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ANAMNESIS AND SYMPTOMS IN CHEST DISEASES DR. MESUT BAYRAKTAROĞLU HISTORY • History taking is one of the most important diagnostic methods • The first step of medical examination • A good history taking and physical examination are enough for a right diagnosis in almost 70-80 of patients in chest d...

ANAMNESIS AND SYMPTOMS IN CHEST DISEASES DR. MESUT BAYRAKTAROĞLU HISTORY • History taking is one of the most important diagnostic methods • The first step of medical examination • A good history taking and physical examination are enough for a right diagnosis in almost 70-80 of patients in chest diseases HISTORY • Introduction (always begin with introducing yourself) • Presenting complaint • History of present complaint • Medical and surgical history (have you had any serious illness? Have you ever been admitted to hospital? Have you had any operations?) HISTORY • Main symptom • Personal habits ( smoking, alcohol, exercising ) • Job (coal mining, silica exposure, asbest exposure, chemical/allergen inhalation ) • Hobbies, pets, exposures ( chemicals, irritants, allergens) • Past diseases, accidents and surgeries • Drugs taken for acute or chronic diseases • Family history (asthma, tuberculosis, lung cancer) • Organ systems HISTORY • Rheumotologic disorders such as scleroderma may be associated with interstitial lung disease, aspiration pneumonia or pulmonary vascular disease • Certain malignancies often metastasize to the lung ( breast / colon carcinoma) or predispose to the development of venous thromboembolism ( pancreatic carcinoma) • Human immunodeficiency virus ( HIV) should not be overlooked since pulmonary complications are often the initial presentation of acquired immunodeficiency syndrome ( AIDS) HISTORY • Drug history ( prescribed drugs for this symptom, herbal or natural treatment, illegal drugs, chronic disease treatment) • Intravenous drug abuse or sexual practisesmay also help to uncover the cause of the pulmonary disorder • Recent treatment of a disorder with immunosuppressive agents can arouse suspicion of toxicity caused by the therapeutic agent or of pulmonary infection by organisms that are usually noninvasive • Certain pharmacologic agents ( bleomycin, n,trofurantoin, methotrexate) have a propensity for inflicting lung damage • Beta blockers can evoke bronchoconstriction • Allergies (pets at home?, exposure at home /work?) HISTORY • Workplace is often the site where toxic air is inhaled • An almost forgotten exposure years ago can explain certain types of pulmonary or pleural diseases • Symptoms that appear to improve during weekends or other periods away from work may be a clue to an occupational exposure that couses a respiratory disease • A newly installed humidifier/ air-conditioning, a new furniture • Moving to a new house or job change HISTORY • Family history ( parents alive? Did they have chronic diseases? How about sister/brother) • Family history can be particularly helpful in uncovering heritable diseases of the lungs ( cystic fibrosis, alfa-1 antitrypsin deficiency, alveoler microlithiasis) • Social history ( marital status, any children, travel history ) • Smoking and alcohol history (how many cigarettes a day and for how long? If a former smoker when stopped? Shisha /cigar smoking) • Conclusion and closure ( Is there anything else you wish to tell me?) HISTORY • Ask the patient to describe the symptom or problem that brought him/her to hospital by using open ended questions • Let the patient describe in his/her own words • When did the symptom start? • Is the symptom decreasing, increasing, persistant or intermittant • Is the symptom related to another condition ( exercise, day time, body position, meals ) HISTORY • What initial action was taken ( any self treatment) • What has happened since then? • What investigation have been undertaken and what are planned? • What action was taken by health professional? • What treatment has been given? HISTORY • The basic symptoms of respiratory diseases are cough, sputum, hemoptysis, dyspnea, wheezing, syanosis and chest pain • These symptoms should be asked and recorded SYMPTOMS OF PULMONARY DISEASES • Dyspnea • Cough • Sputum • Hemoptysis • Chest Pain • Fever Dyspnea • Dyspnea is the medical term for breathlessness or shortness of breath, discomfort in breathing • It is alarming to most patients and one of the most frequent complaints for the patients to seek medical evaluation • It is a range of sensations from awareness of breathing on the one hand, to respiratory distress on the other hand • It is a subjective complaint Dyspnea • Orthopnea: dyspnea in the recumbant, but not in the upright or semivertical position. Usually relieves by 2-3 pillows under head and back. Hallmark of pulmonary congestion • Platypnea: increased blood flow worsens right to left shunting of blood through arteriovenous malformations at the lung bases due to gravity • Paroxysmal nocturnal dyspnea: the patient is aroused from sleep gasping for air and must sit up or stand to catch his/her breath , sweating may be seen adn the patientthrows a window open wide to relieve the sensation of suffocation ( usually seen in left venricule failure) Dyspnea Acute dyspnea causes: - Pulmonary edema - Asthma - Injury to chest wall - Pneumotohrax - Pulmonary embolism - Pneumonia - Pleural effusion - Pulmonary hemorrhage - Adult respiratory distress syndrome Dyspnea Chronic dyspnea causes: - Chronic obstructive pulmonary disease (COPD) - Left ventricular failure - Diffuse interstitial fibrosis - Asthma - Pleural effusions - PE - Pulmonary vascular disease - Severe anemia - Postintubation stenosis Cough • One of the most frequent causes of doctor visits • Cough is an explosive expiration that protects the lungs against aspiration and promotes the movement of secretions and other airway