Taking a Respiratory History - Clinical Skills - Dr James Gill

[Music] good evening previously I've attempted to do the McCloud Clio examination podcasts however they have been put on the back burner somewhat as we focused on releasing the latest 4k clinical skills examination videos however many people have asked if it's possible to do additional videos whereby I explain what particular signs are being looked for and any particular nuances which might be crucial to a certain examination performance the four McLeod's chapters are quite considerable so as a result they'll be sub split into a history podcast where we're going to focus on all of the aspects of the conversation that you better expect to perform with the patient coming in with various different symptoms in that presenting complaint also focusing to any particularly useful areas for clarification on a patient's past medical history their drugs and allergy history along as the family and social histories the second podcast / audio book thing will focus on the examination how to perform it and specifically what it is you're looking for it might seem a bit strange to split things like this however what you must remember is that 90% of your diagnosis is made from the history your examination is only there to confirm what do you think you already know from your history as an example if a patient has come in with what we think might be pleurisy would fully expect them to have a pleuritic rub when we do their respiratory examination it is not the clinical examination which is where we're getting the main diagnosis as a result of these requests we've decided to make a slight variation to the way we're recording the McClouds clinical examination podcasts particularly that we'll be recording the appropriate chapter following the production of a clinical skills video so in this case I'm going back to those which have already been released today going through the respiratory examination so with that in mind here is chapter 5 of McLeod's clinical examination the respiratory system is penned by J Alastair ins and James Tynan and read by yours truly James Gill anatomy and physiology an understanding of the surface anatomy of the lungs and their relation to closely adjacent structures is essential for practice of respiratory medicine at the end of title expiration the dome of the diaphragm extends high into the thorax to around the level of the anterior end of the fifth rib but slightly lower on the left the lower anterior ribs therefore over lie the liver on the right and the stomach and spleen on the left with the parietal pleura extending lower than the lungs on the lateral chest wall posteriorly the lungs extension much lower approaching the 12th rib on full inspiration the lung apex lies immediately beneath the brachial plexus so apical lung tumors commonly disrupt t1 route fibers causing pain and numbness in the interior aspect of the arm and wasting of the small hand of the muscles this is one of the reasons why the respiratory examination and all other examinations start off with the hands the upper thoracic sympathetic outflow in the same way that the hands may be affected by respiratory pathologies so can other regions of the body the upper thoracic sympathetic not fair to the eye may also be compromised leading to a constricted people and ptosis in the mid and lower mediastinum tumors can invade and compromise the pericardium atria and the esophagus in health the lungs optimize gas exchange by closely matching the regional ventilation and perfusion airway and parenchymal lung diseases disrupt this matching causing hypoxia and cyanosis and commonly stimulate breathing through lung afferent nerves leading to a history of breathlessness and tachy Nia on examination the respiratory history patients use a wide range of terms to describe respiratory symptoms such as infection phlegm guitar pleurisy and wheeze these can be ambiguous and require careful definition to avoid misunderstanding wheeze may be used when describing breathlessness or I had a chest infection may denote a breathless episode actually due to pulmonary embolism as with other systems the respiratory history should start with open questions but should also specifically cover the below areas suspicion respiratory symptoms being breathlessness wheeze cough sputum / hemoptysis chest pain fever rivals night sweats weight loss and sleepiness in terms of past medical history we should inquire about other respiratory diseases and all other illnesses and hospital counters drug and allergy histories should include drugs causing or relieving respiratory symptoms along with allergies to pollen pet dust and obviously anaphylaxis in a social and family history we must make sure we have highlighted family history of respiratory disease home circumstances and the effect of and on disease smoking and an occupational history to complete we want the systematic review where abang will also check systemic diseases which may involve the lung along with risk factors for lung disease common presenting symptoms of the respiratory system firstly breathlessness breathlessness or dis Nena denotes the feeling of an uncomfortable need to breathe and is the most commonly reported respiratory symptom it is also one of the most challenging to quantify being inherently subjective breathlessness may originate from spirit Ori or cardiac dysfunction or maybe a manifestation of psychological distress respiratory disease can cause breathlessness through a range of mechanisms the stimulation