Respiratory History Taking Objectives

Goal: After reading the prescribed information and listening to the appropriate lecture(s) the student should be able to take a complete and and appropriate history from a patient for a complete physical examination or with a respiratory complaint.

Objectives

1.         List and define the main symptoms of pulmonary disease (as described on page 320 of Swartz.)

Vince B Swartz pg 320

            Cough- coordinated, forced expiration, interrupted by repeated closure of the glottis.

            Sputum production- substance expelled by cough. may contain cellular debris, mucus, blood, pus, organisms.

            Hemoptysis- coughing up of blood.

            Dyspnea- shortness of breath

            Wheezing- abnormally high-pitched noise resulting from partially obstructed airway.

            Cyanosis-

            Chest pain- involvement of chest wall or parietal pleura.  Described as sharp, stabbing pain, felt usually on inspiration.

            Sleep apnea- excessive daytime fatigue or sleepiness, disruptive snoring, episodes of airway obstruction during sleep by repeated callapse of pharynx.

Paul, Schwartz pg 320 Cough :  normal defense mechanism that protects lungs from foreign bodies and excessive secretions.  Coordinated, forced expiration, interrupted by repeated closure of the glottis.  May be productive (mucus or other materials expelled) or non-productive (dry and does not produce secretions).

Sputum production Paul, Schwartz pg 321: substance expelled by coughing.  Should be described according to color, consistency, quantity, number of times it is brought up during the day and night, and the presence or absence of blood.  

Hemoptysis (coughing up blood) Paul, Schwartz pg 321-322:  careful description is crucial, because it can include clots of blood as well as blood-tinged sputum.

Dyspnea Paul, Schwartz pg 323):  shortness of breath

Wheezing Paul, Schwartz pg 324:  abnormally high pitched noise resulting from a partially obstructed airway.

Cyanosis Paul, Schwartz pg 324:  bluish discoloration of the skin

Chest pain Paul, Schwartz pg 325:  related to pulmonary disease generally results from involvement of the chest wall or parietal pleura.

Sleep apnea Paul, Schwartz pg 325:  potentially disabling condition characterized by excessive daytime fatigue or sleepiness, disruptive snoring, episodes of upper airway obstruction during sleep, and nocturnal hypoxemia.

2.         Describe "stridor" and relate the usual site of the lesion causing it.

Vince B Swartz pg 326

            Stridor- harsh type of noisy breathing with obstruction of major bronchus that occurs with inspiration.

Paul, Schwartz pg 326

Stridor is a harsh type of noisy breathing and is generally associated with obstruction of a major bronchus that occurs with aspiration.

3.         Define dyspnea and describe several conditions associated with it. (Check Swartz page 359  too!)

Anonymous

Dyspnea is the subjective sensation of uncomfortable breathing, the feeling of being unable to get enough air.  It is often described as breathlessness, air hunger, shortness of breath, labored breathing, and preoccupation with breathing.  Dyspnea is a very common symptom of respiratory disease.  Pathophysiology, p. 1158

Anonymous

Air hunger resulting in labored or difficult breathing, sometimes

accompanied by pain.  It is normal when due to vigorous work or exercise.  (Taber's

Cyclopedic Medical Dictionary vo.19 pg. 653).  "An uncomfortable abonormal awareness of

Breathing,  most frequently described as shortness of breath (SOB), inability to take a deep breath, or

Chest tightness" Physician Assistant--Ballweg book pg. 176

Anonymous

Dyspnea is “an uncomfortable abnormal awareness of breathing.  . . .most commonly described as shortness of breath (SOB), inability to take a deep breath, or tightness.”

Anonymous

Shortness of breath.  A non-painful but uncomfortable awareness of breathing that is inappropriate to the situation.

Vince B Swartz pg. 358

            Dyspnea- shortness of breath.  Commonly related to cardiac or pulmonary conditions.  PND- occurs at night- position increases the intrathoracic blood volume, and a weakened heart may be unable to handle this increased lead; CHF may result.  Pt awakened about 2 hours after sleep.  Orthopnea- the need or using more pillows to sleep.  DOE- usually due to chronic congestive heart failure or severe pulmonary disease.  Trepopnea- rare form of positional dyspnea in which dyspneic patients have less dyspnea while lying on left or right side.

Paul, Schwartz pg 323-324, 359

Dyspnea is a subjective sensation of shortness of breath.  It is important to differentiate dyspnea from the objective finding of tachypnea.  Never assume that a patient with a rapid respiratory rate is dyspneic.

Paroxysmal nocturnal dyspnea:  sudden onset of shortness of breath occurring at night during sleep.  Dyspnea improves in upright position.

