Although chest radiography enhances our ability to detect lung pathology that we would miss or misunderstand on physical examination, the clinical history remains our most potent tool in the assessment of the respiratory patient. Only by learning the story of the patient's illness can we hope to understand the meaning of physical signs or interpret shadows on a chest film.
THE CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS
When the chief complaint arouses suspicion of pulmonary disease, the clinician should survey all possible respiratory symptoms, building a chronological account of the patient's illness from its onset to the time of interview. While short-term illnesses are described with comparative ease, protracted or lifelong disease challenges the physician to discover and record significant events, screening out the inconsequential details. Discerning examination of each symptom will elicit details of time and place of occurrence, events that cause or relieve the complaint, and included diurnal, seasonal and year to year changes in the symptom. The treatment that has been previously administered should be sought.
Dyspnea
Dyspnea, the most common respiratory complaint, is the sensation of "shortness of breath." Although most patients who complain of dyspnea are truly breathless, occasional patients confuse dissatisfaction with the depth of sigh with shortness of breath. Simply asking the patient to show how they are breathing when they are troubled helps confirm that the patient is truly short of breath. Since exercise tolerance varies with age, body type and lifestyle, it is useful for patients to compare their abilities with their peer group. While extraordinarily fit subjects may complain of unaccustomed dyspnea at extremes of athletic performance, most patients will initially experience discomfort with simple walking. With increasing dysfunction, subjects may be short of breath with the slightest exertion. The most severely affected patients are short of breath at rest. Most patients are incapable of describing their dyspnea in more precise terms than these. Clinicians should direct their efforts to describing the progression of impairment over time, and recounting the circumstances that may cause or relieve the distress.
Critical to the evaluation of dyspnea is the determination of its mode of onset. Breathlessness that develops over a few brief moments suggests pulmonary thromboemboli, spontaneous pneumothorax, asthma, or catastrophic cardiac dysfunction. While these may cause shortness of breath that develops over minutes or hours, acute infections or other fulminant inflammatory reactions join the list of possible causes. Most other pulmonary diseases have a more prolonged onset, frequently so insidious that the patient has difficulty describing a time of onset of dyspnea.
Asking patients to reflect on their performance one, two, five or ten years in the past may help in gaining insight into the duration of symptoms.
When patients are short of breath at rest it is particularly important to learn if body position alters the distress. Orthopnea, or shortness of breath when lying flat, is common to both patients with lung disease and those with heart failure. While the pulmonary patient may have some immediate relief from sitting or standing, the cardiac patient may have to wait several minutes for comfort. Patients with postural dyspnea frequently prefer to sleep in a sitting position that is often accomplished with the use of pillows. Normal subjects may like to use pillows for comfort, but can lie flat without difficulty.
Paroxysmal Nocturnal Dyspnea suddenly awakens patients. While it may evoke a diagnosis of cardiac failure, it may also be experienced by the asthmatic patient.
Rarely in patients with obstructive lung disease, impairment of the pulmonary circulation or congential heart defects may find that the upright position elicits dyspnea. This phenomenon is called Platypnea.
Wheezing
The patient who affirms that musical sounds are heard with respiration confirms that there is wheezing. Not infrequently, patients will volunteer or agree that the noise sounds "like kittens". While wheezing may be an important companion of dyspnea, it may occur independently. Wheezing is a cardinal manifestation of airway obstruction. When wheezing is sensed only in a particular area of the respiratory system, it suggests a localized obstruction such as tumor or foreign body. Precipitating and relieving factors should be elicited.
Stridor, a coarse musical sound typically heard on inspiration, is usually generated by obstruction at the level of the larynx. When tracheal stenosis is present, a hollow musical sound may be heard on inspiration and/or expiration that evokes memories of Darth Vader in the classic "Star Wars" movie series. Stridor is an observable sign but a patient may occasionally describe it.
Cough
Cough is perhaps the most frequent manifestation of respiratory disease. Frequently, particularly in smokers, subjects so regard cough as part of their daily lives that they fail to report it as a symptom. Many manoeuvres directed to the expulsion of secretions may be described as cough. Asking the patient to reproduce their actions helps to differentiate between throat-clearing motions and the more forceful actions that clear sputum from the lungs.
