Subject: Physical Diagnosis Topic: Hx Taking: patients with pulmonary disease Lecturer: Dr. Gary N.

Carlos Date of Lecture: ----Transcriptionist: elkie Editor: ----Pages: 4

Objectives ` To discuss the basic elements needed in the history taking of a patient with pulmonary disease ` To enumerate the common symptoms presented by patients with pulmonary disease ` To go thru the process of how to dissect attributes of a symptom in a patient with pulmonary disease History taking in patients with pulmonary disease ` Basic Same as general principles in history taking x Make patient comfortable x Concern for privacy make patient feel respected and at ease able to extract information x Subjective Listen well. x Make patient feel that the interviewer is truly interested in his or her problem. x Showing that the patient is important to the physician x Must lead or guide the patient thru the discussion x Avoid lengthy digressions x Start with broad question going for localization x Avoid leading questions, questions answerable by yes or no Not too restrictive. x Patient also has the freedom to mention important items Avoid using medical terms ` Basic Objective Should lead to a list of reasonable list of differential diagnosis x Age / Sex x Risk Factors x Clinical considerations x History

Physical examination Primary impression Forms the basis of a diagnostic and therapeutic plan MEDICAL HISTORY I.General Data II.Chief Complaint (CC) ` Common problems why patients consults a pulmonary clinic Upper respiratory tract symptoms x Nasal congestion / catarrh x Cough x
Some Causes and Characteristics of Cough Cause Characteristics Sinusitis or Cough following an upper respiratory nasopharygnitis syndrome or sinus symptoms; sensation of a need to clear the throat; postnasal drip Acute infections of lungs Tracheobronchitis Cough associated with sore throat, running nose and eyes Lobar pneumonia Dough often preceded by symptoms of upper respiratory infections; cough dry, painful at first; later becomes productive Bronchopneumonia Cough dry or productive , usually begins as acute bronchitis Myoplasma and viral Paroxysmal cough, productive of mucoid or pneumonia blood-stained sputum associated with flulike syndrome Exacerbation of Cough productive of mucoid sputum becomes chronic bronchitis purulent Chronic infections of lungs Bronchitis Cough productive of sputum on most days for more than 3 consecutive months and for more than 2 years Sputum mucoid until acute exacerbation, when it becomes mucopurulent Bronchiectasis Cough copious, foul, purulent, often since childhood ; forms layers upon standing Tuberculosis or fungus Persistent cough for weeks to months, often with blood-tinged sputum Parenchymal inflammatory processes Interstitial fibrosis and Cough nonproductive, persistent, depends on infiltrations origin Smoking Cough usually associated with injected pharynx; persistent, most marked in morning, usually only slightly productive unless succeeded by chronic bronchitis Tumors Bronchogenic Cough nonproductive to productive for weeks carcinoma to months; recurrent small hemoptysis common Alveolar cell carcinoma Cough similar to that with bronchogenic carcinoma except in occasional instances, when large quantities of watery, mucoid sputum are produced Benign tumors in Cough nonproductive; occasionally airways hemoptysis Mediastinal tumors Cough, often with breathlessness, caused by

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Aortic aneurysm Gastrointestinal Gastrioesophageal reflux (GERD)

compression of trachea and bronchi Brassy cough Nonproductive cough often following meals or with recumbancy; may (or may not) be accompanied by other symptoms of GERD (e.g., heartburn, a bitter oral taste , belching) Cough associated with progressive evidence of asphyxiation Nonproductive cough, persistent, associated with localizing wheeze Cough intensifies while supine, along with aggravation of dyspnea Cough associated with hemoptysis, usually with pleural effusion Nonproductive cough, more common in women, may occur at any time (following soon after drug initiation or with years of use)

(Infectious or inflammatory) Difficulty in breathing or breathlessness -Sensation of difficulty of breathing -Subjective -Difficult to quantitate -Usually caused by:  Increased awareness in normal breathing (anxiety)  Increased in work of breathing (Restrictive and obstructive lung diseases)  Abnormality of the ventilatory system (Dysfunction of the nerves, respiratory muscles or thoracic cage) - Causes of Dyspnea  Pulmonary edema  Asthma  Injury to chest wall and intrathoracic structures  Spontaneous pneumothorax  Pulmonary embolism  Pneumonia  Adult respiratory distress syndrome  Pleural effusion  Pulmonary hemorrhage  Left ventricular failure x x Hemoptysis -Coughing out of fresh blood -Can come from any part of the upper respiratory or lower respiratory tract -Should be differentiated from hematemesis -Some Common Causes of Hemoptysis:  Infectious o Bronchitis o Tuberculosis o Fungal infections o Pneumonia o Lung abscess o Bronchiectasis  Neoplasms o Bronchogenic carcinoma o Bronchial adenoma  Cardiovascular disorders

