Chest Case History Taking

• بسم الله الرحمن الرحيم translates to "In the name of Allah, the Most Gracious, the Most Merciful."
• History Taking, specifically of a chest case, will be discussed by Prof./ Dr./ Howaida A. Nafady, a Professor of internal medicine specializing in clinical hematology at Assuit University.

Respiratory System Overview:

• The respiratory system includes the lungs, airways, pleura, mediastinum, chest wall & respiratory centers.
• Gas exchange occurs in the lungs by diffusion in alveoli between bronchioles and capillaries, with O2 entering the bloodstream and CO2 being removed.

Respiratory Problem Cues:

• Dyspnea is a key sign.
• Coughing is another key feature.
• Sputum production is also an important sign.

Subjective Review Elements

• Chief Complaint
• History of present illness
• Past medical history
• Injuries/immunizations
• Medications
• Allergies
• Surgeries
• Hospitalizations
• Family history
• Social history includes diet, exercise, smoking, caffeine, alcohol, nicotine, marital status and occupation.

Pertinent Subjective Data:

• Key areas of questioning are chest pain, dyspnea, orthopnea, cough, fatigue, cyanosis/pallor, edema & nocturia.

Chest Pain Analysis:

• Angina is a key cardiac symptom, often indicated by a "clenched fist" sign.
• Inquire about the pain's onset, location, character & aggravating/relieving factors.
• Assess the pain's character: crashing, stabbing, burning, or vise-like.
• Check for associated symptoms like sweating, ashen gray or pale skin, shortness of breath, nausea/vomiting, racing heart & heart palpitations.

Dyspnea Assessment:

• Paroxysmal nocturnal dyspnea (PND) often indicates heart failure, with the person waking after a couple hours of sleep and needing fresh air.
• Determine the cause, onset, duration & positional effects.
• Determine if shortness of breath interferes with daily living activities.

Orthopnea Questions:

• Ascertain if patient needs to assume a more upright position to breathe.
• Note the exact number of pillows patient uses.

Cough & Other Symptoms:

• Ascertain the duration, frequency, type, and sputum characteristics (color, odor, blood) as well as aggravating/relieving factors.
• Fatigue: Note the onset and relationship to time of day.
• Cyanosis or pallor: Note if it occurs with myocardial infarction or low cardiac output.

Edema Inquiries:

• Edema is swelling of legs or dependent body parts due to more interstitial fluid.
• Find out the onset, recent changes, relationship to time of day, relieving factors & associated symptoms
• Nocturia is linked to heart failure in ambulatory patients and is the need to get up during the night to urinate.

History Taking

• Enquire about past respiratory history and any family history of chest disease.
• Inquire about personal habits that could be chest risk factors: nutrition, smoking, alcohol, exercise & drug use.

Cough (Outline)

• Definition
• Causes
• Classification
• Item Analysis

Cough Definition

• Cough is a defense mechanism with afferent branches of the vagus nerve that are mediated by the cough center in the medulla.
• Efferent branches are mainly phrenic and intercostal nerves to repiratory muscles
• Cough is a forced expiratory effort against a closed glottis, with sudden opening for an explusion of air, sometimes with secretions.

Common Infection Causes

• Viral upper respiratory tract infections
• Sinusitis
• Laryngitis
• Tracheitis
• Acute bronchitis
• Infective exacerbations of chronic bronchitis
• Pneumonia
• Bronchiectasis
• Lung abscess
• Pulmonary tuberculosis (TB)
• Fungal respiratory tract infections

Other Possible Causes

• Inhalation of FB, irritating particles, chemicals, or gases
• Bronchial asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Interstitial lung diseases (ILDs)
• Lung Cancer
• Allergic rhinitis
• Some drugs like angiotensin-converting enzyme inhibitors
• Cardiovascular Diseases, such as left ventricular failure
• Gastroesophageal reflux disease (GERD)
• Brain tumors
• psychogenic factors.