of intrapulmonary afferent nerves but interstitial information or thromboembolism mechanical loading of respiratory muscles by airflow obstruction or reduced lung compliance in fibrosis hypoxia due to ventilation / perfusion mismatches stimulating chemoreceptors keeping in mind the subjective nature of a shortness of breath or dis near the Medical Research Council breathlessness scale is a useful and crucially validated way to document a patient's level of dis near formerly specific questions may help distinguish the causes of breathlessness as well the MRC breathless scale has from grade 1 to grade 5 indicating the degree of breathlessness related to particular activities with grade 1 being the least whereby a patient would not be troubled by breathlessness except on strenuous exercise grade 2 would be shortness of breath when hurrying on the level or walking up a slight Hill grade 3 walks slower than most people on the level stops after a mile or so or stops after 15 minutes of walking at their own pace grade 4 stops of breath after walking about a 100 yards or so after a few minutes on level ground and grade 5 is too breathless to leave the house or breathless when undressing the benefit of the MRC breath nurses scale means that you can discuss this with a patient frequently when taking history you will ask a patient about their breathlessness and they will respond very when you try to get additional information such as how far they can walk they will frequently respond with not very far at all whilst it is important to give the patient the ability to speak on their own this information is obviously a very little use to the clinician whereby highlighting the MRC breathlessness scale to the patient and discussing that with them may yield much more usable information after formally assessing the breathlessness it is important to find out additional information about the breathlessness specifically how did the DISA on if the onset was spontaneous that would lead you to think about a pneumothorax pulmonary embolism or possibly an acute allergy onset over hours is typical in asthma acute pulmonary edema or acute infections whilst insidious onset occurs with developing effusions interstitial diseases and tumors a good question to ask of the patient is how is their breathing at rest or overnight this could be quite instructive for the underlying diagnosis asthma commonly wakes patients whilst most patients with chronic obstructive pulmonary disease COPD are comfortable at rest and when asleep but struggle with exertion breathlessness provoked by lying down orthopnea is a feature of heart failure but also occurs frequently in patients with severe airflow obstruction or - mite weakness because the weight of the abdominal contents displaces the diaphragm towards the head on lying down compromising the vital capacity anxiety is a big issue when cases of breathlessness hence it can be very useful to explain why the patient may have difficulty breathing when they're lying flat because the abdominal contents pressing on their chest hence why they may find greater benefit from sitting propped up or having more pillows at night than would previously have been the case further questioning should ascertain whether on a patient's breathing is normal on some days variable breathlessness is the hallmark of asthma while consistent and daily limitations are typical of COPD further questions which can be illuminating in the respiratory history would be tell me something you would do in a day that would make you breathless and the old standby of how far can you walk on a good day although it's previously highlighted this can be a difficult question in consultations at all opportunities record restrictions on normal activities or work and the corresponding MRC breathlessness score as this may change over time find out when the breathlessness comes on for example asthma induced by exercise frequently appears only after the exercise and during early recovery because the sympathetic Drive during exercise defends airway patency certain phrases in the history strongly suggest a psychological etiology of breathlessness particularly phrases such as I feel I can't get enough air or oxygen into my chest in patients with hyperventilation due to anxiety this symptom is frequently accompanied by a normal measured vital capacity associated symptoms induced by hypercapnia in hyperventilation include digital and periorbital paresthesia lightheadedness and sometimes chest tuck Ness a wheeze wheeze describes the high-pitched musical or whistling sounds produced by turbulent air flowing through small Airways that have been narrowed by bronchospasm and/or airway secretions it is most commonly heard during expiration when the airway caliber is reduced wheeze must be distinguished from the rattling inspiratory and expiratory sounds caused by loose mobile secretions in the upper Airways and from the louder dramatic croak of stride or caused by obstruction in the trachea or large Airways this is always a hugely important factor when dealing with a patient when a person says that they are hearing additional noises when they breathe it is vital to determine whether or not we have the wheeze that breathing noise on inspiration or whether or not they're getting a sound on expiration any expiratory sound should be treated as a medical emergency until proven otherwise identifying the wheeze in a patient's history is very important as a true EES is typical of small airway diseases it is most commonly associated with