Orthopnea:  difficuly breathing while laying flat.  Patients require 2 or more pillows to breathe comfortably.  Possible causes:

•        Congestive heart failure

•        Mitral valvular disease

•        Severe asthma (rarely)

•        Emphysema (rarely)

•        Chronic bronchitis (rarely)

•        Neurologic disease (rarely)

Platypnea:  rare symptom of difficulty breathing while sitting up and is relieved by a recumbent position.  Possible causes:

•        Status post-pneumonectomy

•        Neurologic disease

•        Cirrhosis (intrapulmonary shunts)

•        Hypovolemia

Trepopnea:  condition in which patients are more comfortable breathing while lying on one side.  Possible cause:

•        Congestive heart failure

Organ system or condition                                cause

Cardiac                                                            left ventricular failure

                                                                        Mitral stenosis

Pulmonary                                                        obstructive lung disease

                                                                        Asthma

                                                                        Restrictive lung disease

                                                                        Pulmonary embolism

                                                                        Pulmonary hypertension

Emotional                                                         anxiety

High-altitude exposure                          decreased oxygen pressure

Anemia                                                 decreased oxygen-carrying capacity

4.         Identify dyspnea on exertion as the classic form of dyspnea associated with lung disease and describe how this symptom should be quantified through questioning of the patient.

Anonymous

Dyspnea on exertion (DOE) is classically seen in lung diseases.  The exertion should be quantified.  Typical measures are (1) number of blocks the patient can walk before onset of DOE; (2) number of flights of stairs the patient can climb before DOE, etc.  Keep in mind that this aspect of the history is

subtle, because patients may consciously slow down.  

Anonymous

The exertion should be qualified. Typically measures are:

1. Number of blocks the patient can walk before onset of DOE.

2. Number of flights of stairs the patient can climb before DOE.

3. Relation of DOE to typical household tasks or self-care activities – dusting versus mopping the floor, shaving, taking a bath, or getting dressed.

Anonymous

 (See #2 for description of various lung dz assoc. w/ dyspnea)

Questions:

• When do the symptoms occur? At rest or with exercise? And how much effort produces it?

• How steps or flights of stairs can be climbed before pausing for breath?

• Have symptoms altered pt’s daily activities? How?

• Determine timing and setting of dyspnea

• Determine assoc. symptoms, and factors that aggravate or relieve it

Vince B.  Swartz pg 358

            DOE- usually due to chronic congestive heart failure or severe pulmonary disease.  Quantify by asking how many level blocks a pt can walk.  How many they could walk six months ago.

Paul, Schwartz pg 324 & 359

Dyspnea on exertion (DOE) is usually due to chronic congestive heart failure or severe pulmonary disease.  It is essential to quantify the severity of the dyspnea by asking, “How many level blocks can you walk?” provides a framework for exercise tolerance.  “How many level blocks could you walk 6 months ago?”  The interviewer can thus make a rough assessment of the progression of the disease or the efficacy of therapy.  The examiner can now attempt to quantify the dyspnea:  “The patient has had 1-block DOE for the past 6 months.  Before 6 months ago, the patient was able to walk 4 blocks without becoming short of breath.  In addition, during the last 3 months the patient has noted 4-pillow orthopnea.”

5.         List important associated symptoms which should be asked of any patient with dyspnea.

Anonymous

When did the patient first notice the SOB? (onset: sudden vs. gradual)  How long has the patient had SOB, is it continuous or intermittent? (helps make differential diagnosis) What are you doing when you become SOB? (Can show if the pt. has some type of chronic lung disease going on.)  Does anything make the SOB better? (Can help provider tx pt.)  Does anything make the SOB worse? (Shows relationship to season and environment, respiratory infections, drugs, exercise, etc.)  

Ask all other respiratory ROS eg. sputum, cough, smoking, and occupational hx.  Ask if the patient has ever smoked, how long, how much, and also about second had smoke (eg. spouse may have smoked for 40 years, but not the pt.)  Ask if there has been a fever (Associated with acute and chronic respiratory infections, also some cancers.)  Ask if they have noticed swelling.  Ask if the pt. has noticed a weight change (could indicate CHF).  And ask if they have had any wheezing, or h/o allergies could point to asthma.

Anonymous

Dyspnea is “an uncomfortable abnormal awareness of breathing.  . . .most commonly described as shortness of breath (SOB), inability to take a deep breath, or tightness.” Taking a history of dyspnea involves obtaining the same sort of data required for any HPI.

a.       Onset: Sudden onset suggests an acute process, such as pulmonary embolism, acute pneumonia, pulmonary edema, spontaneous pneumothorax, asthma, anxiety, or hyperventilation.

Gradual onset suggests chronic process, COPD, or

CHF.

b.      Duration:

c.       Description:

d.      Aggravating:

e.       Relieving:   etc. . . .

Anonymous

• If it occurs while lying down? ORTHOPNEA

• If it wakes them at night? PND

• Do they have a cough? Cough up blood?

• Edema?

• Wheezing?

Vince B Swartz 323.

            Length of SOB

            sudden/gradual onset?

            Occur with exertion/ rest/ lying flat/sittig up?

            what makes it better/worse?

            # ob blocks able to walk now/ six months ago?

            Wheezing/ fever/ cough/ CP/ palpitations/ hoarseness?

            Smoking history

            Exposure to asbestos/ sandblasting/ pigeon breeding/ TB?

            residing in San Joaquin Valley/ midwest or southeastern US?

Paul, Schwartz pg 323 – 324

“Is the shortness of breath accompanied by wheezing? Fever? Cough? Coughing up blood? Chest pain? Palpitations? Hoarseness?”

