history taking in pulmonary medicine
TRANSCRIPT
Dyspnea• Dyspnea is defined as "difficult breathing" or "laboured breathing" or the
conscious realization of the effort of breathing. Although it is a subjective feeling (symptom), it is clear to the observer (sign).
• Polypnea is used to denote rapid breathing.• Tachypnea implies shallow rapid breathing.• Hyperpnea is increased depth of respiration.• Oligopnea is slow breathing (or bradypnea).• These terms may be use instead of "dyspnea" to describe the breathing
patterns of the unconscious patient with metabolic or nervous system disorder.
• Orthopnea is inability to breathe except in the upright position.• Platypnea (orthostatic dyspnea) is dyspnea induced by the upright position,
the opposite of orthopnea.• Trepopnea is comfortable breathing in one position and not the other, e.g.,
one lateral recumbent position over the other, as in patients with pleural effusion or tension pneumothorax.
• Ponopnea is painful breathing.
Changes in rhythm of breathing
• Cheyne-Stokes breathing is the cessation of respiration for five to 10 seconds, followed by a gradual increase in the volume of breathing to a maximum, then the breathing gradually decreases until another pause occurs.
• Biot's breathing which usually occurs in meningitis is characterized by short, rapid breathing episodes interrupted by pauses of 10 to 30 seconds.
• Kussmaul's breathing (air hunger) is a distressing shortness of breath that occurs in paroxysms and frequently foretells the development of acidosis of diabetic coma, or uraemia. It is a deep breathing.
Character of cough
• Unproductive (Dry) cough is a short, sharp noise of distinctive quality that does not yield sputum. It is said to be "brassy" when having a strident (element of stridor) quality which is commonly heard in patients with conditions that narrow the trachea or major bronchi.
• A "barking" or "bovine" cough denotes epiglottic involvement as in laryngitis, narrowing of the glottic space by laryngeal nerve paralysis or pressure (aortic aneurysm), and neoplasm of the vocal cord.
• The "whooping" cough is characterized by the long strident inspiratory noise preceding the cough due to a laryngeal spasm, as seen in pertussis.
• i) History• This includes: onset, frequency, kind of cough,
and sputum character and amount .• A history of smoking: A changing pattern of
cough or sputum production in smokers should be investigated for possible bronchial neoplasm by chest x-ray, cytologic examination of sputum or bronchoscopy.
• History of exposure to noxious agents, heart, lung, thyroid, sinus or gastrointestinal disease.
• Complications of cough• 1. Cough syncope (Tussive syncope) A severe paroxysm of
coughing may induce an attack of syncope. The history of the onset is usually diagnostic. The mechanism is either cerebrum compression by the increased intrathoracic pressure transmitted to the cerebrospinal fluid, or reduction of cardiac output by the Valsalva maneuver.
• 2. Rib fracture Any rib from the 5th to the 10th is likely to break by a severe cough paroxysm, this usually being anterior to the attachments of the serratus anterior that pulls the rib upward, and posterior of the fixation of the external oblique of the abdomen that pulls the rib downward. Thus, a sheering force is exerted on the rib. A single cough is not enough to produce fracture: breaking is being attributed to the fatigue from repeated stressful movements.
Chest pain• Thoracic pain is frequently a presenting symptom. Being
exaggerated by fear of heart disease is likely, so a precise diagnosis is necessary. Chest pain is often accompanied by few or no physical signs.
• Questions related to chest pain include (PQRST = Provocation- Palliative factors, Quality, Region Radiation, Severity and Timing).
• Possible causes • Superficial chest pain The patient can localize the pain definitely
and the pain is accompanied by localized tenderness. The structures involved are the skin and the subcutaneous tissue (the fat, or the breasts).
• Pain with tenderness• Skin and subcutaneous tissue: Inflammation, trauma, and
neoplasm. The presence of bruises, lacerations, ulcers, haematomas, masses. Tenderness is usually diagnostic.
• Chronic retrosternal pain• Xiphisternal arthritis: This pain may simulate myocardial ischaemia unless
the xiphoid cartilage is palpated.• Fat Tender fat lobules in obesity, in adiposis dolorosa (Dercum's disease).• Breasts Tissues of the nipples, chronic mastitis, fibroadenosis, acute breast
abscess, and occasionally breast carcinoma.• Chest pain intensified by respiration Thoracic movements displace ribs,
muscles, nerves and pleural surfaces. When these structures are inflamed or traumatized, the pain is accentuated by breathing, coughing, laughing, or sneezing. Tenderness may be present.