asthma and COPD but may also occur with acute respiratory tract infections or with exacerbations of bronchiectasis there due to a combination of airway narrowing and excessive secretions when dealing with the wheeze always ensure you ask the following questions is the wheeze worse during or after exercise if it occurs during exercise and limit set this is suggestive of COPD in asthma as previously mentioned the wheeze and tightness usually appears after the exercise do you wake with the wheeze during the night this would suggest asthma do you have hay fever or other allergies ATP is common in allergic asthma a family history of wheeze or asthma itself is common in patients presenting with suspected asthma is it worse than waking in the morning and relieved by clearing of the sputum in which case this is seen frequently in COPD do you smoke smoking is suggestive of COPD though patients with asthma occasionally smoke are their daily volumes of yellow or green sputum sometimes with blood this may suggest bronchiectasis but keeping in mind that blood stained sputum is always a clinical red flag and needs appropriate investigation cough the cough reflex has evolved to dislodge foreign material and secretions from the central airways and may be triggered by pathology at any level of the bronchial tree inspiration is followed by an expiratory effort against a closed glottis sudden subsequent opening of the glottis with rapid exposure flow produces the characteristic sound when dealing with a history of cough ask about the duration of cough whether it is present everyday whether a cough is intrusive or irresistible or whether the patient coughs deliberately to clear a perceived obstruction or throat clearing whether it produces sputum if so how much and what color although it is worthwhile highlighting that save for blood the particular color of the sputum is not indicative of any particular pathogens as previously was considered to be the case any triggers such as during swallowing in cold air or during exercise smoking as this increases the likelihood of chronic bronchitis or lung cancer associated clinical features wheeze may signal cough variant asthma heartburn or reflux may indicate gastro esophageal reflux which commonly triggers a cough altered voice or swallowing consider laryngeal causes and be aware that both of these will be considered red flags drug history especially angiotensin converting enzyme inhibitors which is the common cause of a dry cough frequently noticed after taking the ACE inhibitor for a couple of months a cough this is productive of green or yellow sputum frequently suggests a bronchial infection volumes of sputum over long periods suggest bronchiectasis him Optus this a vital bed flag will be discussed in more detail in a moment cough is most commonly a symptom of acute viral upper respiratory tract infections these are usually self-limiting over days to weeks a cough that fails to settle over weeks may be the presenting feature of bronchial carcinoma a history of smoking raises further suspicion of malignancy although chronic cough is a nonspecific symptom in smoking other investigations including a chest x-ray are often required to exclude an early cancer and should be considered in any smoker who's had a cough for longer than four weeks chronic cough is defined as a cough lasting more than eight weeks and can be debilitating both physically and socially there are a handful of conditions which should be considered as differentials when dealing with a chronic cough if we were dealing with airway problems would be considering asthma particularly a cough variant asthma chronic obstructive coronary disease persistent airway reactivity following acute bronchitis and possibly bronchiectasis which will be indicated by daily purlins sputum for long periods pneumonia or whooping cough in childhood and may have recurrent hemoptysis other causes of chronic cough may be lung cancer particularly in smokers and would be a worrying factor in pneumonia that fails to clear after four to six weeks rhinitis with a post nasal drip which may also be shown with chronic sneezing nasal blockage or discharge esophageal reflux whereby a patient may complain of heartburn or regurgitation of acid after eating on bending or lying down nocturnal as well as daytime reflux may be able to trigger the cough drug effects as discussed previously with patients on ACE inhibitors interstitial lung disease may have the presentation of a persistent dry cough and when examining the chest fine Inspira crackles will be noted to the basis and finally an idiopathic cough where we have a long history with no signs and negative investigations given the potential severe area diagnosis of lung cancer in a chronic cough and idiopathic cough should only be considered as a diagnosis of exclusion in patients with malignancy at the left hilum damage to the left recurrent laryngeal nerve may paralyze the left of vocal cord making it impossible for the patient to close the glottis and generate a normal explosive cough the resulting hoarse fourth expiration without the initial explosive glottal opening is termed a bovine cough and is an important system warning of possible high LOC malignancy now we turn to sputum production in health the airway lining fluid coating the tracheobronchial tree a sense of the mucosa Larry escalator to the larynx where it mixes with the upper respiratory tract secretions and saliva and as then swallowed in acute or chronic airway and function accumulation of neutrophils