Careful questioning regarding industrial exposure is paramount in any patient with unexplained dyspnea:

•        “have you had any exposure to asbestos? Sandblasting? Pigeon breeding?

•        “have you had any exposure to individuals with tuberculosis?”

•        “Have you ever lived near the San Joaquin Valley? Midwestern or southeastern United States?”

6.         Define wheezing and relate it to its anatomical cause (i.e., narrowing or obstruction of airways).

Anonymous

Wheezing is a abnormal high pitched sound made when breathing, which is caused by narrowing or obstruction of an airway.  

Anonymous

Wheezing is defined as a “ high-pitched abnormal sound made in breathing,” which is caused by narrowing or obstruction of an airway

Anonymous

     Wheezing – a whistling or sighing sound resulting from narrowing of the lumen of a respiratory passageway. Occurs in Asthma, croup, hayfever, mitral stenosis and pleural effusion. May result from presence of tumors, foreign body obstructions, bronchial spasm, T.B., obstructive emphysema or congestive heart failure.(Source: Tabers)

Brent K.  Tabers & Swartz  324

Wheezing is the production of whistling sounds during difficult breathing resulting from narrowing of the lumen of a respiratory passageway.

Fassil B    Swartz pg. 324

Wheezing is an abnormal high-pitched noise resulting from a partially obstructed airway. It is usually present during expiration when slight bronchoconstriction occurs physiologically.

7.         List common causes of wheezing.

Anonymous Ballweg pg. 176-177

It is most commonly associated with asthma, but can also be caused by

            allergies to medications or environment, sensitivity to environment or occupational sensitivity to

            inhalants, mechanical obstruction of the larynx, trachea, or a mainstem bronchus, emphysema, or CHF.  

            Almost any acute or chronic lung disease may manifest as wheezing at some point.  "Remember: All that wheezes is not asthma."

Anonymous

Wheezing is most commonly associated with asthma but may also be connected with allergies, environmental or occupational sensitivity to inhalants, mechanical obstruction of the larynx, trachea, or a mainstem bronchus (e.g., foreign body, tumor), emphysema, or CHF.

Anonymous Source: Noble –old pg 125

    “All that wheezes is not asthma” .  

    Causes include: Asthma; irritants such as cigarette smoke, smoke from burning wood and air pollution; Upper respiratory infections; bronchiolitis; pulmonary edema/congestive heart failure; bronchopulmonary dysplasia (in infants); food aspiration; bronchial stenoosis; cystic fibrosis (see also list provided in question #6 from a 2^nd source).

Brent K. Tabers & Swarts 324

Causes of wheezing include bronchospasm from asthma, mucosal edema, loss of elastic support, tortuosity of the airways, foreign bodies or secretions and tumors.  

Fassil    Swartz pg. 324

Bronchospasm, mucosal edema, loss of elastic support, and tortuosity of the airways are usual causes. Asthma causes bronchospasm, which result in the wheezing associated with condition. Obstruction by intraluminal material, such as aspirated foreign bodies or secretions, is another important cause of wheezing.

8.         List specific questions that should be asked in taking a history of wheezing, particularly of aggravating and relieving factors.

Anonymous Ballweg pg. 177

Ask the Onset, Duration (continuous or intermittent, better, worse, or staying the same, episodic, and are the number of episodes increasing), Description (a typical episode, and its length), Aggrivating

Factors: establish relationship of wheezing to seasons, environment, respiratory infections, drugs,

Exercise, dusts, pollens, animals, and emotions.  Relieving factors: use of medications (RX or OTC),

Change of environment, or season, or by change of position--lying down vs. sitting up.  Ask questions pertaining to effect on patients life.  PMH, and FH.

Anonymous

 “All that wheezes is not asthma.”

Questions that should be asked include:

1. Onset: When did the wheezing begin? (e.g.,15mins, 2 weeks ago)

2. Duration: Is it continuous or intermittent. Better, or worse? If intermittent, how frequently does it occur? Are the number and frequency of episodes increasing?

3. Description: How severe is it? What is a typical episode like?

4. Aggravating factors: Is it seasonal, or environmental? (e.g., wood-burning stoves for home heating) respiratory infections, drugs, exercise, (exercise-induced asthma) dust, pollens, animals, and emotions. Do you know of anything in particular that guarantees an attack?

5. Relieving Factors: Prescription medications, OTC meds, changes in the environment or seasons, or position (e.g., standing or sitting)

6. Associated symptoms: Ask all respiratory ROS questions

7. Effects on the patients life:

8. Pmhx:

9. Family Hx:

10. Cough:

11. Sputum production:

12. Chest pain:

Anonymous       Souce: Emergency Medicine pg 631

     When did the wheezing begin?

      How bad is it? Is it getting worse?

      Do you have a cold, cough or fever?

      Are there any suspected triggers that may have set off this attack?

       What medications do you take? Ever been on steroids?

       Do you have any family history or past medical history of asthma or allergies?

      Have you eaten anything new? Been exposed to any new cleaning products or soaps?

