UKRAINIAN MINISTRY OF PUBLIC HEALTH
Vinnytsya National Medical University n. a. M.I. Pyrogov
«APPROVED»
At the methodological meeting of the
internal medicine propedeutics department
Chief of the department
___________ prof. Mostovoy Y.M.
«______»_______________ 2017 y.
Guidelines
for Third-year Students of the Medical Department
Subgect
Module №
Enclosure module №
Topic
Propedeutics of the internal medicine
1
1
The main complains of the respiratory patients.
Management of patients and writing of the case history.
Course
Faculty
3
Medical № 1
Methodical recommendations are made in accordance with educationally-qualifying
descriptions and educationally-professional programs of preparation of the specialists ratified
by Order MES of Ukraine from 16.05 2003 years № 239 and experimentally - curriculum,
that is developed on principles of the European credit-transfer system (ECTS) and Ukraine
ratified by the order of MPH of Ukraine from 31.01.2005 year № 52.
Vinnytsya- 2017
1. Importance of the topic
Inquiring patients is the basic, informative method of examination. It is the first interaction
between the patient and doctor. If it has been done correctly, it provides valuable information
that cannot be obtained in any other way. It allows recognizing symptoms of disease and
points, in the most cases, diagnostic search on the right way. If patient suffers from the
respiratory diseases he has a lot of specific and general symptoms that must be reveal and
rightly assess. It is very important part of the diagnostic process.
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2. Concrete aims:
asking about main respiratory symptoms
refinement respiratory symptoms
taking medical history
assessment of the obtained data
3. Basic training level
Previous subject
Normal anatomy
Normal physiology
Histology
Obtained skill
Anatomy of the airways and lungs, their blood supply and
innervation
Mechanics of breathing, gas exchange
Ontogenesis of the respiratory tract, histological structure of
the respiratory tract and alveoli
4. Task for self-depending preparation to practical training
4.1. List of the main terms that should know student preparing practical training
Term
wheezing
dyspnea
cough
hemoptysis
smoking
history
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Definition
Whistle and noise breathing with feeling breathlessness
Difficult breathing
Reflective act for self-cleansing of the airway from physiologic or
pathologic contains
Coughing up blood
Amount of cigarettes that patient smoke in a day multiply to number of
smoking years and divide to 20 (pack/years)
4.2. Theoretical questions:
Rules of the interviewing respiratory patient.
Main respiratory symptoms
What is cough and its refinement, features at the respiratory patients?
What is dyspnea and its refinement, features at the respiratory patients?
What is wheezing? Which syndrome and diseases can it appear in?
What is hemoptysis? How is it differenced from lung bleeding?
Features of the chest pain in case of the respiratory diseases.
Peculiarities of taking history respiratory patients.
Assessment of the obtaining data during inquiring respiratory patient.
4.3. Practical task that should be performed during practical training
Inquiring patient about respiratory symptoms
Refinement of the respiratory symptoms
Taking history of the respiratory patient
Assessment subjective data revealed at the respiratory patient
5. Write a part of the case history the respiratory patient.
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5. Topic content
The main complaints of the respiratory patients are cough, sputum production,
dyspnea, wheezes, chest pain, and hemoptysis.
Cough (tussis) is a difficult reflex-protective act that arises up at the irritation of
cough areas:
larynx,
bifurcation of trachea and bronchi,
gullet,
pleurae sheets,
external acoustic ducts.
There are many different factors (sputum, mucus, blood, dust, toxic gases, pieces of
meal and other) can provoke cough.
Cough occurs due to inflammatory, mechanical, chemical, thermal irritation of cough
receptors. In case of inflammation, exudative processes irritate the mucous membrane of the
respiratory tract (laryngitis, tracheitis, bronchitis, and bronchiolitis) as well as from the
alveoli (pneumonia, lung abscess). Mechanical irritants are small particles breathed in with
the air (dust) or disturbance of the respiratory tract patency due to compression or increased
tone. Thermal irritants are very cold or very hot air. Chemical irritants are gases with strong
odor, including cigarette smoke.
The clinical description of cough relies to its character, timing and sputum
production.
According to the rhythm, three forms of cough can be distinguished: a cough is
permanent, periodic and fit-like. Permanent cough occurs in laryngitis, acute bronchitis,
bronchogenic tumor of the lungs and in certain forms of tuberculosis.