mucus and proteinaceous secretions in the airway results in a cough with the expiration of sputum ask about the characterís of sputum to consider the pathology a change in color or consistency or an increase in volume may indicate a new infection in chronic disease when dealing with color again I highlight that a particular organism would not be indicated by any specific colors however we can still get additional information from the color of a sputum clear what mucoid sputum may suggest COPD or bronchiectasis without current infection / rhinitis yellow or mute capira 'land would suggest an acute lower respiratory tract infection or potentially asthma green or purulent sputum suggests a current infection acute disease or an exacerbation of chronic disease such as COPD red or brown also known as rusty sputum may indicate pneumococcal pneumonia but you should try to distinguish between rusty and frank red blood pink saris or frothy may indicate an acute pulmonary edema we also want to find out about the volume of sputum particularly established the amount produced over 24 hours small amounts into a tissue or enough to fill a spoon egg cups or an egg compare the current volume with the patient's baseline or normal minimum volume consistency of sputum an increase in thickness of viscosity may indicate exacerbation in bronchiectasis large volumes of frothy secretions over weeks or months are a feature of the uncommon bronco alveolar cell carcinomas occasionally sputum is produced as firm plugs by a patient with asthma sometimes indicating an underlying allergic bronchopulmonary aspergillosis now the most worrying sign in terms of features of a cough hemoptysis M Optus means coughing up blood from their spirit retract it can complicate any severe forceful cough but it is most commonly associated with acute and chronic respiratory tract infections hemolysis may also indicate pulmonary embolism and lung cancer never assumed hemoptysis has a benign cause until serous pathology has been considered and excluded asked about how it appeared how much blood there was and whether there any associated features and over what time period it came on questions with regarding hemoptysis would be as follows was the blood definitely coughed from the chest blood in the mouth may be vomited or may have come from the nose in epic ass taxes or may appear on chewing or tooth brushing in patients with gum disease a short history of streaks of blood with purulent sputum suggests acute bronchitis a sudden episode of small volume of blood with a pleuritic pain and breathlessness suggests pulmonary embolism recurrent streaks of blood in clear sputum should prompt a search for lung cancer recurrent blood streaks in purlins sputum over weeks suggest possible TB or cancer with infection over years they may suggest Brockie excess larger volumes of hemoptysis specifically greater than 20 milliliters suggest specific causes those being lung cancer eroding a pulmonary vessel bronchiectasis such as cystic fibrosis cavity tree lung disease such as bleeding into an especial OMA pulmonary vasculitis and pulmonic arteriovenous and malformations stride or this harsh of grating respiratory sound is caused by the vibration of the walls of the trachea or major Branka when the airway lumen is critically narrowed by compression tumor or inhaled foreign material the inspiration lowers the pressure inside the extra thoracic trachea so critical narrowing here leads to the inspiratory stridor in contrast the intrathoracic large Airways are compressed during expiration by positive pressure in the surrounding lung leading to the fixed expiratory wheezes Oh large airway narrowing at the thoracic Inlet for example to keep compression by a large goiter may cause both inspiratory and expiratory Strider rapid investigation and treatment of vital when this sign is present as a GP it's not unusual to come across a patient with an inspiratory wheeze these patients if severe are normally put a nebulizer or use more of their salbutamol inhaler whilst in the practice however a Strider is always going to be a worrying sign as briefly indicated above there can be a vast range of conditions leading to that Strider so goiter if you've got problems with your thyroid directly pressing over the trachea if we've got food stuck in the trachea or if we've got tumors pressing on the trachea all of these are going to be significantly worrying features as a result of which I'd be very very strongly inclined to get urgent assistance and review of the patient rather than discharging them home for further investigations now that might seem a little bit over cautious but we have just identified that a Strider is due to an airway obstruction of some form thus I want to know what is going on to make sure both the patient and myself can sleep well at night if we want to boil it down really to brass tacks if something obstructs your airway you've got about two minutes before the brown stuff really hits the fan and in that situation I want the patient in a location where they can be effectively managed which is not going to be in a GP surgery so moving on what additional symptoms do we have a patient might complain of chest pain chest pain may originate from musculoskeletal respiratory cardiovascular or gastroesophageal reflux disease in which case make sure that you establish the site and severity of chest pain was the character of the chest pain sharp pain for example would suggest a plural pain what is the onset has it been gradual or rapid exacerbating