      Have you ever lost consciousness or been intubated or on a ventilator due to wheezing?

Brent K. Tabers & Swarts 324

At what age did the wheezing begin?

How often does it occur?

Are there any precipitating factors, such as foods, odors, emotions, animals, etc?

What usually stops the attack?

Have the symptoms worsened over the years?

Are there any associated symptoms?

Is there a history of nasal polyps?

What is your smoking history?

Is there a history of heart disease?

Fassil B.   Swartz pg. 324

Questions to ask include:

•        At what age did the wheezing started?

•        How often does it occur?

•        Are there any precipitating factors, such as foods, odors, emotions, animals?

•        What usually stops the attack?

•        Have the symptoms worsened over the years?

•        Are there any associated symptoms?

•        Is there a history of nasal polyps?

•        What is your smoking history?

•        Is there a history of heart disease?

9.         Define atopy and recognize its familial tendency and associated conditions.  (Swartz page 170 second paragraph.)

AnonymousTaber vol. 19 pg. 193.

Atopy is a type I hypersensitivity  or allergic reaction for which there is a genetic predisposition.  It differs from normal hypersensitivity reactions to allergies that are not genetically determined.  The basis for the predisposition lies in the histocompatibility genes.  The child with two parents with the atopic allergy has a 75% chance of developing similar symptoms; if only one parent is affected then  The child has a 50% chance of developing the atopy.  (Hayfever and asthma are the two most common Inherited allergies, contact dermatitis, and gastrointestinal reactions may also be inherited.)  

Anonymous

The term atopy refers to the triad of dermatitis, asthma, and hay fever.  It is characterized immunologically by high concentrations of serum IgE, a high incidence of IgE-mediated response by skin test to common inhaled antigens, decreased numbers of immunoregulatory T cells, defensive antibody-dependent cellular cytotoxicity, and reduced cell-mediated immunity. Although it seems to run in families, the precise genetics of it’s familial are not fully understood.

Anonymous

    Many patients with astma tender to produce IgE to one or more antigens in the environment (designated as allergins) and are therefore related as atopic. The tendency to develop a certain type of allergy can be inherited but not the allergy itself. Atopy may also be associated with eczema and hayfever. The priniciple atopic manifestations are bronchial asthma, vasomotor rhinitis and chronic uticaria. Source: Noble pg 654 and Tabers

Brent K.  Tabers & Swarts 170

Atopy is a Type I hypersensitivity or allergic reaction due to a genetic predisposition.  The basis for the disposition lies in the histocompatibility genes.  The child of 2 parents with the atopic allergy has a 75% chance of developing similar symptom’s, if one parent is affected, the child has a 50% chance.  Hayfever, asthma, contact dermatitis, and GI reaction are examples of inherited allergies.  IgE is the primary antibody involved.  

Fassil B   Taber’s

Atopy is a Type I hypersensitivity or allergic reaction for which there is a genetic predisposition. It differs from normal hypersensitivity reactions to allergies that are not genetically determined. The basis for the predisposition lies in histocompatibility genes. The child of two parents with the atopic allergy has a 75% chance of developing similar symptoms; if one parent affected, a child has 50% chance. Hey fever and asthma are two of the most commonly inherited allergies; contact dermitis and gastrointestinal reactions may also be inherited. As with all type I hypersensitivity reactions, IgE is the primary antibody involved.  Taber’s dictionary

10.       List specific questions and emphases that should be followed in taking a history of cough.

Anonymous Bates pg 53

Cough is a frequent symptom that varies in significance from the trivial to the ominous. A person may cough voluntarily, but more typically cough is a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi. These stimuli include both external agents such as irritating dusts, foreign bodies, and even extremely hot or cold air, and internal substances such as mucus, pus, and blood. Inflammation of the respiratory mucosae, and pressure or tension on the air passages as from a tumor or enlarged peribronchial lymph node, may also cause coughing.

Although cough typically signals a problem in the respiratory tract, the underlying cause may also be cardiovascular. A cough is an important symptom of left-sided heart failure.

'Do you have a cough?" may be an adequate opening question, but for some patients, especially those who smoke, a morning cough may be so habitual that they fail to mention it. Further questions here are "Do you have to clear your throat in the morning?" and "Do you have a cigarette cough?" Determine the timing of the cough. Is it a new symptom or more chronic? How frequent is it? When does it occur? Is it seasonal? Are there factors that seem to precipitate or aggravate it? Has a chronic cough changed in any way?

Assess the cough qualitatively by whether it is dry or productive of sputum (phlegm). Ask the patient to describe the volume of the sputum and its color, odor, and consistency. Many patients have difficulty describing sputum volume. A multiple-choice question may be helpful. "How much do you think you cough up in 24 hours: a teaspoon, tablespoon, quarter cup, half cup, cupful?" If the patient coughs in your presence, offer a tissue, ask the patient to cough into it, and inspect any phlegm. A specimen from deep in the chest is desirable. Symptoms associated with the cough often lead you to its cause.  

Anonymous see Ballweg pg. 177.