Coughing may occur in discrete episodes or in prolonged spasms. The patient may experience other symptoms such as pain, dyspnea, "gagging", light-headedness or even syncope with cough. Patients may know specific things that cause them to cough; these may include environmental stimuli, activities or body positions. Cough may be more prominent at certain times of the day or night.
Abnormal Airway-Reactivity:
While all persons might experience dyspnea, wheezing, or cough when challenged by highly noxious fumes, the individual with increased airway reactivity will also react to more modest challenges. Commonly, the reactive individual will experience symptoms with exposure to more benign stimuli such as cigarette smoke-filled rooms, hair spray, perfumes, chlorine bleach, talc, pain fumes, smoke from frying foods or cold air. Even deep breathing, laughing, crying or even coughing itself may cause symptoms! Although abnormal airway reactivity is easily identified in individuals who are usually symptom-free between episodes, individuals with severe compromise of their airways will frequently complain that such stimuli will exaggerate their underlying limitations. If provoking stimuli are not intrinsically irritating, an allergic etiology is suggested. Commonly, "extrinsic asthmatics" may cite specific exposures that provoke episodes. Pets, house dust, pollen or specific foods are common examples of allergenic stimuli.
Exercise Induced Asthma is a variety of airway reactivity in which exercise itself provokes dyspnea, wheezing and cough that may begin even after the exercise has stopped.
Sputum
While a few subjects deny ever examining their sputum, most can describe its color and consistency. Patients have difficulty describing the volume of their sputum. Offering a simple menu of choices such as teaspoons, tablespoons or cups will aid the subject in crude quantitation. The association of sputum production with specific postures may direct the clinician to localized pathology.
Hemoptysis:
Hemoptysis alarms both the patient and the physician. When patients complain of coughing up blood, the astute clinician first seeks to confirm that the secretions are indeed sputum. Bleeding gums may be misinterpreted as hemoptysis. Blood seeping from the posterior nasopharynx may be expelled by throat-clearing. Patients may confuse vomiting with coughing of blood. Careful determination of the sensations and manoevres associated with the expulsion of blood will usually aid in confirming the presence or absence of hemoptysis. Since vomitus is bitter, it is wise to ask the taste of the blood. When hemoptysis is confirmed, the bloody sputum should be described in terms of its colour (bright red or dark), quantity and consistency. Precise details of its time of onset, frequency and duration should be sought. Since hemoptysis in an ominous complaint, the coincidence of other symptoms such as chest pain or syncope should be sought.
Chest pain:
Several types of chest pain are experienced by patients with lung disease. Knife-like pain that is felt either with inspiration or with expiration and may be relieved by breath-holding is commonly called Pleuritic Pain. These pains may be exaggerated or relieved by specific changes in posture. Virtually identical pains can originate from the chest wall, particularly in the instance of fractured ribs.
When air suddenly floods the pleural space as in spontaneous pneumothorax, the patient may describe a feeling of an explosion in the chest. The chest wall may ache in those stressed by increased work of breathing or by protracted coughing. Such discomfort is frequently felt near the sternal angle, along the costal margins, or in the posterior thorax.
Elevated pulmonary artery pressures can cause central chest pain suggestive of cardiac ischemia. Tumors, perhaps by distorting pulmonary arteries, may be associated with vague chest pain that is frequently ipsilateral.
Right upper quadrant or epigastric pain brought on by exercise and relieved by rest is called Hepatic Angina. It is attributed to elevated venous pressures in association with cor pulmonale.
Heart Failure and Palpitations:
Pulmonary diseases may cause right heart failure that is most frequently manifest by edema. Gravity causes the earliest edema to occur in the feet in upright subjects. More severe failure may cause swelling of the legs, or even the abdomen. Elevation of pressure in the right atrium may cause dysrhythmias which are appreciated as palpitations.