or relieving factors worsening with cough or deep breaths suggests again pleural disease and any associated symptoms breathlessness fever cough all suggests an effective course with any pain we can use the squit us mnemonic to guide us in our history taking squit us s qi tas standing for slight quality intensity timing aggravating and relieving factors and symptoms associated it doesn't matter how long you have been graduated from medical school you'll still go to fall back on that simple squid ass acronym in almost daily use so continuing on with the concept of chest pain a large pulmonary embolus can cause angina like chest pain this is due to increased right ventricular work together with the reduced coronary oxygen delivery caused by hypotension and hypoxemia resulting in right ventricular ischemia can't make sense if you think about if you've got a massive plug sitting in one of the blood vessels of your lungs that's going to have a huge impact on how much blood is actually going to pass through the lungs and get oxygenated do not forget that you cannot get inverted commas lung pain as pain does not originate in the lung parenchyma or the visceral pleura as these only have autonomic nerve supplies pain that is considered to be from the lungs is essentially pleuritic pain and this is worse on inspiration and coughing and is usually described as sharp stabbing or knife like it's usually cited away from the midline and may be localized or affect a wide area of the chest wall there are several diseases which are acknowledged to cause prattle pleural pain let's have a look at a few of those now tolerant embolisms or palma infarct pneumonia can cause parietal pain in the same way this is either from direct plural inflammation the way I've thought about that with pulmonary embolisms in the past is you literally have a small in fact you've got an area of death to the lung that causes swelling and in doing so you get that direct pleural information around the area of the in fact you also have adhesions with pleural traction occurring on respiratory movement in pneumonia and pulmonary emboli both of which are going to give you a source of pain a pneumothorax is a major cause of pleural chest pain here you have mechanical distortion of the pleura with the lung collapsing and finally and most obviously lung cancer here the pleura is simply distorted by infiltration of the cancer although the pain there tends to be more constant in lung cancer patients rather than purely on inspiration muskers lethal chest pain is common and can occur with chest trauma forceful coughing or connective tissue disease the chest is characteristically tender to local palpation and pain can be reproduced by respira movements and or movement of the spine or shoulders frequently I have patients particularly younger ones who come in saying that they have chest pain and they're worried that they may be having a heart attack or having significant internal pathology if you're able to press on the chest wall and cause the chest pain they've been complaining of then is frequently the case that everybody in the room can relax a detailed history of events preceding chest pain is obviously vital as an injury can be easily overlooked by the patient on their initial presentation two other common conditions which can cause acute chest pain would be ball home disease an infection with an enterovirus specifically Coxsackie B which causes an acute but self-limiting inflammation of the intercostal muscles then episodes of unilateral severe stabbing myalgia or muscle pain may develop over an intercostal space and settle after a few days a very common diagnosis is costochondritis also tsetse syndrome when costal swelling is present this is an idiopathic information of the costal cartilages adjoining the sternum and can cause acute localized pain and tenderness thankfully the pain settles there it was simple analgesia and the passage of time will ease both of these conditions however in clinical medicine it is vital that you explain this fact to the patient and what the underlying pathological process is otherwise you will unlikely or leave their fears and results in them returning once more herpes zoster infection or shingles may start with a superficial itch or burning pain in a thoracic dermatome which is then followed by the appearance of a vesicular rash pain and autumn sensation may present long after the rash is resolved often with scarring in the set dermal terminal distribution burning retrosternal pain may indicate esophagitis but this can also occur with myocardial ischemia alteration of discomfort after eating or antacids help distinguish esophageal pain and cardiac pain which will come in two and a later podcast in terms of esophagitis I myself have had this and I think the best way of describing it as is if someone has taken a lightsaber push it through your chest and wiggled it around I was using a medication doxycycline whilst on my elective in Africa and unfortunately was not taking the medication quite as advice and had occasionally missed breakfast I was taking my anti malarial tablets as a result it developed as mentioned the Sofia retrosternal burning pain of esophagitis and kanka test that even drinking fluids is very painful in those situations central constant progressive non pleuritic chest pain may represent mediastinal disease particularly malignancies similarly chest wall pain without trauma that is constant progressive and non pleuritic may suggest chest wall invasion by a malignancy