• Rib fracture gives well localized, sharp, intense pain. History may include trauma or fracture from cough. The diagnostic signs include point tenderness at the fracture site, bone crepitus, and induction of pain by remote bimanual pressure on the rib.
• Periostitis of rib Inflammation of the periosteum is very painful. Trauma or acute osteomyelitis produces periostitis with severe pain and tenderness. The condition is associated with fever and leukocytosis before x-ray signs. A localized haematoma from trauma is easily diagnosed.
• Costochondritis of a rib is a common cause of chest pain. The pain is usually dull and increases by thoracic movement. Tenderness can be elicited in the groove at the junction of rib and cartilage.
• Tietz's syndrome (costochondral syndrome) is a tender fusiform swelling in the cartilage, usually of the second rib.
• A slipping cartilage fractured from old trauma can slip over on adjacent rib giving a palpable or audible click.
• Intercostal myositis results in a severe aching pain that increases by motion and a tender nodulation may appear. The muscles are tender by palpation. An example is strain of the pectoralis minor from overuse such as lifting a baby.
• Disorders of the shoulder girdle such as arthritis or osteoarthritis, whether infectious or traumatic, result in pain in the upper chest that increases by movement.
• Intercostal neuralgia due to irritation of an intercostal nerve produces a sharp, stabbing pain along the nerve that increases by movement. Exposure to cold may accentuate it. Tenderness along the nerve is diagnostic especially near the vertebral foramen, in the axilla, or in the parasternal line that corresponds to its cutaneous branches. It occurs in mediastinal neoplasm or neurofibroma.
• Herpes zoster (Shingles) This is a specific type of intercostal neuralgia of a sudden onset pain as above, until herpetic eruption results along the nerve, associated with burning pain and erythema. The erupted vesicles slowly heal and are always unilateral, the pain persisting for about a week or staying for months as a manifestation of post herpetic neuralgia.
• Cervical and dorsal spines• Spondylitis frequently causes pain that may be mistaken for angina by encroaching on the
dorsal nerve roots.• The pain is catching and sharp in character, may be intercostal, substernal, or precordial in
location and often preceded by a feeling of stiffness of the chest. The symptoms may be prolonged over years with an intermittent course or with severe symptoms with rapid progression.
• Diagnosis is by x-ray to detect early changes of narrowed joint space and sclerosis of bone.• In osteoarthritis pain may result from nerve root compression or associated muscle spasm. The
pain distribution may resemble that of coronary artery disease due to involvement of the lower cervical nerves supplying pectoral muscles. Traumatic causes include strain, dislocation, fractures and traumatic arthritis.
• In "straight back syndrome" the normal upper dorsal curve becomes straightened with decreased anteroposterior diameter of the chest. Compression of mediastinal structures causes a false impression of heart enlargement in the frontal x-ray view that can easily be recognized in the lateral view. Systolic cardiac murmurs over the heart base may be heard, which are due to encroachment on the great vessels.
• Pleurisy (pleuritis) produces a knifelike or shooting pain. The pain is in the skin over the inflamed pleura (submammary, shoots to the axilla, girdle like), intensified by breathing, coughing and laughing. A friction rub may be felt or heard, but is not constant. Signs of a pleural effusion may develop.
• Pathophysiology The visceral pleura is insensitive, but the parietal pleura contains sensory fibers that join the trunks of adjacent intercostal nerves, giving off twigs to the overlying skin. Anaesthesia of the skin will relieve the pain.
•Diaphragmatic pleurisy produces a sharp shooting pain, increasing by movement, occurring in the epigastrium, lower retrosternal region or in the shoulder.•The pain is sharp and lancinating, augmented by deep breathing, coughing, or laughing. It may be localized along the costal margins, the epigastrium, the lumbar region, or into the neck at the supraclavicular fossa. The painful areas are all on the same side. A pleural friction rub may be present.•Pathophysiology The peripheral portion of the diaphragmatic pleura is supplied by the 5th and 6th intercostal nerves, so involvement of these regions produces pain near the costal margins. However, the central portion of the diaphragm is served by the phrenic nerve that also supplies the neck and the peritoneal surface of the diaphragm at its central area. Thus, pain in the neck results from irritation of the diaphragmatic pleura by subphrenic abscess or splenic infarction or rupture.•Diagnosis The pleuritic pain is accompanied by fever and friction rub, later, a pleural effusion may appear. A pleural effusion occurs if a subphrenic abscess perforates the diaphragm. Similar pain is met with in gastric herniation through the oesophageal hiatus of the diaphragm. Pericarditis with pleuritic pain should be suspected. History of dysphagia or intraabdominal disease should suggest disorders of the oesophagus, subphrenic abscess, peptic ulcer, or pancreatitis.