            With cough you want to ask all the regular HPI questions: Onset, Duration, Description, Aggrivating and relieving factors, associated symptoms, effect, PMH, and FH (of cough or other respiratory disease).  In regards to associated symptoms you would want to know about sputum, fever, if the cough seems chronic in nature, night sweats, and weight loss.  Chest pain associated with cough may indicate pleural involvement.  Ask about HEENT symptoms such as ear pain, rhinorrhea, and sore throat: would indicate URI.  Sneezing, itchy or watery eyes suggests allergies.  With effect you would want to know if cough is interfering with work or sleep.  

Anonymous

When taking a history for cough, you want to know the same information as required for any HPI of any complaint – onset, duration, description, aggravation, and relieving factors, associated symptoms, effects, and PMH and FH (of cough or other respiratory diseases). With associated symptoms you are particularly interested in sputum, fever, and (if the cough seems chronic in nature) night sweats and weight loss. Chest pain associated with cough may indicate pleural involvement. HEENT symptoms such as ear pain, rhinorrhea, and sore throat point to URI; sneezing and itchy water eyes suggest allergies. With effect, you want to know whether the cough is interfering with work or sleep. You also want a good description of the cough – frequency, relationship to time of day or activities. Do they smoke; is there sputum – how much, and what does it look like; is there hemoptysis, chest pain, etc. . .

Anonymous Source: Bates pg 953.

     Ask if cough is new or chronic.

     How frequent is it? When does it occur?

     Is it seasonal? Has a chronic cough changed in anyway?

     Are there factors that seem to precipitate or aggravate the cough?

     Have you had any associated symptoms such as fever, chest pain, dyspnea, orthopnea or wheezing?

     Ask pt to describe the volume of the sputum and its color, odor and consistency.

    Any blood in your sputum?

     Do you smoke?  Have any environmental or occupational exposures?

    Does the cough worsen when you lay down?

     Any previous allergies, astma, sinusitis, recent URI and /or TB exposure?    

Brent K. Tabers & Swartz 320

When assessing a cough, emphasis should be put on whether the cough is productive or nonproductive.  If productive, what color and how much sputum, is important.  Also, coughing up of blood (hemoptysis) should be emphasized.  

Specific questions for coughing include:

            Can you describe your cough?

            How long have you had the cough?

            Was there a sudden onset of coughing?

            Do you smoke?  If so, what do you smoke?  How much and for how long?

Does your cough produce sputum?  If so, can you estimate the amount of your expectorations?  What is the color of the sputum?  Does it have a foul odor?

Does the cough occur for prolonged periods?

Does the cough occur after eating?

Is the cough worse in any position?

What relieves the cough?

Are there any other symptoms associated with the cough?  Fever? Headaches? Night sweats? Chest pain? Runny nose? Shortness of breath? Weightloss? Hoarseness? Loss of consciousness?

Do you have any birds as pets?  Do you feed pigeons?  

Have you ever been exposed to anyone with tuberculosis?

Fassil B    Swartz pg. 320

Questions to ask include:

•        Can you describe your cough?

•        How long have you had a cough?

•        Was there a sudden onset of coughing?

•        Do you smoke? If so, what do you smoke? How much and for how long?

•        Does your cough produce sputum? If so, can you estimate the amount of your expectorations? What is the color of the sputum? Does the sputum has foul odor?

•        Does the cough occur for prolonged periods?

•        Does the cough occur after eating?

•        Is the coughing worsen in any position?

•        What relieves the cough?

•        Are there any symptoms associated with the cough? Fever? Headaches? Night sweats? Chest pain? Runny nose? SOB? Weight loss? hoarseness? Loss of consciousness?

•        Do you have any birds as pets? Do you feed pigeons?

•        Have you ever been exposed to anyone with tuberculosis?

11.       Identify the usual character of a smoker's cough.

Anonymous Merck Manual pg. 652; 17th ed.

In patients with chronic bronchitis, increased intensity and intractability of a preexisting cough suggest a neoplasm.

Anonymous Kraytman, p.24

A change in the character of a chronic smoker’s cough may be contributed to bronchogenic malignancy.       

Anonymous

A change in the character of a chronic smoker’s cough may be the first sign of lung cancer.

AnonymousKraytman, P. 24

Bronchogenic malignancy is suspected in the change of usual character or pattern of a smokers cough.  

Sung K, Swartz, p.320

Mostly productive coughing in the morning to clear the respiratory passages. Coughing is normally decreased during sleep.

12.       Identify the potential significance of different kinds of sputum.

Anonymous– Bates, pp. 53, Kraytman pp. 24

•Mucoid sputum is translucent, white or gray.  Indicates viral infection; foreign substances (smoke, pollution); long-standing bronchial irritation; bronchoalveolar carcinoma.  

•Purulent sputum is yellowish or greenish. Purulent sputum indicates infection in the tracheobronchial tree or lung; bacterial pneumonia; lung abscess; chronic or recurrent mucopurulent bronchitis.  Large volumes of purulent sputum suggest bronchiectasis or lung abscess.

•Mucopurulent sputum has components of both mucoid and purulent sputum.