pain induced sleep disturbance is also a feature of malignant pains and is a very worrying sign what you have to think about is that at night your natural levels of cortisol an inflammatory steroid hormone dip if you have a bony tumor or an invasion of malignancy at night the natural levels of your own steroids your anti-inflammatories will reduce allowing the tumor to swell if that tumor is in a bone or in a small volume area that swelling will cause intense pain causing pain and Joost sleep disturbance pain and you sleep disturbance or simply night pain is a major red flag fevers Rygel's and night sweats these symptoms are not specific to respiratory medicine but a common reporter by patients with respiratory diseases infection bit acute or chronic is the usual cause but other etiologies such as lung cancer lymphoma or vasculitis also must be considered patients use a range of terms to describe fevers such as shivers chills being hot and bothered having the shakes in my practice I've recently had someone describe it to miss having the egg ooze or others so when a patient is providing you with terminology that you do not understand and shortly ask for a detailed explanation of their symptoms and perhaps an alternate word use the way I've always thought about it is if a patient tells you something you would not be able to explain to another person you need to find out more information or ask them to clarify what they mean with that word Rygel's are generalized uncontrollable episodes of vigorous body shaking lasting a few minutes despite high fever the patient may complain of feeling cold and seeking extra clothing Rygel's usually indicates her back to your sepsis Loba pneumonia and acute pyelonephritis as the most common causes they can be misinterpreted as a seizure but the retention of consciousness and the associated pyrexia would suggest Rygel's night sweats are more closely associated with chronic infection such as tuberculosis and malignancy all in firma rather than acute infections occasional episodes of a sweaty head or a pillow are inconclusive but if the patient reports having to change their night clothes or sheets frequently due to profuse nocturnal sweating over several weeks this is more likely to indicate an underlying disease it's very very common for me to see a nurse of surgery a patient saying oh I've got terrible night sweats and it is vital that you get that clarification if a patient isn't having to change their bed sheets or pajamas at least nightly because the sweating because they're wet through it's highly unlikely that we're looking at a significant problem and I would be inclined to reassure them at that point weight loss weight loss is a common feature of several important respiratory diseases lung cancers chronic infective diseases such as tuberculosis and bronchiectasis and diseases causing chronic breathlessness such as COPD and interstitial lung disease the pathophysiology of weight loss is complex however breathlessness is associated with the diminished appetite and the systemic inflammatory responses are also thought to contribute to weight loss I'm sure we've all been there you've had the flu you're in bed you're hot you're sweaty and you don't want to eat small amounts of weight loss all in acute infection due to as mentioned that consequent loss of appetite particularly during hospitalization although in my own experience I haven't found the hospital food to be particularly appetizing but we'll leave that be ask the patient to estimate the extent and duration of weight loss and inquire about appetite and dietary intake being underweight is a poor prognostic indicator in any chronic respiratory disease recently I've read a couple of studies which has suggested that that is more than chronic respiratory disease but is actually for any hospital admission obviously being overweight is not good for your health however there is some suggestion that those who are a slighter build tend to have worse outcomes on long-term hospital admissions sleepiness excess daytime sleepiness may be a symptom of an underlying sleep related breathing disorder such as obstructive sleep apnea or sleep hyper near in these conditions frequent episodes of upper airway obstruction at night cause repeated micro arousal from sleep leading to complete disruption of the normal sleep cycle date on somnolence impairs work and driving performance causing dangers to the patient and others if you're concerned about excess sleepiness you must make sure you ask about normal sleeping habits does the patient keep powers that are normal to allow rest do they have shift or night work as this can disrupt and prevent healthy sleeping patterns does the patient wake refreshed or do they wake exhausted sleep apnea patients tend to be exhausted in the morning have they struggled to stay awake in the day for example at work or when driving it's vital to advise cessation of driving pending investigations if obstructive sleep apnea is suspected this can be a particularly difficult consultation ideally seek a description of any nighttime breathing disturbance from a bad partner n obstructive sleep apnea the patient may observe periodic cessation of breathing accompanied by increased respiratory efforts followed by a sudden and loud resumption of breathing often with postural repositioning then repetition of this cycle validators sleepiness scores such as the Epworth sleepiness scale can be used to quantify daytime somnolence and are helpful if considering referral to sleep disorder