Syncope
Because cardiovascular regulation may be disturbed by pulmonary disease, symptoms of cerebral ischemia ranging from light-headedness to unconsciousness may be felt. An interesting variant is "Cough Syncope" which occurs in occasional patients who have prolonged bouts of coughing.
Fever
Inflammation frequently betrays its presence with fever. Elevations of body temperature frequently accompany infectious lung disease. Although "Night Sweats" traditionally were viewed as a cardinal symptom of tuberculosis, in the current era they may signal HIV infection. Fever should always be described as to the time of day of its occurrence as well as its severity.
Sleep Disordered Breathing:
Since this occurs while unconscious, the patient has a limited perception of difficulties. The patient may complain of excessive daytime sleepiness, morning headache, memory loss, or sexual dysfunction. Ask if the patient's family, particularly bed partners, have noted excessive snoring or interruption of breathing during sleep (sleep apnea).
Cyanosis
Although cyanosis is an observable sign, patients will sometimes relate that they have observed or have been told of a blue colour of hands, lips or ears.
Clubbing of the Fingers:
Commonly even patients with the most obvious clubbing of the fingers are unaware of the deformity! Clubbing of recent onset, particularly if accompanied by pain, may signal the presence of an occult malignancy.
MEDICATIONS
Medications, both prescribed and "over the counter" drugs, can either alter defense mechanisms or directly damage the lungs, the neuromuscular apparatus or alter respiratory drive. The use of any herbal or "natural" products should be included. A complete record of all drug use is a proper goal.
THE HISTORY OF PAST HEALTH
While a history of frequent "chest infections" as a young child is often the earliest indication of asthma, the possibility of cystic fibrosis or defective immune response should be considered. Prudent clinicians will ask about previous respiratory infections, chest injuries or chest surgery. All patients should be asked about previous surgery, hospitalizations or extended illnesses.
It is efficient to ask the patient the time and place of any past chest x-rays that may later provide rapid resolution of problems occasioned by puzzling films. Any recollections of past tuberculin tests and their results is valuable information. Immunizations should be recorded.
THE FAMILY HISTORY
Either by intimate contact or by genetic predisposition, respiratory diseases may cluster in families. Common among these is asthma that is, in part, genetically determined. Clinicians should not only ask about a family history of asthma, but should search for any tendency to other allergic disease such as hives, hay fever or eczema. A family history of asthma or allergies greatly increases the probability of asthma in an individual. Although particular patients may have a genetic predisposition to the development of emphysema, frequently their family history is confounded by the smoking habits of their family.
Cystic Fibrosis, transmitted as an autosomal recessive gene, may find expression as a familial disease. Ask if siblings or close relatives had pulmonary problems in childhood. Since families may have a predisposition to develop tuberculosis, particularly in the intimacy of a home, one should ask about family members with tuberculosis.
THE SOCIAL AND PERSONAL HISTORY
While we instinctively think of the skin as the surface of the body, as anatomists we realize that the lining of the gut and the conducting airways and alveoli contact the environment. While the gut mucosa with all its enfoldings and crevices has an enormous area, it only contacts ingested water and foodstuffs. By contrast, the conducting airways and alveoli, with the surface area of a tennis court, encounter 7200 liters of air per day. Since the lungs are our major interface with the world, they are plagued by environmental contacts with rigorous detail.
Personal Environmental Pollution:
Humans, unlike other creatures, actively seek pollutants. Since smoking is the major cause of lung disease, a good history describes what was smoked, how much was smoked and the number of years the habit continued. Wise clinicians will include details of smoking recreational drugs.
Recreational drugs, including alcohol, may depress consciousness, defeating the body's defenses against aspiration or oral contents. Further, since the pulmonary capillaries are a sieve for intravenously injected materials, those who "shoot up" may damage their lungs. Illicit drug use is not limited to those younger than forty. Ask all patients about recreational drug use. Use discretion about recording details if absolute secrecy and security of documents is not guaranteed.
Since sexually transmitted diseases may be expressed as lung pathology, the complete history will include discreet questions about sexual preferences and practices.