Above is most likely the answer they’re looking for.  Below is a list of other causes/descriptions of sputum.

•Foam/pink-tinged sputum indicates pulmonary edema

•Sometimes black w/ soot particles indicates chronic bronchitis; coal miner’s sputum may contain coal dust.

•Gelatinous and rusty “prunejuice” sputum indicates pneumococcal pneumonia.

• “Currant jelly”, tenacious sputum indicates Klebsiella pneumonia

•Sputum which contains threads may contain casts of the bronchial tree; indicate bronchitis; bronchial asthma.

Anonymous

Mucoid sputum: clear, white. Viral infection, foreign substances (smoke, atmospheric pollution: any form of long –standing bronchial irritation

Foamy and pink-tinged-pulmonary edema.

Black with soot particles- chronic bronchitis from coal dust.

Thick, yellowish, or green- purulent: infection in the tracheobronchial pneumonia,

More on page 24 of Kraytman.

Anonymous

It is very hard to have sputum without a cough, so you will usually be taking a cough history with this complaint. The question is: “what does it look like?”      

a.       Color: Clear or white is usually benign, but some lung cancer  sputum remains white for some time. Yellow or green usually means infection

b.      Blood: Is there any blood in it? Blood might be bright red, rusty, or brown, depending on how fresh it is. I may appear in streaks or in large amounts.

c.       Odor: Does it stink? Such characteristic are seen in lung   abscess, and bronchiectasis.        

Anonymous Kraytman, P. 24

a)      Clear and white – Mucoid sputum: viral infection, foreign substances, any form of long-standing bronchial irritation, bronchoalveolar carcinoma

b)      Foamy and pink-tinged – Pulmonary edema

c)      Sometimes black, with soot particles – chronic bronchitis, coal miners’ sputum may contain coal dust

d)      Thick and yellowish, or greenish – purulent:  infection in the tracheobronchial tree or lung, bronchiectasis, bacterial pneumonia, lung abscess, chronic or recurrent mucopurulent bronchitis

e)      Gelatinous and rusty, “Prune juice” – pneumococcal pneumonia

f)        Similar to currant jelly? Tenacious – Klebsiella pneumonia

g)      Containing threads – Casts of the bronchial tree, bronchitis, bronchial asthma

h)      Blood-streaked – Tuberculosis, bronchiectasis, lung tumor, pulmonary infarction

i)        Bloody – Pulmonary infarction, bronchogenic carcinoma, tuberculosis

Sung K, Swartz, p.322

13.       Define hemoptysis and identify several potential causes, including the most common cause.

Anonymous

Hemoptysis refers to coughing up of either blood-tinged or grossly bloody sputum. In the office, the primary physician is usually confronted with a patient who has noted sputum streaked with blood.      -Goroll: Primary Care Medicine, 3rd ed., pp. 237

Most common cause: Inflammatory causes account for 80 to 90% of hemoptysis cases. Acute or chronic bronchitis is probably the most common cause, because bronchitis and, to a diminishing extent, bronchiectasis cause about 50% of all cases.  --- Merck Manual Section 6 Chapter 63, topic: Hemoptysis.  Online resource has no page #s.

Other causes: Recent infection in an old bronchiectatic sac, a healed cavity, or a cystic lesion may cause a slow ooze or frank bleeding. Infestation of cavities by Aspergillus sp (mycetoma, fungus ball) is an increasingly recognized cause of significant hemoptysis.

Tumors (especially carcinoma), perfused primarily by bronchial vessels, account for about 20% of cases; bronchogenic carcinoma must be strongly suspected in smokers who have hemoptysis and who are >= 40 yr old. Metastatic cancer rarely causes hemoptysis.

Pulmonary infarction in association with thromboembolism and left ventricular failure (especially secondary to mitral stenosis) are less common causes of hemoptysis. Primary bronchial adenoma and arteriovenous malformations are rare but tend to cause severe bleeding. Rarely, hemoptysis of obscure origin occurs at the time of menstruation. See Table 63-1 for conditions that may cause hemoptysis.  -- Merck Manual Section 6 Chapter 63, topic: Hemoptysis.  Online resource has no page #s.

Anonymous

Hemoptysis is expectoration of sputum either streaked or grossly contaminated with blood. The most common causes are from, acute and chronic bronchitis, tuberculosis, and bronchiectasis. Other causes include carcinoma neoplasms, cardiac and vascular lesions, and other hemorrhagic diseases. Kraytman, p68

Anonymous

Hemoptysis is coughing up blood from the lungs and upper respiratory system. The most common cause is from is acute bronchitis. Other causes include:

1. Tuberculosis

2. Lung cancer

3. Pulmonary embolus

Anonymous Kraytman P. 68

Hemoptysis is the expectoration of sputum either streaked or grossly contaminated with blood.  