constituents upward toward the mouth • It is a critical element in the self-cleansing and protective machanisms of the lungs • A cough may be voluntary, involuntary or a combination of two • It may be dry or productive • Patients are frequently anxious about the possibility of a serious disease as the cause • Cough complications like chest pain, inconsistence of bladder or stool, social isolation because of others’ infectious fears Cough • It may have various couses • Sinusitis and nasopharyngitis is one of the most common causes and occurs following an upper respiratory tract infection and patient needs to clear the throat, has postnasal drip Cough • Acute infections of the lung: - Tracheobronchitis: associated with sore throat, running nose and eyes - Lobar pneumonia: cough often preceded by symptoms of upper respiratory infection; cough dry, painful at first then becomes productive - Bronchopneumonia: cough dry or productive, usually begins as acute bronchitis - Mycoplasma and viral pneumonia: paroxysmal cough, productive of mucoid or blood-stained sputum associated with flu-like syndrome - Exacerbation of chronic bronchitis: cough productive of mucoid sputumbecomes purulent Cough • Chronic infections of the lung: - Chronic Bronchitis: cough productive of sputum on most days for more than 3 consecutive months and for more than 2 years . During exacerbations the mucoid sputum becomes mucopurulent - Bronchiectasis: purulent cough often since childhood - Tuberculosis: persistent cough for weeks to months, often with bloodtinged sputum - Fungus: persistent cough for weeks to months, often with bloodtinged sputum Cough • Parenchymal inflammatory processes: - Interstitial fibrosis and infiltrations: nonproductive persistent cough - Smoking: persistent cough, most marked in the morning, usually only slightly productive unless progresses to chronic bronchitis Cough • Tumors: - Bronchogenic carcionama: cough nonproductive to productive for weeks to months; recurrent small hemoptysis is common - Alveolar cell carcinoma: cough similar to bronchogenic carcinoma. Sometimes watery, mucoid large amount of sputum may occur differently - Benign tumors in airways: cough nonproductive, occasionally hemoptysis is seen - Mediastinal tumors: cough often with breathlessness coused by compression of trachea and bronchi Cough • Gastrointesitnal causes: Gastroesophageal reflux : nonproductive cough often following meals or with recumbancy, may be accompanied by other GERD symptoms like heartburn, a bitter oral taste • Foreign body: while still in the upper airway cough associated with progressive asphyxiation, when lodged in lower airway a persistent nonproductive cough with localized wheezing • Cardiovascular : left ventricular failure: cough intensifies whilw supine along with increased dyspnea • Drug induced: angiotensin-converting enzyme inhibitors: nonproductive cough ,more common in women Sputum • The secretion that is produced in respiratory airways mucus glands and expectorated with cough • Healthy people also have a little amount of sputum that is swallowed and that is not a symptom for people Sputum • Rust-colored sputum: pneumococcal pneumonia • Purulent sputum with a foul odor : anaerobic infections • A persistant cough that is productive of purulent sputum : COPD, bronchiectasis • Pink-red coloured: left heart failure Hemoptysis • The coughing up of blood is termed hemoptysis • The material and amount produced varies from only blood trace of expectorated sputum to massive volumes of pure blood • Any portion of the respiratory tract can be the source of bleeding including a main broncus, the lungs, nose or throat. • Hemoptysis also should be distinguished from hematemesis ( vomited blood) Hemoptysis • Infections: - Bronchitis - Tuberculosis - Fungal infections - Pneumonia - Lung abscess - Bronchiectasis Hemoptysis • Neoplasms: - Bronchogenic carcinoma - Bronchial adenoma Hemoptysis • Cardiovascular disorders: thromboembolism, mitral stenosis • Trauma: foreign body • Hematologic/immunologic: blood dyscrasia, goodpasture’s syndrome Chest Pain • • • • • • • • • • • Exact site or location of pain Nature of pain ( dull, sharp) Onset of pain ( sudden, gradual) Severity of pain ( can use a scale 1-10) Duration of pain ( seconds, minutes, hours, days) Progress including frequency and timing of pain ( constant, intermittant) Radiation of pain Aggravating and relieving factors Previous occurrences Associated symptoms The patient’s Notion of what is causing pain Chest Pain • The visceral pleura and lung parenchyma does not have sensory nerves • For this reason pneumonia and lung cancer can only cause chest pain if they infiltrate the parietal pleura • First thoughts about chest pain almost invariably turn to the pain of myocardial ischemia. • Cardiac pain is often distinguishible from other types of chest pain. It has a characteristic radiation to the left arm, shoulder or neck and does not have a relation to breathing. Chest Pain • Chest Wall • Parietal pleura: generally associated with fever and dyspnea. Increses with deep breathin or coughing. Tachypnea and shallow tidal volumes ara seen. Usually affects the lower parts of the chest • Pericard: often aggrevated by deep breathing, pain may decrease by leaning forward • Myocard • Mediastinum • Abdominal organs Fever • Fever usually signifies infection ( but not allways) • In bronchitis and emphysema during an acute attack there is only a modest fever and the sputum turns to purulent • Neoplasms are also often associated with fever • Pulmonary sarcoidosis allthough not an infecitous disease may often cause fever • The diseases of the lung that do not cause fever are idiopathic pulmonary fibrosis, lymphangitic carcinomatosis, multiple pulmonary metastases, alveolar proteinosis, idiopathic pulmonary hemosiderosis and alveolar microlithiasis