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The Respiratory System History

The Respiratory System History. Dr. J.A. Coetser Department of Internal Medicine CoetserJA@ufs.ac.za. Presenting symptoms. Cough Sputum Haemoptysis Dyspnoea Wheeze Chest pain Fever Hoarseness Night sweats. SOCRATES. S ite O nset C haracter R adiation A lleviating factors

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The Respiratory System History

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  1. The Respiratory System History Dr. J.A. Coetser Department of Internal Medicine CoetserJA@ufs.ac.za

  2. Presenting symptoms • Cough • Sputum • Haemoptysis • Dyspnoea • Wheeze • Chest pain • Fever • Hoarseness • Night sweats

  3. SOCRATES • Site • Onset • Character • Radiation • Alleviating factors • Timing • Exacerbating factors • Severity

  4. Cough • Cough clears airways from secretions or foreign bodies • ONSET • Acute = e.g. bronchitis / pneumonia • Chronic = e.g. asthma • CHARACTER • Sound • Barking = croup • Loud and brassy = compression of trachea • Bovine (hollow) = recurrent laryngeal nerve palsy • Productive of sputum?

  5. Cough • ALLEVIATING FACTORS • Asthma inhaler improves cough in asthma • TIMING • Lying down = GERD or cardiac failure • Coughing at work = occupational irritants • Worse at night = asthma / cardiac failure • Worse in morning = chronic bronchitis • EXACERBATING FACTORS • Eating / drinking = incoordinate swallowing / GERD / tracheo-oesophageal fistula • SEVERITY • How does coughing influence daily functioning / work?

  6. Cough • Associated symptoms with coughing: • Postnasal drip or sinus congestion = upper airway cough syndrome • Irritating dry cough = GERD / ACE-I / interstitial lung disease

  7. Sputum • Ask about type and amount • Purulent (yellow or green) = pneumonia / bronchiectasis • Foul-smelling, dark-coloured = lung abscess • Frothy pink = pulmonary oedema

  8. haemoptysis • Def: Coughing up of blood • Mild <20mL/24h • Massive >250mL/24h • Must distinguish haemoptysis from: • Haematemesis • Nasopharyngeal bleeding • How much blood was produced? • Spotting in sputum / cup / bucket? • Most common causes: • Carcinoma • Tuberculosis • Bronchiectasis

  9. dyspnoea • Def: an awareness of effort required to breathe • ONSET • Worsening slowly over weeks / months or years = interstitial lung disease • Rapid onset = acute infection / pulmonary embolism / pneumothorax • CLASSIFICATION • Class I – disease present but no dyspnoea / dyspnoea only with heavy exertion • Class II – dyspnoea on moderate exertion • Class III – dyspnoea on minimal exertion • Class IV – dyspnoea at rest

  10. Wheeze • Whistling noise coming from chest • Usually maximal during expiration • Causes • Asthma • COPD • Infections e.g. bronchiolitis • Airway obstruction e.g. foreign body / tumor • Differentiate from stridor • Loudest over trachea • Occurs during inspiration

  11. Chest pain • Pleura and airways have abundant pain fibre innervation • Sudden onset of pleuritic pain • Lobar pneumonia • Pulmonary embolism and infarction • Pneumothorax

  12. Other presenting symptoms • Flu-like viral prodome preceding viral pneumonia • Fever at night • TB (also ask about night sweats) • Pneumonia • Lymphoma • Hoarseness (dysphonia) • Laryngitis • Vocal cord tumor • Recurrent laryngeal nerve palsy

  13. Other presenting symptoms • Sleep apnoea • Central = no respiratory effort for at least 10s • Obstructive = respiratory effort present, but airflow stops for at least 10s • Typical presentation • Daytime somnolence • Chronic fatigue • Morning headaches • Personality disturbances • Loud snoring often present • Epworth sleepiness scale to quantify severity • Hyperventilation • Often due to anxiety • Development of alkalosis = parasthesiae, light-headedness, chest pain

  14. treatment • Chronic drugs taken by patient • Steroids (chronic lung disease, e.g. COPD, sarcoidosis) • Inhalers (COPD and asthma) • Pulmonary side-effects of drugs • Oral contraceptives = pulmonary embolism • Cytotoxic agents, e.g. MTX = interstitial lung disease • Beta-blockers = bronchospasm • ACE-inhibitors = chronic dry coughing

  15. Past history • Previous respiratory illness? • Previous respiratory investigations? • Bronchoscopy • Lung biopsy • Spirometry

  16. Occupational history • Very, very important in the respiratory history • Ask about the occupation • What patient does specifically at work • Duration of exposure • Use of protective devices • Have other workers become ill? • Ask about exposure to • Dusts in mines (e.g. asbestos, coal, silica) • Industrial exposures (cotton, beryllium) • Exposure to animals (psittacosis, Q-fever) • Organic dusts, e.g. bird feathers, mould (allergic alveolitis)

  17. Social history • Smoking history • Calculate the number of pack years • How does the condition interfere with work, daily activities and family life? • Alcohol intake • Predisposes to pneumococcal and Klebsiella infections • IV drug users at risk for lung abscess

  18. Family history • Family history of asthma, cystic fibrosis, lung cancer or emphysema • Family members infected by tuberculosis

  19. Thank you!

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