Cough Classification based on duration

• Acute cough is less than three weeks in duration
• Subacute cough is three to eight weeks in duration
• Chronic cough is more than eight weeks in duration

Common Causes of Chronic Cough

• Asthma
• Chronic bronchitis
• Gastro-oesophageal reflux disease
• Postnasal drip (Rhinitis/sinusitis)
• Tuberculosis
• Drugs, especially the antihypertensive drug; angiotensin converting enzyme (ACE) inhibitors

Cough Classification based on presence of sputum

• "Productive" cough is wet with expectoration
• "Non-productive" cough is dry and without expectoration

People Often Deny Sputum

• Farmers
• Smokers
• Females
• Children

Analyzing Cough

• Onset
• Course
• Duration
• Type (dry or productive)
• Relation to posture
• Relation to time
• Associated symptoms
• Precipitating/aggravating factors
• Special types of cough

Analyzing Sputum

• Amount
• Color
• Consistency
• Odor
• Relation to posture
• Relation to time

Analyzing Sputum Amount

• Quantify sputum in terms of known coffee-cup, tea-glass, or water-glass.
• Scanty amount means few cubic centimeters
• Moderate amount is up to 100 cubic centimeters
• Large amount means bigger than 100 cubic centimeters
• Large sputum in suppurative lung disease such as bronchiectasis and lung abscess.

Analyzing Sputum Color

• Colourless/white can mean bronchitis, asthma, or viral infection
• Yellow/green can mean bacterial infection
• Rusty can mean pneumococcal pneumonia
• Gray/black can mean smokers, heavy smoky dusty area exposure

Analyzing Sputum Consistency

• Watery consistency = viral infection, allergy, or alveolar cell carcinoma
• Frothy consistency = pulmonary edema
• Mucoid consitency = asthma or COPD
• Purulent (pus) consistency = suppurative lung diseases
• Mucopurulent consitency = infective exacerbation of asthma and COPD

Analyzing Sputum Odor

• Check to see if it is odorless or bad/fetid
• Bad odor could indicate infection by anaerobic organisms
• Bad odor can occur in suppurative lung diseases

Analyzing Cough & Sputum in relation to posture

• Cough &/or sputum increases when lying on the healthy side in suppurative lung diseases.
• Cough increases when lying down in Lt sided heart failure & in asthma and COPD exacerbations.

Analyzing Cough & Sputum in relation to time

• Nocturnal can mean asthma or cardiac issues
• Before dawn is often associated with asthma
• Morning (on getting up from the bed) can mean chronic bronchitis & bronchiectasis
• Most of the day can mean viral infection
• Seasonal/on change of weather can mean asthma
• Winter exacerbation can mean COPD

Analyzing Cough: Associated symptoms

• Haemoptysis
• Breathlessness
• Chest pain
• Chest wheezes
• Fever
• Heart burn
• Symptoms of toxemia (anorexia, weight loss)

Analyzing Cough: Precipitating/aggravating factors

• Allergic triggers (as animals, pollens)
• Non-specific triggers (as dust, smoke, exercise, cold air)
• After eating
• Some drugs

Analyzing Cough: Relieving/ameliorating factors

• Avoiding triggering factors
• Treating the original cause
• Taking cough sedatives
• Attaining a specific posture

Analyzing Cough: Special types of cough

• Brassy cough: non-productive metallic cough occurring in children with acute bacterial or viral laryngotracheitis, and in tracheal compression.
• Whooping Cough: paroxysmal attacks of cough that terminate by an inspiratory whoop. Occurs in children with pertussis infection

Clinical Approach for Cough Checklist

• Steps of the skill include: greet patient, introduce yourself, take permission, explain your intentions, have patient sit, listen and respect confidentiality
• Enquire about the onset, course, duration, type & the relation to posture & time.
• Ask about associated symptoms (haemoptysis, breathlessness, fever, chest pain/wheezes, heart burn/weight loss)
• Find out what precipitating/aggravating and relieving/ameliorating factors exist

Clinical Approach for Haemptysis Checklist

• Steps of the skill: greet patient, introduce yourself, take permission, explain your intentions, have patient sit, listen and respect confidentiality.
• Enquire about the onset, course, duration, type/color
• Is there blood streaks or tinge in the sputum, or frank haemoptysis?
• If frank, how much?
• The frequency and if single episode or recurrent?
• The time of last attack?
• Are there any associated symptoms such as cough, breathlessness, chest pain, paroxysmal nocturnal dyspnea, fever, weight loss, hoarseness of voice, vomiting or melena and bleeding from gums?
• What precipitates, aggravates or relieves cough?