clinic that pretty much wraps up opera history of presenting complaint for respiratory patients now let's look at some of the specifics we would want to find out about in their past medical history past illnesses which may surprisingly be related to respiratory problems are as follows eczema or hay fever due to an allergic tendency which might turn into asthma childhood asthma many wheezing children do not have asthma as adults yet many adults with asthma had a childhood wheeze so looking backwards may give us an idea about what's going on in the present whooping cough measles or an inhaled foreign body all of these are recognized causes of bronchiectasis especially if complicated by pneumonia pneumonia obviously it's going to have a significant impact on a patient's respiratory system going forwards as well pleurisy both these are again recognized course of bronchiectasis and recurrent episodes may actually be the manifestation of bronchiectasis it won't be surprised anybody to know that a past history of tuberculosis may put a patient at risk of other respiratory problems particularly the TB returning if a patient is not previously being fully treated or treated effectively reactivation can be quite common it's also worthwhile finding out what treatments that they had at the time as respiratory failure may be a complication of the thoracoplasty mice automa in the lung cavities may also present with hemoptysis any of the connective tissue disorders for example rheumatoid arthritis may have an impact on the lungs lung diseases are recognized complications of connective tissue disorders for example pulmonary fibrosis effusions again bronchiectasis are you beginning to get the feeling that bronchiectasis is probably one of those conditions this is worthwhile putting a lot of attention to for your spiritual revision immuno modulated treatments for connective tissue disorders may cause pulmonary toxicity or render patients susceptible to respiratory infections as we cause suppression of the immune system if a patient has had previous malignancy whether or not is in the lungs or otherwise recurrence is always going to be a problem as could be metastatic or pleural disease some cancers are known to be more likely to spread or develop secondaries to the lungs than other areas these include water euphemistically termed the B type cancers so that being bowel breast bladder testicles or balls and bydd knee yeah kidney we're kind of straining there metaphor that there are other areas such as the stomach the esophagus melanomas and sarcomas which are known to spread commonly to the lungs in fact up to 50% of lung cancers are thought to be related to metastasis rather than the primary in his own right recent surgery or loss of consciousness puts a patient at risk of respiratory issues due to potential aspiration of foreign bodies or in the case of surgery potential gastric contents pneumonia and lung abscesses are also a risk if anything ends up in the respiratory which shouldn't be there another major area of potential problems for the respiratory system its neuromuscular disorders if a pay has weakness of their chest wall muscles that is going to vastly increase the risk of aspiration as has been said as a patient may not be able to cough with full force in order to bring about expiration or removal of a foreign body similarly as the chest wall muscles weaken respiratory failure is also a high risk as you've seen a past medical history must include respiratory diseases that might reoccur or cause long term symptoms and disease in other symptoms which may cause complicate or present withdrew security problems also to be considered will be thrombotic cardiovascular hematological obviously malignancies and connective tissue diseases note the prior respiratory treatment including them for critical care and the degree of chronic symptoms such as usual exacerbation frequency antibiotic prescription rate and previous hospitalizations are vital bits of information for documentation drug and allergy history note all drugs that a patient is currently using including inhalers nebulized bronchodilators and domiciliary oxygen non prescription remedies and recreational drugs cross-check the drug names and doses with a separate source if possible such as the general practitioners records drugs given for other problems commonly cause respiratory side-effects here's an overview of the symptoms which drugs may cause and those particular causative agents bronchoconstriction could be due to beta blockers opioids or non-steroidal anti-inflammatories as a result these three types of medications should always be avoided in asthmatics cough can be produce by an angiotensin converting enzyme inhibitor bronchiolitis obliterans can we do two penicillamine diffuse parenchymal lung disease has a range of potential triggering drugs particularly cytotoxic agents such as bleomycin and methotrexate anti-inflammatory agents such as for Salle's een penicillamine again gold salts and aspirin cardiovascular drugs such as amiodarone or hydralazine antibiotics such as nitro front turn and intravenous drug misuse pulmonary embolisms may be triggered by estrogens asthma porn or hypertension which is one of the reasons why pill checks do require you to clarify that there has been no history of DVTs either personally or in the family and as an obvious extension of that that they have not had any issues with pulmonary blood clots either pulmonary fusions may be seen in amiodarone not your friends own phenytoin methotrexate