Causes:

Infections:  acute and chronic bronchitis, TB, bronchiectasis, lung abscess, pneumonia, necrotizing pneumonia, fungus infections, parasitic diseases

Neoplasms:  bronchogenic carcinoma, bronchial adenoma, miscellaneous rare tumors

Cardiac and vascular lesions:  pulmonary thromboembolism, left ventricular failure, mitral stenosis, primary pulmonary hypertension, arteriovenous malformations, hereditary hemorrhagic telangiectasis, polyarteritis nodosa, etc

Miscellaneous: hemorrhagic diseases (purpura, leukemia, hemophilia), anticoagulant therapy, broncholith, foreign body, cystic fibrosis, trauma, lung sontusion, amyloidosis                                            

Sung K, Swartz, p.321-2

Hemoptysis – coughing up of blood.

Most common cause – bronchitis

Potential causes – bronchiectasis, bronchogenic carcinoma, DVT w/ PE, tuberculosis, abscess 

14.       List specific questions that should be asked in taking a history of hemoptysis (amount, color, duration, associated factors, and weight loss.)

Anonymous Kraytman, p69-71

Make sure the blood is not coming from a nosebleed, bleeding in the mouth, or even the stomach. Amount: can you give an estimated of the amount of sputum, teaspoon, cups?

Character of sputum: streaked with blood? Jelly? (dark blood intermixed with sputum, pink frothy)     fresh, brisk bleeding vs. old blood.

Duration: How long have you noticed the presence of blood in your sputum? first episode vs. intermittent or chronic.

Associated or precipitating factors: Hemoptysis occurred after coughing? Exertion? Sexual intercourse? Anticoagulant therapy, and chest trauma.

Weight loss: Have you experience any weight lost? Or lost of appetite? 

Anonymous

1. Make sure the blood is not coming from a nosebleed, bleeding in the mouth, or even the stomach.

2. Amount: teaspoon, cups?

3. Exact color: fresh, brisk bleeding vs. old blood.

4. Duration: first episode vs. intermittent or chronic.

5. Associated or precipitating factors: exertion, anticoagulant therapy, BCPs, and chest trauma.

6. Weight loss: or a chronic chest symptom such as cough or sputum.

Anonymous kraytman, P68-71

Duration of Bleeding – “How long have you noticed the presence of blood in your sputum?”  and “Do you have recurrent episodes of minor bleeding?”

Amount of blood coughed up – “Can you give an estimate of the amt of blood?”  “Do you have slight, persistent bleeding?”  “Do you have large amts of blood coughed up?  More than one-half cup?”

Associated factors – Ask the pt if he/she has: chest pain, burning sensation, fever/ chills, night sweats, shortness of breath, palpitations, hoarseness, a loss of weight a swollen painful leg, bloody urine, purulent rhinorrhea, nasal or sinus pain.

Color – Ask if the sputum is: streaked with blood? Intimately mixed with blood? “rusty?” currant jelly?(dark blood intermixed with sputum) pink frothy? Blood mixed with pus? Frankly bloody – without mucus or pus? At first red and becoming progressively darker for 24 to 48 hours? Brown? Magenta? Mixed with food particles?                                                                    

Sung K, ??

“How much blood was coughed up?”

 “Did the coughing up of blood occur suddenly?”

“Have there been recurrent episodes of coughing up blood?”

“Is the sputum blood-tinged, or are there actual clots of blood?”

“How long have you noticed the blood?”

“What seems to bring on the coughing up of blood? Vomiting? Coughing? Nausea?”

“Have you ever had tuberculosis?”

“Do you smoke?” If yes, “What do you smoke?”

“Is their a family history of coughing up blood?”

“Have you had a recent surgery?”

“Do you take any blood thinners?”

“Are you aware of any bleeding tendency?”

“Have you had any recent travel on airplanes?”

“Have you had night sweats? Shortness of breath? Palpitations? Irregular heartbeats? Hoarseness? weight loss? Swelling or pain in your legs?”

“Have you felt any unusual sensation in your chest after coughing up blood?” If so, “Where?”

For a woman with hemoptysis, “Do you use oral contraceptives?”

15.       Define pleuritic pain and distinguish it from the typical pain of cardiac origin. (Be sure to check-out Swartz page 355 also)

Anonymous Primary care Medicine p112

Pain worsened by deep inspiration or cough is an indication of pleural irritation. It is also suggestive of pericarditis and chest wall pathology. Focal chest wall tenderness worsened by movement quickly narrows the differential to a chest wall origin.  Pleuritic pain worsened by turning but relieved by sitting up and leaning forward is indicative of pericarditis. Pneumothorax should come to mind when pleuritic pain is sudden in onset and accompanied by dyspnea in a young patient with a previous hx of pneumothorax or when the patient has long-standing bullous emphysema.

Anonymous

Chest pain is not very typical of lung disease because the lungs themselves do not have pain sensitive nerves. However, the pleurae do, so pleural involvement in a disease (e.g., inflammation, tumor) causes classic pleuritic pain, which is characterized by sharp, localized pain on inspiration or with coughing.  This is usually easy to distinguish from chest pain of cardiac origin, which is brought on by exertion, relieved by rest, and unaffected by respiration.  Pleuritic pain can also result from chest wall trauma (e.g., fractured ribs).

Anonymous

     Evaluating pleuratic chest pain – “pain worsened by deep inspiration or cough is the hallmark of pleural irritation”. Focal chest wall tenderness worsened by movment quickly narrows the differential to a chest wall orgin. Pleuratic chest pain is aggravated by deep inspiration, cough , direct palpation and movement.