Periodic cough is characteristic of influenza, pneumonia, pulmonary tuberculosis, and
chronic bronchitis.
Certain aspects of the timing of coughing may give useful diagnostic clues. Morning
cough is characteristic chronic bronchitis and sometimes asthma. Nocturnal cough is
characteristic of tuberculosis, limphogranulomatosis, tumor. Evening cough can happen at
the patients with pneumonia and acute bronchitis.
As to the character, the cough can be dry (without sputum, tussis sicca) and
productive or moist (with sputum, tussis humida). Dry cough is observed in bronchitis,
pleura irritation, miliary tuberculosis, in affection of the bronchopulmonary lymph nodes
(pressure on the vagus nerve), whooping cough, asthma; Productive cough is present in
bronchitis, pneumonia, lung tumor, purulent diseases of the lungs, bronchiectasis.
As to the timber, there are several patterns:
1) hacking cough, short and long, usually is accompanied by a painful mimic, is
observed in dry pleurisy, initial stages of pleuropneumonia;
2) stridor in trachea compression with a tumor, goiter, in hysteria, laryngeal diseases;
4) hoarse — in inflammation of the vocal cords;
5) soundless — in ulceration, edema of the vocal cords, general malaise.
According to perspective of the conditions causing cough or the phenomena
accompanying the cough, the following types can be distinguished:
1) cough caused by the changes in the position, observed when cavities in the lungs
are present (bronchiectasis, caverns, abscess, gangrene of the lungs);
2) cough associated with meals (especially when food particles are present in the
sputum), is seen when the esophagus is joined with the trachea or bronchus (esophageal
cancer perforated to the respiratory tract);
3) cough accompanied by abundant sputum discharge, characteristic for emptying
cavities, perforation of the abscess or empyema to the bronchus;
4) cough accompanied by vomiting, observed in whooping cough, pulmonary
tuberculosis, chronic pharyngitis.
The character of the sputum may be helpful in the differential diagnosis. Thus, a
cough producing frothy, pink-tinged sputum occurs in pulmonary edema; clear, white,
mucoid sputum suggests viral infection or longstanding bronchial irritation; thick, yellowish
or pus-containing (purulent) sputum suggests an infectious cause; rusty sputum suggests
pneumococcal pneumonia; blood-streaked sputum suggests tuberculosis, bronchiectasis,
carcinoma of the lung, or pulmonary infarction. Large amounts (copious) sputum is
characterized bronchiectasis.
Hemoptysis (haemoptoe). Hemoptysis is blood discharge at cough. If patient
expectorates more than 50 ml blood in a day this condition is named pulmonary bleeding.
This may be caused by the diseases of the lungs, airways (bronchi, trachea, larynx),
cardiovascular system.
The expectoration of blood or of sputum, either streaked or grossly contaminated with
blood, may be due to:
1) transudation of red cells into the alveoli from congested vessels in the lungs (acute
pulmonary edema);
2) rupture of dilated endobronchial vessels that form collateral channels between the
pulmonary and bronchial venous systems (mitral stenosis);
3) necrosis and hemorrhage into the alveoli (pulmonary infarction);
4) ulceration of the bronchial mucosa or the slough of a caseous lesion (tuberculosis);
minor damage to the tracheobronchial mucosa, produced by excessive coughing of any
cause, can result in mild hemoptysis;
5) vascular invasion (carcinoma of the lung);
6) necrosis of the mucosa with rupture of pulmonary-bronchial venous connections
(bronchiectasis).
Massive hemoptysis may also be due to rupture of a pulmonary arteriovenous fistula;
exsanguinating hemoptysis may occur with rupture of an aortic aneurysm into the
bronchopulmonary tree.
Hemoptysis associated with shortness of breath suggests mitral stenosis; in this
condition the hemoptysis is often precipitated by sudden elevations in left atrial pressure
during effort or pregnancy and is attributable to rupture of small pulmonary or
bronchopulmonary anastomosing veins. Blood-tinged sputum in patients with mitral stenosis
may also be due to transient pulmonary edema; in these circumstances it is usually associated
with severe dyspnea.
A history of hemoptysis associated with acute pleuritic chest pain suggests pulmonary
embolism with infarction.