and per glide and finally restorative depression can be caused by opioids and benzodiazepines as I'm sure you can see from that little list there are certain medications which keep returning as problems for respiratory patients particularly I'd highlight the beta blockers amiodarone from cardiovascular drugs and not your phone tone along with estrogens these are medications which are frequently used in day to day practice and this should be considered whether or not their prescription is likely to cause problems for patient as with any patient it is always vital to ask and record whether or not the patient has any known allergies firstly as allergic asthma is far more common in those who have a history of a tepee but also specify whether or not the patient has any specific drug allergies that they are aware of and if they are aware of any ensure that you document what that allergic reaction was whether or not it was a rash or whether or not the patient had full-blown anaphylaxis personally I'd like to ensure that the requirement to check for allergies and drug allergies is rigorously drummed into my students or do you have to remember is that as a student you have the potential to save a patient's life by ensuring that they are not given the incorrect drug if you have the information about their drug allergies actually I perhaps go a little bit further and consider failure to ask drug allergies when you are arranging a patient's management should be a trigger for an automatic fail event during examinations but then again when it comes to exams I am a little bit of a hawk family history should be considered a crucial area as well of a respiratory patients history ask about family history of asthma although this is common in the population and therefore might not be highly predictive respira diseases with a known genetic course are also relatively rare most patients with cystic fibrosis may have unaffected carry parents but may have affected siblings I find cystic fibrosis one of those very interesting conditions because in Europe we have a high prevalence of carriers the reason being it's thought that carries status may have provided some evolutionary benefit in terms of protection against diseases or illnesses causing diarrhea and dehydration in the past such as cholera or dysentery social history always start by identifying the patient's normal level of daily activity and the impact of their recent symptoms on this can they still manage their work their self-care and any caring that they themselves have to deliver to others what for a patient's home circumstances ie are they limited by their chronic respiratory conditions and then may become confined to their own homes this particularly might be the case if they become too breathless to manage stairs always ask a patient about their home environment and what support they receive if any in order to enable them to function smoking this is an utterly vital part of the respiratory history obtaining an honest and accurate history of tobacco use is difficult but can be achieved with a good rapport with the patient ask if other smoke in the house as well as this can be a major obstacle to bringing about smoking cessation remember to also inquire about the use of cannabis and a cigarette an occupational history is normally very illuminating on a respiratory history many respira diseases are caused by occupational or domestic exposure to inhaled substances common examples may be a coal miner who is exposed to coal dust then putting at risk of progressive pulmonary fibrosis or co-workers pneumoconiosis certain factory workers such as paint sprayers bakers and joiners may be at risk of asthma due to exposure of isocyanates flower and wood dust similarly distillers may actually be exposed to aspergillosis in malt and thus potentially at risk of hypersensitivity pneumonitis this condition is also a risk for farmers and laborers who might be exposed to fungal spores in moldy hay if we are concerned that a potential employee exposure has occurred and may be impacting on their respiratory health it is useful to record an employer's name the dates and duration of exposures and whether any personal protective equipment or masks were offered and used to wrapper we should do a systemic inquiry asking about any risk factors such as malignancy for thromboembolism the remaining history may reveal previously unsuspected pathologies presenting with respiratory symptoms or complicating respiratory illnesses such as ovarian malignancy presenting as a pleural effusion that pretty much wraps up our overview of respiratory history and the particularly important features that we would need to inquire about I'm going to be recording the next section of the respiratory examination that being the physical examination and we go about doing the examination and what we're going to be looking for I'd be really grateful if people have any comments or feedback before I get round to that recording so that I might tweak things and hopefully make this a better learning experience for the listeners one of the things that I am aware of is that just the history itself is currently taking over at 55 minutes so I'm not sure whether or not this could be cut down further or whether or not you're happy with the detail in order to have to pause and drop in and drop out as the listener prefers either way if you could put some information about your preferences in the comments I'd be massively grateful to you thank you very much in advance take care bye bye [Music] you