•Epidemic pleurodynia (Bornholm's disease, Devils' Grip) produces a sudden severe pain in the thorax or abdomen with frequent shifts of location and asymptomatic intervals. Fever and headache occur without leukocytosis and with a duration of a few days. The pain is intensified by breathing or change in body position and the thorax may be splinted and the thighs flexed from the severity of the pain. The disease occurs sporadically or in epidemics. Mild pharyngitis is usually noted. The muscles of the neck, trunk and limbs may be tender. A pleural friction rub may be detected. Orchitis or pericarditis can be complications. X-ray of the chest is usually negative.•Pathophysiology The usual cause is infection with group B Coxsackie virus, or group A or Echo virus.•Laboratory tests The virus can be detected from the throat and the leukocytic count is normal.•Differential Diagnosis The two main entities are myocardial infarction and dissecting aortic aneurysm. Fever suggests pneumonia or acute appendicitis. A normal leukocytic count suggests the disease. A period of watching until symptoms subside is the usual method of making the diagnosis in sporadic cases.
•Deep retrosternal or precordial pain•The upper six thoracic intercostal nerves cover the thoracic surface from the neck to beneath the xiphoid process, extending to the anteromedial aspects of the arms and forearms. All the thoracic viscera are served by sensory fibers in the pathway of T1 to T4 nerves: myocardium, pericardium, aorta, pulmonary artery, oesophagus and mediastinum. So irritative lesions in any of these structures produce pain of the same quality: deep, visceral and poorly localized. The pain is maximum in the retrosternal region or the precordium, extending with lesser intensity upward into the neck and then to either the right or left hemithorax and downwards on the anteromedial aspects of one or both arms and forearms.•Dermatomes T5 and T6 comprise nerve fibers from the lower thoracic wall, the diaphragmatic muscle and its peritoneal surface, the gall bladder, the pancreas, the duodenum, and the stomach. Inflammation of these structures causes deep, visceral poorly localized pain similar in quality to the upper dermatome band T1 to T4. Usually the maximum intensity is in the xiphoid region and in the back, inferior to the right scapula. Nevertheless, the pain may extend to the upper dermatome area of T1 to T4 through posterior connections in the sympathetics, so that the pattern may be indistinguishable from that arising from that above the diaphragm. •Angina pectoris•Produces a deep steady pain or discomfort for one to 10 minutes in the six dermatome region, initiated by exertion and relieved by rest and nitroglycerin (NG).•The pain•Quality Burning, aching or a sense of tightness or pressure. To illustrate the sense of constriction, the patient frequently clenches the fist.•Severity The discomfort may be mild, moderate, or severe. The patient may have the feeling of impending death.•Timing The pain is continuous, never sharp or lancinating, the duration is usually more than one minute but less than 10 minutes.•Region The pain occurs anywhere in the six dermatome area and is more intense behind the sternum or in the precordium, radiating upwards toward the neck or down the anteromedial aspect of the left arm, forearm or hand. Less frequently the pain occurs in the thoracic vertebrae, the right hemithorax and limb and occasionally in the limbs or neck exclusively.
•Provocation factors1. Exertion such as walking, climbing. In the minority of cases, angina occurs at rest or sleep.2. Postprandial: After eating a heavy meal.3. Intense emotion.4.Tachycardia: From ectopic rhythm such as paroxysmal atrial tachycardia, AF or flutter or the sinus tachycardia of thyrotoxicosis.5. Cold environment with or without exertion.6. Rest: When oedema fluid is being resorbed.7. Hypoglycaemia whether spontaneous or insulin - induced.Palliative factors1. Rest.2. Warm environment.3. Administration of NG.4. The Valsalva maneuver.Physical signs Dysrhythmia may be the only sign.Diagnosis by the relief achieved using nitroglycerin.