Recurrent hemoptysis in a young, otherwise asymptomatic woman favors the
diagnosis of bronchial adenoma.
Hemoptysis associated with congenital heart disease and cyanosis suggests
Eisenmenger syndrome.
A history of recurrent hemoptysis with chronic excessive sputum production suggests
the diagnosis of bronchiectasis.
Hemoptysis associated with the production of putrid sputum occurs in lung abscess,
whereas hemoptysis associated with weight loss and anorexia in a male smoker suggests
carcinoma of the lung. When blunt trauma to the chest is followed by hemoptysis, lung
contusion is the probable cause.
A history of drug ingestion may be helpful in elucidating the etiology of hemoptysis;
e.g., anticoagulants and immunosuppressive drugs can cause bleeding.
A history of ingestion of contraceptive pills may be a risk factor for the development
of deep vein thrombosis and subsequent pulmonary embolism and infarction.
The blood may be bright red (in pulmonary tuberculosis, bronchogenic lung cancer,
actinomycosis, vasculitis, bronchiectasis) or rusty-colored (in pleuropneumonia, lung
infuriation) due to decomposition of the erythrocytes and hemosiderin formation.
Dyspnea (dyspnoea) may be both subjective and objective. In subjective dyspnea the
patient notices difficulties in respiration. In objective dyspnea, the frequency, depth and
rhythm of respiration change, as well as duration of inspiration and expiration. Subjective
dyspnoea is present in hysteria, thoracic radiculitis, diencephalic syndrome, objective is
observed in lung diseases (COPD, bronchogenic cancer, pneumonia, tuberculosis, pulmonary
emphysema, bronchial asthma, pleura obliteration, etc.). Two types of dyspnea can be
distinguished as to the phase of respiration in which the patient has difficulties: in difficult
inspiration — inspiratory, in difficult expiration — expiratory, in simultaneous difficulties in
both breathing in and out — mixed dyspnea. Dyspnea may be physiological (on physical
exercise) and pathological (in diseases of the respiratory system, cardiovascular system,
hemopoietic organs, poisoning, etc.).
 Inspiratory dyspnea (dyspnoea inspiratoria) occurs when some mechanical obstacle gets
into the upper respiratory tract, at narrowing of the trachea or a large bronchus (chiefly
bronchiogenic cancer). The respiration becomes noisy (stridor). Inspiratory edema appears in
prolapse of the tracheal or bronchial mucosa.
 Expiratory dyspnea (dyspnoea expiratoria) develops when opening of the small bronchi
is narrowed due to inflammatory swelling of the mucous membrane, bronchospasm
(bronchial asthma), hypersecretion which prevents reverse movement of the air from the
alveoli.
 Mixed dyspnea occurs in considerable reduction of the respiratory surface of the lungs
(thrombosis of the pulmonary artery, pneumonia, bronchiolitis, lung edema, etc.).
Intensive dyspnea frequently accompanied by asphyxia is called suffocation, which
develops in bronchial asthma, lung edema, fibrous alveolitis.
Wheezes are caused by air passing through narrowed airways and heard for a distance
by patient. They are symptoms of acute bronchial asthma, asthma attack, sometimes COPD.
Origin of difficulty in breathing a patient often binds to the action of allergens (paint,
pollen of plants, smoke, domestic chemistry, a dust is domestic, book, tissue).
During the attack of difficulty in breathing of patient occupies the forced position
with fixing of overhead humeral belt. Difficulty in breathing is accompanied a fit-like dry
cough. Exhalation is laboured. During exhalation dry wheezes are audible. Duration of attack
a few minutes to 24 hours. An attack is halted after the removal of action of allergen and
application of medications of extending shallow bronchial tubes. At the end of attack a
patient expectorates viscid glassy sputum.
In respiratory diseases, pleura involvement results in a chest pain (dolor in pectore),
because the pleura contains sensitive nerve endings, which are absent in the lung tissue.
The location of the pathological focus is responsible for the place of the pain. In dry
pleurisy the pain develops in the low lateral portions of the chest, "pain in the side". When
the diaphragmatic pleura is involved, the pain is felt in the abdomen and mimics such
diseases as appendicitis, acute cholecystitis, pancreatitis. The pleural pain is piercing,
becomes worse on deep breathing, cough and when the patient is lying on the healthy side. In
diaphragmatic pleurisy and spontaneous pneumothorax the pain is usually acute and
intensive, accompanying with dyspnea.
