Respiratory Flashcards
(24 cards)
Taking history of presenting complaint
Focus on in why the patient has come to see you
Let them speak, language they can understand, prompt but no leading
6 symptoms of respiratory disease
- Cough
- Sputum production
- Haemoptysis
- Shortness of breath (dyspnoea)
- Unusual breathing (wheeze)
- Chest pain
Describe cough
- Rhinitis, colds
- Patients are consistent in the way they describe coughs
- Persistent or recurrent (disruptive at night, in front of others= distressing)
Common respiratory disorders that present as cough
- Asthma
- Chronic bronchitis
- Bronchial carcinoma
- Bronchiectasis (less common)
- Gaud
- Gastro-oesophageal reflux disease
- Drugs (ACE inhibitors)
- Chronic sinusitis= post nasal drip of secretions that cough up
Features of asthma cough
- Asthma= dry, irritating cough, can be productive of small sputum, at worst in small hours of morning= inadequately controlled- occupational? Environmental?
- Intermittent
Features of chronic bronchitis cough
- Chronic bronchitis (spectrum of COPD)= mucus hypersecretion and inflammation, increased risk of bacterial infection.
- Sputum production most days of the week for 3 consecutive months in 2 successive years
- More persistent than asthma, productive, not disturbed at night
- Do you usually bring up flehm in the winter months?
- Does this go on for a period of several months each year
- Do you have repeated chest infections during the year/ winter?
Features of lung cancer cough
- Difficult to notice as already may have COPD
- Persistent, blood stained if encroaching airway, haemoptysis= slight to significant
- Central tumours in left lung invade left recurrent laryngeal nerve that hooks around the left main bronchus= bovine sounding cough, hoarseness of voice
Describe sputum
- Amount, character, colour, viscosity, smells, taste
- Large amounts= bronchiectasis
What does mucopurulent mean?
Mucus that is infected
Colour of sputum
clear, whitish/grey (smokers), yellow, green (invasion of neutrophils or eosinophils infiltrating airway), red/ brown sputum= pneumococcal pneumonia
Thickness of sputum
watery (acute pulmonary oedema, bronchio-alveolar cell carcinoma= rare), mucoid (chronic bronchitis, chronic asthma), thick
Taste and smell of sputum
-Taste and smell= anaerobic infections of lung
Describe haemoptysis
Coughing up blood
Malignancy- tumour within airways/ chest infection that doesn’t go away
Pulmonary infarction and embolism- tissue destruction, bright red blood initially then darkens, severe pleuritic chest pain, breathlessness and hypoxia
-Infections= cavitation (TB, fungal like aspergillosis, chronic bronchiectasis)
Sudden shortness of breath
Duration- hyper acute to gradual
-Sudden shortness= pneumothorax (puncture in lung surface leading to deflation), pulmonary embolism (pleuritic pain), PND (Paroxysmal nocturnal dyspnoea, acute left ventricular failure), acute myocardial infarction?
Shortness of breath- hours
Pneumonia, acute asthma, acute left ventricular failure, COPD (can be acute deterioration with infection), acute alveolitis environmental exposure
Shortness of breath- days to weeks
Pleural effusion (weeks to occupy hemithorax), carcinoma (collapse of major lobe), sub acute alveolitis, heart failure, congestive cardiac failure, anaemia as gradual onset shortness
Shortness of breath- chronic
COPD, parenchymal lung diseases (fibrotic), congestive heart failure (ankle swelling), anaemia, anxiety and panic attacks
How to talk about breathlessness
MRC dyspnoea scale- Grade 1 (normal) to Grade 5 (breathless on minimal exertion)
Describe chest pain
- Inflamed pleura (pleuritic chest pain)
- Bony structure= crush, fractures, tumour invasion of vertebral bodies, chronic and persistent pain
- Inflammation of the costochondral joints Tietze’s syndrome (benign)
- Neuralgic pain in thorax= intercostal nerve compression by vertebral collapse, herpes zoster
- Oesophagus and heart= chest pain
Describe wheeze
- Musical sound produced by the passage of air through narrowed airways
- Expiration over inspiration
- Pitch reflection of diameter of airway
- Asthma and bronchitis= polyphonic wheeze
- Monophonic wheeze, loud in one area= fixed lesion (tumour/ inhaled foreign body)
What is stridor?
Sound worse on inspiration, caused by partial obstruction of a major airway such as the trachea/ one of two main bronchi
Often tumour, foreign body
Audible over trachea
Other history taking in adults
-Airways disease- *asthma as child/ atopic diseases (eczema, hay fever) = common clinical trajectory to recur in middle age
=Asthma more clinically responsive than COPD
-Chronic bronchiectasis, COPD= childhood infections (pneumonia, measles, TB, whooping cough)
-Pulmonary embolism= extensive foreign travel, surgery
What is involved in a systematic enquiry?
Underlying tumour/ COPD= appetite, weight loss
- Morning headaches= respiratory failure, CO2 retention
- Nasal polyps in asthma
- Post nasal drip in chronic cough
- Ankle swelling- cor pulmonale, right sided failure of chronic lung disease
- Anorexia and weight loss
- Recurrent pneumonia, aspiration of stomach and oesophageal content
Family and social history
- Smoking= person themselves, passive smoking, occupational and environmental exposure
- How old when started smoking
- Still smoking? Given up? When?
- How many cigarettes a day at peak and how long that continued for
- Quantify in pack years, 1 pack year= 20 cigarettes a day for a year
- COPD= 10 pack year smoking history or more (not including passive smoke or occupational exposure)
- Family history of asthma= can happen later on in life
- Pets- dogs and cats
- Hobbies- soldiering and paint
- Pigeon fanciers
- Abroad= TB, legionella (bacterial pneumonia)
- Social circumstances= quality of living, bungalow/ flat, stairs, bathroom same floor as bedroom, living alone, support network, nursing services
