HISTORY AND SYMPTOMS IN PULMONARY DISEASES Dr. S. Özdoğan

Patient name Age Sex Occupation 1 Place of birth Date Smoking history 2 (pack- years) Personal habits 3 Drugs used Complaints: Should be written in a word, with the patients expression

History Listen to the patient Can be guided at some points Write the history afterwards in a chronological order Dates should be mentioned Past history, Family history System inquery

Main Symptoms of Pulmonary Diseases Cough Sputum production Hemopthysis Chest pain Dyspnea General Symptoms Fever Weight loss Fatigue Night sweats (Cyanosis)

Cough Cough is an explosive expiration that protects the lungs against aspiration and promotes the movement of secretions upward toward the mouth A reflex act usually arises from the stimulation of cough receptors in the bronchial mucosa and/or interstitium

Mechanism of Cough Cough receptors: (RAR, C fibers) –Nose, paranasal sinus (N.Trigeminus) –Farenx (N. Glossofaringicus) –Larenx, trachea, main bronchia, interstitium, stomach (N. Vagus) –Pericardium, diaphragma (N. Frenicus) Efferent ways to respiratory muscles –N Vagus –N Frenicus –Spinal nerves

The categories of cough stimuli –Mechanical (inhalation of irritants; distortions of the airways) –Inflammatory –Chemical –Thermal –Psychogenic

Factors that depress cough Old age Unconciousness Local or general anesthesia Alcohol Drugs or neural diseases Larengeal pathologies Recurrent stimuli

Cough Acute or chronic ( > 6/8 weeks) Productive or non productive (Swallowed?) Change in the nature? in chronic coughing patients Prominent day time (night or daytime)

Causes of Cough Acute cough –Exogenious irritant inhalation –Aspiration, foreign body –Common cold, viral infections –Acute bacterial sinusitis –Exacerbation of chronic bronchitis –Rhinitis –Pneumonia –Congestive hearth failure –Pulmonary embolism Chronic cough –Postnasal drip syndrome –Asthma –Gastroesophageal reflux disease –Chronic bronchitis –Drugs –Bronchiectasis –Bronchogenic carcinoma, adenoma –Chronic interstitial pneumonia –Psychogenic

Complications of Cough Syncope Vomiting Pneumothorax / Pneumomediastinum Fractures Inguinal hernia Urinary incontinans

Sputum Amount Mucoid or loose Duration, positional change Color Odor (Bronchore, melanoptisis, biliptisis)

Hemoptysis The coughing up of blood. Varies from blood tinged sputum to virtually pure blood Hemoptysis or hematemesis (vomited blood) should be distinguished Blood from the upper airways should be distinguished Massive hemopthysis (> ml/day) Bleeding diathesis should be considered Chest x ray should be taken

Main Causes of Hemoptysis Infections –Pneumonia –Tuberculosis –Lung abscess –Bronchiectasis –Fungal and parasitic disease –Bronchitis Neoplasm –Bronchial carcinoma –Bronchial adenoma Foreign body Bleeding diathesis Idiopathic Cardiovascular –Pulmonary infarct (embolism) –Mitral stenosis –Pulmonary edema –AV malformation Trauma –Pulmonary contusion –Iatrogenic Alveolar hemoragie –Good pasture sendr –SLE –Vasculites –Behçet sendr Endometriosis

Diagnostic algoritm for hemopthysis Appropiate therapy Specific tests Thorax CT Neoplasm/ Infection Bronchiectasis ILD normal FOB Low risk of malignancy No Observation Yes

Chest Pain May originate from –Pleura (inspiratory pain) –Mediastinum (retrosternal) –Chest wall (Changes in body position) –Trachea and main bronchi –Cardiac pain –Abdominal pain

Approach to chest pain Onset Duration Location and radiation pattern Character Intensity

Causes of Chest pain Pleural –Pleural effusion –Pneumothorax –Pulmonary embolus –Mesothelioma Pulmonary –Pulmonary hypertension –Tracheobronchitis –Tumour Mediastinal –Myocardial infarction –Angina pectoris –Pericarditis –Aortic dissection –Mediastinitis or emphysema –Esophagitis, reflux

Chest wall –Myalgia –Costochondritis –Subacromial bursitis –Shoulder and spinal arthritis –İntercostal muscle cramps –Fibromyalgia –Rib fractures –Sternal marrow pain –Breast inflammation –Chest wall tumours –Diaphragm spasm –Herpes zoster Abdominal –Peptic ulcus –Cholesistitis Panic attacks

Dyspnea Dyspnea is a term implying an unusual awareness of breathing or the need to breathe more

Dyspnea is related to: –An increase in airway resistance –An increase in the elastic recoil of the lungs or chest wall –Hyperventilation

Causes of Dyspnea Respiratory –Airway disease COPD, Emphsema Asthma Bronchiectasis Tumoral obstructions of the airways Bilateral vocal cord paralysis –Paranchymal Alveolitis Sarcoidosis Fibrosis Pneumonia Respiratory distress syndrome İnfiltrative tumour

–Pulmonary circulation P. Embolism P. Hypertension P. Arteritis –Chest wall and pleura Effusion Pneumothorax Tumour Rib fracture Nöromuscular diseases Thoracal deformities Diaphragmatic paralysis Cardiac –Left ventricular failure –Mitral valve disease –Cardiomyopaties –Pericardial effusion, constriction Non cardiorespiratory –Psychogenic –Anemia –Asidosis –Hypotalamic lesions

Types of dyspnea Ortopnea: Dyspnea that occurs when lying flat Paroxysmal nocturnal dyspnea: Wakes the patient at night Platipnea: Dyspnea that occurs in sitting position Trepopnea: Dyspnea occurs when lying aside İnspiratory dyspnea Expiratory dyspnea

Medical Research Council (MRC) Dyspnea Scale Stage 1: Breathless on hills or during a rapid movement on the level Stage 2: Unable to keep up with people of similar age on the level Stage 3: Able to walk only 100 m or few minutes on the level and have to rest Stage 4: Breathless at rest, home bounded

Asthma

General Symptoms Fever Weight loss, loss of appetite Fatigue Night sweats Hoarseness

Extrapulmonary symptoms Upper airway –Hoarsness –Nasal poliposis (obstruction) –Postnasal drip –Keratokonjonktivitis sicca –Hypertrophy in parotis glands –..... Endocrinologic –Cushing –Gynecomasty –D. İnsipitus –Carsinoid syndrome Neuromuscular –Peripheral neuropathy –Myastenic syndrome –Encephalomyelitis Connective tissue –Clubbing –Hypertrophic osteoarthropathy –Thromboflebitis –Purpura –Skin lesions