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Features of history
Risk factors of the respiratory diseases:
Humidity of apartment, overcooling
Contact with patient who has respiratory inflectional diseases
Professional to harmfulness (poultry houses, miners, chemical and cements productions
sewing factories and other)
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Smoking history more than 10 pack/year (amount cigarettes in a day*number years of
smoking/20)
Family history of the respiratory disease.
6. MATERIALS FOR SELF-CONTROL
Tests for self-control
1. What are the respiratory symptoms?
A. *Chest pain, cough, dyspnea, wheezes, haemoptysis.
B. Pain in the heart region, palpitation, intermissions, oedema
C. Headache, dizziness, dysphagia, nausea, vomiting.
D. Pain in the right subcostal region, bitter taste, brown urine, skin itching, jaundice.
E. Back pain, dysuria, ishuria, eyes oedema, weakness.
2. What are the respiratory symptoms?
A. Abdominal pain, nausea, vomiting
B. Heartburning, faint (syncope), palpitation
C. *Cough with rusty sputum, chest pain, dyspnea
D. Swelling abdomen, constipation, melena
E. Oedema, dysuria, haematuria
3. What feature does pleural pain have?
A. Be caused by physical extension
B. Radiate to the right hand
C. *Appears and increases due to cough and deep breathing
D. Radiate to the left hand and scapula
E. Duration under 15 minutes.
4. What are the cough causes?
A. Irritation of the larynx receptors
B. Irritation of the trachea and bronchus receptors
C. Irritation of the pleural receptors
D. *All mentioned above
E. Northing from above
5. If patient has laryngitis his cough is characterized with
A. *harsh and hoarse sound
B. absent of sputum
C. it is permanent
D. it is loud
E. all mentioned above.
6. If patient has clear, thick sputum it is named
A. *Mucoid
B. Purulent
C. Copious
D. Fetid
E. Hemoptysis
7. Chronic expectorating copious sputum is observed at patient with
A. Acute bronchitis
B. Asthma
C. Atelectasis
D. Emphysema
E. *Bronchiectasis
8. What is an objective dyspnea?
A. Disorders of the respiratory rate
B. Disorders of the respiratory depth
C. Disorders of the respiratory rhythm
D. *Disorders of the respiratory rate, depth, rhythm
E. Northing from above
9. Which type of dyspnea is observed at the patients with obstructive syndrome?
A. *Expiratory
B. Inspiratory
C. Mixed
D. Changing
E. All mentioned above.
10. Which types of dyspnea do you know?
A. Mixed
B. Expiratory
C. Inspiratory
D. *All mentioned above
E. Northing from above
11. Sputum production that contains pus is described by what term?
A. *Purulent
B. Fetid
C. Copious
D. Colored
E. None of the above
12. Which of the following characteristics is not typical of pleuritic chest pain?
A. *Increases with deep breathing
B. Increases with coughing
C. Radiates to the jaw
D. Is located laterally
E. Diminishes with splinting of the affected side
13. Which type of pulmonary problem usually causes a breathing pattern with a
prolonged expiratory time?
A. *Chronic obstructive pulmonary disease
B. Atelectasis
C. Pulmonary edema
D. Pneumonia
E. Pleural effusion.
14. Inspiratory dyspnea is –
A. Difficult breathing during exhalation
B. *Difficult breathing during inhalation
C. Difficult breathing during exhalation and inhalation
D. Difficult breathing during hyperventilation
E. Northing from above
15. Expiratory dyspnea is –
A. *Difficult breathing during exhalation
B. Difficult breathing during inhalation
C. Difficult breathing during exhalation and inhalation
D. Difficult breathing during hyperventilation
E. Northing from above
16. Mixed dyspnea is –
A. Difficult breathing during exhalation
B. Difficult breathing during inhalation
C. *Difficult breathing during exhalation and inhalation
D. Difficult breathing during hyperventilation
E. Northing from above
17. Whistle and noise breathing with feeling breathlessness is named …
A. Dyspnea
B. Respiratory noise
C. Musical breathing
D. *Wheezing
E. All mentioned above
18. What quantity of the blood is characterized hemoptysis?
A. *20-50 ml
B. 60 – 70 ml
C. 140 - 250 ml
D. All mentioned above
E. Northing from above
19. Lung bleeding is a pathological condition when the blood expectorates from
airways. What quantity of the blood is characterized lung bleeding?