The Geographic History:
Environmental microorganisms vary from place to place. Within a country, specific geographic areas may harbour pulmonary pathogens, while others are comparatively benign. Since people are mobile it is essential that the environmental history include details of all areas in which a patient has lived, and the length of their stay in each. Remember that chemical hazards abound in specific geographic areas, as happens with chemical pollutants found in certain urban environments. Although it is usually sufficient to state the city or county of residence, if there is a known source of pollution such as a hazardous industry, the astute doctor will ask about proximity to industries and the direction of the prevailing winds. Since traveling may involve exposure to pathogens, a model history describes the areas of the world to which the person has wandered.
The Occupational History:
Many jobs expose patients to hazards. While the non-professional recognizes that miners may encounter the rock dust that causes silicosis, the pulmonary clinician realizes that any occupation may have specific dangers. The farmer exposed to moldy hay, the garment-worker exposed to fumes from plastic foam, the mechanic exposed to the asbestos containing dust from brake linings. All are examples of industrial exposure. Each occupation, the years of employment, and the specific exposures should be documented.
People rarely include their hobbies when speaking of their occupations. The accountant seated in your office may have his asthma aggravated by the red cedar he is using to build a cedar chest for his wife! Hobbies should be detailed as part of the occupational history.
The Patient's Home:
Houses vary in age, humidity, cleanliness and air quality. Specific details as to the age of the house, the frequency of cleaning, laundering of bedclothes and the presence of dusts or molds should be recorded. Microorganisms that may cause disease either by invasion of the body or by stimulating immune responses thrive in moisture, particularly in stagnant water. Air conditioners, humidifiers and dehumidifiers, all of which are notorious culture media, should be documented in describing the ventilation of a home. The type of heating system is important, e.g., forced air systems may have dust laden ducts that have not been cleaned since the house was built.
As well as being potential carriers of pathogenic organisms, others living in a home may bring physical, chemical or biological hazards. Even a smoker in the home may be an ongoing source of irritant gases that stress the sensitive patient. Wise clinicians ask about other persons living in a home, including the details of their occupations, their health and their habits.
Pets may be hazards either as vectors of infectious disease or as antigenic stimuli. Although dogs and cats are commonly known to incite attacks in the sensitive asthmatic, seemingly harmless pets such as birds may provoke immune responses such as allergic alveolitis. It is prudent to ask about all pets the patient has sheltered, including particulars of timing and during of exposures.
THE FUNCTIONAL INQUIRY (REVIEW OF SYSTEMS) - pertinent to Respirology
Head and Neck:
Since the swallowing reflexes which guard against aspiration are complex and fragile, particular attention should be paid to any history of aspiration of oral contents. Aspiration may be associated with chest infections or worsening of obstructive lung disease and may be a cause of unusual infiltrates on a chest x-ray. Particular attention should be paid to a history of "sinus problems", sinus pain, nasal stuffiness, rhinorrhea, hay fever, nosebleeds, post-nasal drip or "ear infections". Hoarseness may be related to lung disease or caused by inhaled medications.
Cardiovascular:
There is much overlap in symptomatology between the cardiac and respiratory symptoms. Any questions that have not been covered in the history of presenting illness should be completed in the functional inquiry.
Gastrointestinal System:
Esophageal reflux (e.g. heartburn, acid taste in mouth or epigastric discomfort) may be accompanied by aspiration with its attendant pulmonary manifestations. Further, reflux may exacerbate or aggravate obstructive lung disease.
Renal:
Since pulmonary renal syndromes frequently manifest as hematuria, specific questions regarding hematuria are prudent.
Musculoskeletal:
Rheumatologic and collagen-vascular diseases frequently affect the respiratory system. Thorough questioning regarding joint symptoms may provide clues as to the nature of unusual pulmonary diseases.
Skin:
Since the above diseases may also have dermatologic manifestations, particular attention should be paid to the history of skin lesions, particularly eczema.
Neurologic
Since depressed consciousness is frequently accompanied by aspiration, it is appropriate to ask specific questions about such episodes.
