Respiratory history

Question 1

6 main questions?

Answer 1

• cough
• sputum
• haemoptysis
• chest pain
• SOB
• wheeze

(+/-
• fever
• weight loss
• apnoea)

Question 2

Hx: patient presents with feeble non-explosive “bovine” cough, hoarseness, weight loss?

Answer 2

ΔΔ
• lung CA invading left recurrent laryngeal nerve (vocal cord paralysis)
• NMD

Question 3

Hx: patient with harsh barking cough, pain upon coughing, and stridor?

Answer 3

ΔΔ
• laryngeal inflammation
• infection (epiglottitis)
• laryngeal tumour

Question 4

Hx: patient presents with a chronic (>3 month) history of moist “smoker’s cough” first thing in the morning, coughing up sputum?

Answer 4

ΔΔ
• chronic bronchitis
• bronchiectasis

Question 5

Hx: patient presents with nocturnal cough disrupting sleep?

Answer 5

• asthma

Question 6

Hx: patient who works in a bakery notices that they have a chronic cough and SOB that lessens during weekends and holidays?

Answer 6

ΔΔ
• occupational asthma
• extrinsic allergic alveolitis

Question 7

Hx: patient presents with daytime cough?

Answer 7

• GORD

* chronic sinus disease + postnasal drip

Question 8

Hx: hypertensive patient presents with a dry cough?

Answer 8

• ACEi

Question 9

Hx: chronic dry cough?

Answer 9

• ILD/PF

Question 10

Hx: centrally painful cough, dry, non-productive?

Answer 10

• tracheitis

* pneumonia

Question 11

RED FLAGS to ask with cough?

Answer 11

• heamoptysis
• fever
• weight loss
• chest pain
• SOB

Question 12

Qs to ask about sputum?

Answer 12

• 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)

Question 13

Hx: patient with wet cough, producing large volumes of purulent green sputum which varies with posture?

Answer 13

bronchiectasis

Question 14

Hx: sudden production of large amounts of purulent green sputum on a single occasion?

Answer 14

• ruptured lung abscess

* epmyema into bronchial tree

Question 15

Hx: large volumes of serous, watery sputum with a pink tinge, acutely SOB?

if occurring over weeks (bronchorrhoea)?

Answer 15

• pulmonary oedema

* alveolar cell cancer

Question 16

Hx: purulent yellow sputum vs green?

Answer 16

• yellow = acute LRTI (neutrophils), or asthma (eosinophils)

* green = longer-standing - dead neutrophils (pneumonia, bronchiectasis, CF, lung abscess, COPD)

Question 17

Hx: patient coughing up rusty red sputum?

Answer 17

• pneumococcal pneumonia (lysis of rbcs)

Question 18

Hx: patient coughing up clear/white mucoid sputum, for over 3 months?

Answer 18

• COPD (can be green in the morning)

* chronic bronchitis

Question 19

Hx: patient presents with vile-tasting , smelly sputum?

Answer 19

anaerobic bacterial infection:
• bronchiectasis
• lung abscess
• empyema

Question 20

Qs to ask about haemoptysis?

Answer 20

• coughed up or V?
• suddenly appeared in the mouth? (nasopharyngeal)
• amount
• appearance

Question 21

Hx: patient presents with daily coughing up of blood-streaked CLEAR sputum/blood clots in sputum, for >1 week?

Answer 21

• lung CA

also consider TB, and lung abscess

Question 22

Hx: patient presents with blood in purulent sputum?

Answer 22

infective cause

Question 23

Hx: patient presents with coughing up large volumes of pure blood?

Answer 23

• lung CA
• bronchiectasis
• TB

rarely:
• lung abscess
• mycetoma
• CF
• aorto-bronchial fistula
• Wegener's granulomatosis

Question 24

Hx: patient has intermittent haemoptysis with respiratory tract infections over years?

Answer 24

bronchiectasis

Question 25

Hx: patient presents with a single episode of coughing up blood, with pleuritic chest pain and breathlessness?

Answer 25

PE and infarction | Ix!!!

Question 26

Hx: pt presents with sharp, stabbing chest pain, intensified by coughing or breathing in?

Answer 26

``` ΔΔ • PE • pneumonia • pneumothorax • #ribs ``` rarely: • infection - bronchiectasis, TB • CA - mesothelioma, mets • connective tissue disease (RA, SLE)

Question 27

where does pain refer to from the pleura overlying the central diaphragm?

Answer 27

* innervated by the phrenic nerve | * referred to neck or shoulder tip

Question 28

Hx: pt presents with chest wall pain in a dermatomal distribution?

Answer 28

* prevesicular herpes zoster | * intercostal nerve root compression

Question 29

Hx: pt describes dull, aching/gnawing pain in the chest wall, unrelated to respiration, progressively worsening and disrupting sleep?

Answer 29

• CA invading the chest wall - lung CA - mesothelioma - rib mets

Question 30

Hx: patient presents with weight loss, new cough, and pain spreading down the medial side of the arm?

Answer 30

Pancoast tumour of the lung apex | erodes the first rib and brachial plexus, causing referred pain

Question 31

Hx: patient presents with central, retrosternal pain?

Answer 31

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

Question 32

Qs to ask about SOB?

Answer 32

• 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

Question 33

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?

Answer 33

• psychogenic SOB (anxiety, etc)

Question 34

MRC classification of SOB? (1-3)

Answer 34

1) hurrying on level ground 2) when walking with people own age on level 3) has to stop whilst walking alone on level ground

Question 35

Qs to ask if suspect asthma?

Answer 35

* exercise induced? worsens 5-10 mins after stopping * occupational? * allergens * cold * perfumes * fumes * drugs * NSAIDS

Question 36

Hx: acute SOB + NO pain?

Answer 36

* PE * pneumothorax * metabolic acidosis * hypovolaeamic shock * acute LVF

Question 37

Hx: acute SOB + pleuritic chest pain?

Answer 37

* PE * pneumonia * pneumothorax * rib fracture

Question 38

Hx: acute SOB + central chest pain?

Answer 38

* MI with LVF | * massive PE

Question 39

Hx: acute SOB + cough + wheeze?

Answer 39

* asthma | * COPD

Question 40

what other than the PC to ask about in a resp Hx?

Answer 40

``` • 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) ```