Symptoms: Dyspnea – Lung Disease

00:02 To identify what history… what disease they may have, that requires taking a history.

00:06 Now the format of the history for respiratory disease is the same as the format of the history for any other medical problem: patient's age, sex, country of birth, which we've already discussed. The next question is What is their main problem? What is their presenting complaint? And that may be one complaint—breathlessness—or maybe they've got two: breathlessness with chest pain. You then need to take a very detailed history of that presenting complaint. And this is something that students often fail to do effectively, is to take a very good assessment of the history of the presenting complaint so that you can fully describe what the patient has been suffering over the past day, minutes, weeks, months, years (depending on whether it's a chronic or acute problem). Past medical history may dictate the problem that they… respiratory problem that they're suffering from to a certain extent, so that needs to be explored. Social history is incredibly important for respiratory disease, as occupational and recreational exposures will often lead to respiratory diseases of very specific types.

01:14 The review of symptoms is something where you're basically asking the patient whether they have any other issues which may be affecting them at the present time, and they're not terribly important for most respiratory diseases. Treatment history is where you identify what medications or drug… and drug therapies the patient has been using, and that is important for all assessments—clinical assessments—of patients.

01:37 So to take the main symptoms that you might get in respiratory disease: These are breathlessness, cough, chest pain, wheeze. Those are the main problems that you might have. Taking dyspnea—shortness of breath—to start with: This can be caused by respiratory disease, obviously, but also by cardiac disease and by anemia, so you need to think about whether those are present as well. The important thing about breathlessness is to define how long the patient has been breathless for. Whether the breathlessness has a specific periodicity: Is it constant? Does it go up and down? Is it variable or intermittent? And it if it is there the whole time, is it a problem that's stable or is it getting worse? Because this feel for what's happening with the breathlessness will give you a good idea about what's going on.

02:30 So for example, asthma is an intermittent cause of breathlessness, whereas COPD will cause breathlessness the whole time, although there might be intermittent situations where it gets worse when you have an exacerbation. And some diseases—say, if you've had a resection for lung… for a lung cancer—may leave you more breathless than before, but that won't change over time. That would be a stable breathlessness since the surgery. If the disease is getting worse, then you need to get a feel for the speed of progression, because that will give you a feel for what the underlying cause is. So, for example, COPD (chronic obstructive pulmonary disease)—lung damage due to smoking—progresses slowly over months and years, in general.

03:15 It takes a long time to develop breathlessness due to COPD. However, if you've got a pleural effusion, that normally develops over a period of days and weeks, and so the breathlessness—as the effusion gets bigger—the breathlessness will get worse over that sort of period of time. And you work this out by assessing the patient's level of exercise tolerance. So for example, you can ask the patient, "Okay, you've been breathless for six months. What does it stop you from doing?" And the patient may say, "Well, I can walk to the bus, but that's about 200 yards. But if I try to go to the park, which is 400 yards, I can't do it." And that gives you a feel for how breathless they are, and it also gives you a measure. And you say, "Okay, a year previously, could you walk to the park?" And they say, "Yes." That means that the disease has progressed over that period of time. By using this assessment of what the patient can do without getting breathless and comparing to the past, you get a feel for whether it's constant, progressive, and also the level of severity of the problem. There is an MRC (a medical research council) scale that's used for breathlessness. I don't think it's particularly helpful, but it's important to know about it, as it is used often in papers and in clinical trials. So MRC Scale 0 means the patient's not breathless. Grade 1 means they're dyspneic on climbing hills and stairs, but they're okay if they're walking on the flat. Grade 2: Actually walking on the flat becomes a problem, but only after walking 1.5 km or thereabouts, and only if they're... or if they're forced to walk faster than usual for some reason, i.e. if they're walking with a friend who hasn't got a problem, is able to walk a bit faster than them. Grade 3 is where they get breathless on exertion after walking about 100 m. So they can walk 100 m; then they have to stop to catch their breath. And Grade 4 is severe breathlessness, which means they're breathless either at rest or on doing minimum effort: undressing, moving from the chair to the toilet, etc. So they're breathless pretty much the whole of the time.

05:30 So I mentioned before: Speed of onset is important for breathlessness. So there are a limited number of causes which cause very rapid deteriorations in your breathing over a short period of time, over minutes. A pneumothorax (air in the pleural space) comes on very suddenly, and that will be a sudden cause of breathlessness. An occlusion of the pulmonary arteries—a pulmonary embolus—again, that's a sudden cause of breathlessness. One minute the patient is fine; the next, they're breathless. Other causes which come on over a period of a few minutes or a few hours is pulmonary edema, left ventricular failure with fluid filling up the lungs, and asthma exacerbations. Episodic breathlessness: Periods when the patient is well with no breathlessness intermingled with periods where they are breathless: That tends to suggest asthma for respiratory disease, but it could also be due to heart disease in the form of ischemic heart disease, where you get periods of ischemia which make you feel breathless, but they're normally associated with chest pain (not always so). And then hyperventilation is a problem where patients will be hyperventilating and feeling breathless, but that's largely an anxiety-related problem rather than a physiological problem due to lung disease. And then there's progressive breathlessness.

06:43 And that could be over a short period of time, over days or weeks, and that would suggest a pleural effusion, developing anemia, or developing a collapse of the lung. So if you've got a tumor that's blocking a main bronchus, then slowly over time as that tumor grows, that bronchus becomes more and more blocked, and the patient becomes more and more breathless.

07:01 Also occurs with multiple pulmonary emboli, where small pulmonary emboli are blocking off individual small arteries over time. Progression over months or years: That will be a classical situation for somebody with chronic obstructive pulmonary disease, chronic asthma (so that's patients with slowly worsening asthma leading to airways obstruction over time). Bronchiectasis potentially can lead to progressive respiratory impairment over time. Interstitial lung disease and multiple pulmonary emboli. You also need to think about cardiac failure as a potential problem as well. But the classic situation there with people presenting with breathlessness over months is you need to think about COPD if they're a smoker, and if you hear crackles in their chest, it's… interstitial lung disease is the big thing that you need to consider.