A. 15 - 20 ml
B. 30–40 ml
C. *240 - 250 ml
D. All mentioned above
E. Northing from above
20. Amount of cigarettes that patient smokes in a day multiply to number of smoking
years and divide to 20 (pack/years) use for calculating …
A. Smoking history
B. *Smoking consumption
C. Smoking habit
D. Smoking abuse
E. All mentioned above.
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Control questions
Main respiratory symptoms
What is cough and its refinement, features at the respiratory patients?
What is dyspnea and its refinement, features at the respiratory patients?
What is wheezing? Which syndrome and diseases can it appear in?
What is hemoptysis? How is it differenced from lung bleeding?
Features of the chest pain in case of the respiratory diseases.
Peculiarities of taking history respiratory patients.
Assessment of the obtaining data during inquiring respiratory patient.
Practical tasks
Asking patient about respiratory symptoms as main complaints
Refinement respiratory complains and their assessment
Taking disease history and its assessment
Taking life history patients with respiratory diseases and its assessment
Making conclusions after inquiring respiratory patient
Writing part of case history of the respiratory patient
Situation tasks
Task 1. 25-year-old male patient suddenly felt breathlessness with audible whistle noise after
contact with dust. He noted similar respiratory disorders periodically during last 7 years.
1. Which respiratory symptom does patient have?
2. How should the symptom be specified?
3. What parts of life history are the most informative in this case?
Task 2. 67-year-old female patient complains of dyspnea, cough and left side chest pain. The
symptoms appeared after hard work and overcooling 3 days before.
1. What additional questions should you ask for refinement the symptoms?
2. Is the disease acute or chronic? What should you ask for obtaining this data?
3. How may origin of the chest pain be established using interviewing?
Task 3. 34-year-old female was admitted to pulmonology department with severe mixed
dyspnea, high fever (39°C), cough with rusty sputum, piercing chest pain.
1. What questions should be asked for refinement chest pain?
2. How should the anamnesis morbi be collected?
3. What parts of the anamnesis vitae must be take into account for prescribing treatment?
Task 4. 70-year-old male patient notes increasing dyspnea, cough with purulent sputum
production during last week after overcooling. Mild dyspnea and periodical morning cough
disturbed patient long time (15 years). Patient is long time smoker (has been smoking 55 year, on
average 1 pack cigarettes in a day).
1. What type of dyspnea does patient have?
2. How is present condition of the patient named?
3. Calculate patients smoking history parameter.
7. Reference source
1.
Olga Kovalyova, Tetyana Ashcheulova Propedeutics to internal medicine, Part 1. –
Vinnytsya: NOVA KNYHA, 2006. – p. 15-18, 70-76.
2.
V. Vasilenko, A. Grebenev. Internal disease. An Introductory Course. – English
translation, Mir Publishers. – Moscow, 1987 – P. 33-40, 111-116.
3.
Barbara Bates. A guide to Physical Examination and History Taking. – J. B. Lippincott
Company, Philadelphia, 1995. – P. 3-24, 237-252.
4.
Oxford Handbook of Clinical Medicine. –6th edition / Murray Longmore, Ian B.
Wilkinson, Supraj Rajagopalan. – OXFORD University Press, 2004. – P. 48-52.
5.
Bajraktarevic, Jakob. Respiratory pocket. Clinical Reference Guide. – Borm Bruckmeier
Publishing LLC, 2004. – P, 29-40,
6.
Harrison’s principles of internal medicine.-.16th ed.- McGraw-Hill, Medical Publishing
Division, 2005. – Vol. 1. - P. 201-216, Vol. 2. – P. 1504-1574.
7.
Guide to case report writing, history taking and physical examination of the therapeutical
patient / Textbook for the medical students by Ukrainian, English or Russian / 2nd editional with
correction and added/ Y. M. Mostovoy, A. V. Demchuk, T. V. Konstantynovych, T. D.
Danilevych, V. L. Poberezhets. – Vinnytsia: Center DZK, 2016. – 120 p.
Professor
T. V. Konstantynovych