The Health History

Common or Concerning Symptoms

■ Blood-streaked sputum (hemoptysis)

Complaints of chest pain or chest discomfort raise the specter of heart disease, but often arise from structures in the thorax and lung as well. To assess this symptom, you must pursue a dual investigation of both thoracic and cardiac causes. Sources of chest pain are listed below. For this important symptom, you must keep all of these in mind.

■ The myocardium

■ The pericardium

■ The trachea and large bronchi

■ The parietal pleura

■ The chest wall, including the musculoskeletal system and skin

■ The esophagus

■ Extrathoracic structures such as the neck, gallbladder, and stomach.

This section focuses on pulmonary complaints, including general questions about chest symptoms, dyspnea, wheezing, cough, and hemoptysis. For

Angina pectoris, myocardial infarction

Pericarditis

Dissecting aortic aneurysm Bronchitis

Pericarditis, pneumonia

Costochondritis, herpes zoster

Reflux esophagitis, esophageal spasm

Cervical arthritis, biliary colic, gastritis health history questions about exertional chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, and edema, see Chapter 7, The Cardiovascular System.

Your initial questions should be as broad as possible. "Do you have any discomfort or unpleasant feelings in your chest?" As you proceed to the full history, ask the patient to point to where the pain is in the chest. Watch for any gestures as the patient describes the pain. You should elicit all seven attributes of this symptom (see p. 27) to distinguish among the various causes of chest pain.

A clenched fist over the sternum suggests angina pectoris; a finger pointing to a tender area on the chest wall suggests musculoskeletal pain; a hand moving from neck to epigastrum suggests heartburn.

Lung tissue itself has no pain fibers. Pain in lung conditions such as pneumonia or pulmonary infarction usually arises from inflammation of the adjacent parietal pleura. Muscle strain from prolonged recurrent coughing may also be responsible. The pericardium also has few pain fibers—the pain of pericarditis stems from inflammation of the adjacent parietal pleura. (Chest pain is commonly associated with anxiety, too, but the mechanism remains obscure.)

Anxiety is the most frequent cause of chest pain in children; costochondritis is also common.

Dyspnea is a nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of exertion. This serious symptom warrants a full explanation and assessment, since dyspnea commonly results from cardiac or pulmonary disease.

Ask "Have you had any difficulty breathing?" Find out when the symptom occurs, at rest or with exercise, and how much effort produces onset. Because of variations in age, body weight, and physical fitness, there is no absolute scale for quantifying dyspnea. Instead, make every effort to determine its severity based on the patient's daily activities. How many steps or flights of stairs can the patient climb before pausing for breath? What about work such as carrying bags of groceries, mopping the floor, or making the bed? Has dyspnea altered the patient's lifestyle and daily activities? How? Carefully elicit the timing and setting of dyspnea, any associated symptoms, and relieving or aggravating factors.

Most patients with dyspnea relate shortness of breath to their level of activity. Anxious patients present a different picture. They may describe difficulty taking a deep enough breath, or a smothering sensation with inability to get enough air, along with paresthesias, or sensations of tingling or "pins and needles" around the lips or in the extremities.

Anxious patients may have episodic dyspnea during both rest and exercise, and hyperventilation, or rapid, shallow breathing. At other times they may have frequent sighs.

Wheezes are musical respiratory sounds that may be audible both to the patient and to others.

Wheezing suggests partial airway obstruction from secretions, tissue inflammation, or a foreign body.

Cough is a common symptom that ranges in significance from trivial to ominous. Typically, cough is a reflex response to stimuli that irritate re-

See Table 6-3, Cough and Hemoptysis, p. 238.

ceptors in the larynx, trachea, or large bronchi. These stimuli include mucus, pus, and blood, as well as external agents such as dusts, foreign bodies, or even extremely hot or cold air. Other causes include inflammation of the respiratory mucosa and pressure or tension in the air passages from a tumor or enlarged peribronchial lymph nodes. Although cough typically signals a problem in the respiratory tract, it may also be cardiovascular in origin.

For complaints of cough, a thorough assessment is in order. Ask whether the cough is dry or produces sputum, or phlegm. Ask the patient to describe the volume of any sputum and its color, odor, and consistency.

Cough is an important symptom of left-sided heart failure.

Dry hacking cough in Mycoplasmal pneumonia; productive cough in bronchitis, viral or bacterial pneumonia

Mucoid sputum is translucent, white, or gray; purulent sputum is yellowish or greenish.

Foul-smelling sputum in anaerobic lung abscess; tenacious sputum in cystic fibrosis

To help patients quantify volume, a multiple-choice question may be helpful . . . "How much do you think you cough up in 24 hours; a teaspoon, tablespoon, a quarter cup, half cup, cupful?" If possible, ask the patient to cough into a tissue; inspect the phlegm and note its characteristics. The symptoms associated with a cough often lead you to its cause.

Hemoptysis is the coughing up of blood from the lungs; it may vary from blood-streaked phlegm to frank blood. For patients reporting hemoptysis, assess the volume of blood produced as well as the other sputum attributes; ask about the related setting and activity and any associated symptoms.

Before using the term "hemoptysis," try to confirm the source of the bleeding by both history and physical examination. Blood or blood-streaked material may originate in the mouth, pharynx, or gastrointestinal tract and is easily mislabeled. When vomited, it probably originates in the gastrointestinal tract. Occasionally, however, blood from the nasopharynx or the gastrointestinal tract is aspirated and then coughed out.

Large volumes of purulent sputum in bronchiectasis or lung abscess

Diagnostically helpful symptoms include fever, chest pain, dyspnea, orthopnea, and wheezing.

See Table 6-3, Cough and Hemoptysis, p. 238. Hemoptysis is rare in infants, children, and adolescents; it is seen most often in cystic fibrosis.

Blood originating in the stomach is usually darker than blood from the respiratory tract and may be mixed with food particles.

Important Topics for Health Promotion and Counseling

■ Tobacco cessation

Despite declines in smoking over the past several decades, more than 27% of Americans age 12 and older still smoke.* All adults, pregnant women, parents, and adolescents who smoke should be counseled regularly to stop smoking. Smoking has been definitively linked to significant pulmonary, cardiovascular, and neoplastic disease, and accounts for one out of every five deaths in the United States.* It is considered the leading cause of preventable death. Nonsmokers exposed to smoke are also at increased risk for lung cancer, ear and respiratory infection, asthma, low birthweight, and residential fires. Smoking exposes patients not only to carcinogens, but also to nicotine, an addictive drug. Be especially alert to smoking by teenagers, the age group when tobacco use often begins, and by pregnant women, who may continue smoking during pregnancy.

The disease risks of smoking drop significantly within a year of smoking cessation. Effective interventions include targeted messages by clinicians, group counseling, and use of nicotine-replacement therapies. Clinicians are advised to adopt the four "As":

■ Ask about smoking at each visit.

■ Advise patients regularly to stop smoking in a clear personalized message.

■ Assist patients to set stop dates and provide educational materials for self-help.

■ Arrange for follow-up visits to monitor and support progress.

Preview: Recording the Physical Examination— The Thorax and Lungs

Note that initially you may use sentences to describe your findings; later you will use phrases. The style below contains phrases appropriate for most write-ups. Unfamiliar terms are explained in the next section, Techniques of Examination.

"Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or rhonchi. Diaphragms descend 4 cm bilaterally."

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