new cough, and pain spreading down the medial side of the arm?
Pancoast tumour of the lung apex
erodes the first rib and brachial plexus, causing referred pain
Hx: patient presents with central, retrosternal pain?
ΔΔ mediastinal pain:
• irritants/dust/infection of tracheobronchial tree (raw, burning retrosternal pain worse on coughing)
• CA invading mediastinal lymph nodes (dull, aching retrosternal pain that is disturbing sleep and unrelated to cough)
• massive PE
• MI
Qs to ask about SOB?
• onset
- mins? = PE, asthma, pneumothorax, inhaled FB, LVF
- hours/days? = pneumonia, COPD exac
- weeks? = anaemia, pleural effusion, NMD
- months? = COPD, PF, TB
• aggravating/relieving factors
- lying flat (orthopnoea) = LVF/resp muscle weakness
- wakes from sleep (paroxysmal ND) = LVF
- wakes 3-5am with wheeze = asthma
- worst in morning = COPD
• severity
- MRC classification; how far can they walk?
• associated Sx
Hx: patient complains of SOB that occurs suddenly whilst at rest or whilst talking, feeling of light-headedness, dizziness, tingling in fingers and around mouth, with a tight chest?
• psychogenic SOB (anxiety, etc)
MRC classification of SOB? (1-3)
1) hurrying on level ground
2) when walking with people own age on level
3) has to stop whilst walking alone on level ground
Qs to ask if suspect asthma?
- exercise induced? worsens 5-10 mins after stopping
- occupational?
- allergens
- cold
- perfumes
- fumes
- drugs
- NSAIDS
Hx: acute SOB + NO pain?
- PE
- pneumothorax
- metabolic acidosis
- hypovolaeamic shock
- acute LVF
Hx: acute SOB + pleuritic chest pain?
- PE
- pneumonia
- pneumothorax
- rib fracture
Hx: acute SOB + central chest pain?
- MI with LVF
* massive PE
Hx: acute SOB + cough + wheeze?
- asthma
* COPD
what other than the PC to ask about in a resp Hx?
• PMHX - atopy (asthma) - whooping cough, measles, CAP (bronchiectasis) - previous TB, RA, CA, surgery, NMD • DHx - chemo (PF) • FHx - atopy, CF • SHx - travel (PE) - smoking - asbestos etc - pets (birds - alveolitis) (parrots/parakeets - psittacosis pneumonia)