     Cardiac chest pain usually described as squeezing, heaviness, or pressure, although it may be burning or sharp in character. Radiation of pain to the jaw, neck, shoulder, arm, back or upper abdomen is common. Diaphoresis, nausea and dyspnea may accompany the episode. If in doubt, treat chest pain as cardiac until proven otherwise. Source: Primary Care Medicine pg 112-113.

Sung K, Swartz, p.325, 355

Pleuritic pain – a common symptom of inflammation of the parietal pleura that is described as a sharp, stabbing pain, which is usually felt during inspiration and may be localized to one side, and the patient may splint (making chest muscles rigid to avoid motion of that part of the chest) to avoid the pain.

Characteristics of chest pain

16.       Define pack years and list specific questions that will help quantify a patient's smoking history. Swartz Page 20, 320

Anonymous Bates, p723, 36,268

Pack years can be assessed by calculating packs smoked per day (ppd.) multiplied  

by the years the patients claims to have smoked: i.e., 2ppd x 15 years = 30 pack-year history

Specific questions include do you smoke? Have you ever smoked? How long have you smoked? How much do you smoke now? Have you ever smoked more than that? Have you ever tried to quit?

Include type of tobacco used (e.g., cigarettes, cigars, pipes, chewing tobacco, clove.), and if someone has quit using, how long ago.

Anonymous

a.       Pack years can be assessed by calculating packs smoked per day (ppd) multiplied  

by the years the patients claims to have smoked:

  f.ex., 1 ½ ppd x 12 years = 18 pack-year history

b.      Specific questions include:

1.      Do you smoke?

2.      Have you ever smoked?

3.      How long have you smoked?

4.      How much do you smoke now?

5.      Have you ever smoked more than that?

6.      Have you ever tried to quit?

c.       Also include the type of tobacco used (e.g., cigarettes, cigars, pipes, chewing tobacco, clove, (are you inhaling?) etc.), and if someone has quit using tobacco products, how long ago.

Tim Swartz, Ch. 12,pgs. 20 and 320

            A pack-year is the number of years a patient has smoked cigarettes multiplied by the number of packs per day.  Important ?’s to ask are;  “What do you smoke?”,  “How much and how long?” 

17.       Describe the importance of environmental and occupational exposures in the respiratory history and list several examples of conditions associated with these factors.

Swartz Page 24-25

Anonymous

As part of Respiratory Hx, providers should inquire about occupational and environmental exposures. Where do they live, where do they work?  About 15% of newly diagnosed cases of asthma in adults are the consequence of occupational exposures. Occupational lung disease is on of the 10 leading causes of work-related health problems in the US. Furthermore, latency period between exposure and subsequent development of disease may be long. It is critical that primary providers be familiar with occupational lung diseases and their diagnosis if unnecessary morbidity is to be avoided. Respiratory symptoms caused by toxic exposures are nonspecific. Early diagnoses is also critical in reversing pathology.

Occupational asthma- Chemials;formaldehyde,gases,vapors,fumes

Byssinosis-cotton,flax,and hemp dust

Multiple chemical sensitivity-isocyanates,ammonia acetone, sodium hypyochlorite.

Industrial bronchitis- diesel exhaust,dust, welding fumes, coal dust, sulfurdioxide

Pulmornay Fibrosis- asbestos, silica beryllium,talc,kaolin

Cancer- radon, radiation, uranium, nickel

Noncardiogenic pulmonary edema- chlorine,ammonea,sulfuric acid

See Primary care medicine p.263-266

Anonymous

Fewer than 5% of respiratory diseases cases are correctly identified as being associated with work. A primary care provider should routinely ask about occupational and environmental exposures whenever a patient has respiratory symptoms. Furthermore, most work-related respiratory diseases are not curable and must be discovered early to avoid future disability. Some diseases take years to develop.

Examples of occupational and environmental respiratory diseases include:

Condition                                Agent                                                              Potential exposures  

Asthma             formaldehyde, toluene, animal dander    Textiles, plastics, animal

handlers.

Pneumonitis                  nitrogen oxides, phosgene, halogen                    Welding, farming, chemical

Operators, smelting

Pulmonary fibrosis        Asbestos, silica, beryllium, coal, aluminum         Mining, metal alloy work,

aircraft maintenance.

Emphysema                  cotton dust, coal dust, organic solvents  Textile industry, battery

production, soldering, mining    

Lung cancer                  asbestos, arsenic, uranium, coke oven-  Insulation, pipefitting,

emissions                                                          smelting, shipyard worker.

Tim Swartz, Ch. 12, pgs. 24-25

The importance of exposure in resp. HX is latency between exposure and illness which can lead to manifestations many years after exposure.

Asbestos exposure: malignant mesothelioma.

Aliline dye: bladder cancer.

Woodworkers: neoplasms of the nasal cavity.

Many more on pages cited.

18.       Given a patient with a respiratory complaint, be able to obtain a complete, accurate, and  detailed history.