Foreign body Immediate, while still in upper airway Later, when lodged in lower airway Cardiovascular Left ventricular failure Pulmonary infarction Medication-induced Angiotensinconverting enzyme (ACE) inhibitors

Lower respiratory tract symptoms x Cough -Generally caused by irritation of the cough receptors -Change in character and frequency of cough -May be acute and self limiting but may be progressive and problematic x Sputum production -Can be caused by a variety of conditions:  Chronic stimulation and hypertrophy of the bronchial glands as a defense mechanism -Should inquire about  Duration  Character  Volume  Associated hemoptysis x Chest pain -Visceral chest pain  Not well localized  May be related to a variety of organs related to the chest wall (Cardiac, esophageal, great vessels) -Chest wall pain  Sharp, well localized (pleuritic)  Associated with inflammation of the parietal pleura

o  Trauma o Foreign body  Hematologic/ immunologic o Blood dyscrasia o Goodpasteure s syndrome Abnormal laboratory findings III. History of Present Illness (HPI) ` 7 Attributes 1. Location 2. Quality 3. Quantity or Severity 4. Timing onset, duration, frequency 5. Setting 6. Factors that aggravate or relieve 7. Associated manifestations

Pulmonary infarction from thromboembolism Mitral stenosis

` Symptom analysis / Attributes (OPQRSTU) 1. Onset Acute x Causes of Acute Dyspnea:  Acute  Pulmonary edema  *Asthma  Injury to chest wall and intrathoracic structures  Spontaneous pneumothorax  Pulmonary embolism  Pneumonia  Adult respiratory distress syndrome  Pleural effusion  Pulmonary hemorrhage  *Left Ventricular failure Chronic x Causes of Chronic Dyspnea:  Chronic progressive  Chronic obstructive pulmonary disease  *Left Ventricular failure  Diffuse interstitial fibrosis  *Asthma  Pleural effusions  Pulmonary thromboembolic disease  Pulmonary vascular disease  Psychogenic dyspnea  Anemia, severe  Postintubation tracheal stenosis  Hypersensitivity disorders Acute on top of chronic

Overlaps Sequence of events -Which came first -Temporal relationship -complications 2. Palliative/Precipitating 3. Quality/Quantity MMRC Dyspnea Scale: Grade Description of Breathlessness  0 I only get breathless with strenuous exercise.  1 I get short of breath when hurrying on level ground or walking up a slight hill.  2 On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace.  3 I stop for breath after walking about 100 yards or after a few minutes on level ground.  4 I am too breathless to leave the house or I am breathless when dressing. 4. Region/Radiation 5. Severity / Setting Severity -Effects on daily activities -Rating scale Setting -Environmental factors -Personal activities -Emotional reactions -Circumstances that may have triggered the symptoms 6. Time 7. Usual associated sign/symptoms Other Upper respiratory tract symptoms: x Rhinorrhea, conjunctivitis, sneezing x Allergic rhinitis, asthma x Postnasal drips x Common cause of chronic cough x Nosebleeds/epistaxis x Tumors, FB, hematologic problems, hypertension x Upper respiratory tract abnormalities x Infections of the lungs and pleura IV. Past Medical History ` Allergies to food and drugs? ` Previous hospitalization / Surgery ` Immunizations ` Asthma ` Pulmonary tuberculosis

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Childhood illness pneumonia, TB Any drugs taken? Present / Past Dose,frequency,duration

V. Family History ` Hereditary familial disease  Asthma  Allergies  Cancer  Chronic Obstructive Pulmonary Disease VI. Personal/ Social History ` Occupation  What?  Any irritating odors?  Upper respiratory symptoms upon exposure  How long?  Any protective gears?  Similar problems in the work place?  Job history in chronologic order  Hobbies / daily routine `       ` `      Smoking When started ? How much? How long? Current? If stopped, why? Passive? Risk factor Alcohol/drinking Quantity? Frequency? Sexual history Not always? Active?

VII. Review of Systems VIII. Physical Examination ` Common associated symptoms of pulmonary diseases  Fever  Hoarseness of voice  Weight loss  Edema  Snoring  Cyanosis

 Clubbing x Clinical disorders commonly associated with clubbing of digits o Pulmonary and thoracic x Primary lung cancer x Metastatic lung cancer x Bronchiectasis x Cystic fibrosis x Lung abscess x Pulmonary fibrosis x Pulmonary arteriovenous malformations x Empyema x Mesothelioma x Neurogenic diaphragmatic tumors o Cardiac x Congenital x Subacute bacterial endocarditis o Gastrointestinal and hepatic x Hepatic cirrhosis x Chronic ulcerative colitis x Regional enteritis (Crohn s disease) o Miscellaneous x Hemiplegia _____________end of transcription_____________ According to one of our lectures in PD, we should familiarize ourselves with the proper format of history taking. So instead of copying the exact order of the powerpoint, I arranged it according to the format of history taking.