1 history taking of chest & lungs

8/22/2019 1 History Taking of Chest & Lungs

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HISTORY TAKING for the

CHEST & LUNGS

Caesar L. Mendoza, M.D.,FPCP,FPCCP

SECTION OF PULMONARY MEDICINEMEDICAL CENTER MANILA


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80% of clinical information comes from

the history

Accurate and detailed chronologic events


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medical interview :

patient-centered

Set the Stageo Welcome the patient

ensure comfort & privacy

o Know & use the patient's nameintroduce & identify yourself


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Set the Agenda

o Use open-ended questions initiallyo Negotiate a list of all issues

avoid detail!

Chief complaint(s) & other

concerns


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Chief complaint

Main problem

Prioritize among problems


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History of Present Illness (HPI)

Story behind the present illness


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main respiratory symptoms

Dyspnea

Cough

Hemoptysis

Chest pain

wheezing


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HPI

Interview with "WH" questions

what?

when?

where?


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HPI

Quantify whenever possible

number of days instead of a while,

kaunti lang

Be as specific as possible and try to

record what the patient says

accurately

No interpretation


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Address as many of these details as

appropriate

Location Radiation

Quantity

Frequency

Relieving FactorsEffect on Function

Associated Symptoms

Aggravating Factors

DurationQuality


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Secondary History

expands on the primary history

a focused review of systems

interpretation (& experience)is necessary.


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Shortness of breath

Ask about effort intolerance

Ask if it happens even while at rest

Is it associated with chest pain

Cough

Secondary History


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Tertiary History

brings in elements of the past

medical history

that have direct bearing on the patient's

condition

Do you smokehow much how

long


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HPI

CC: Shortness of breath

Onset of symptom/s: when? Acute/sudden,

subacute, chronic

Sudden Anaphylaxis

Anxiety

AMI PE

Acute exacerbation of asthma

Long term onset of shortness of breathCOPD Asthma Heart failure Lung cancer

Fibrotic lung disease

Pulmonary hypertension


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Sub-acute presentations

HPI

Infection bacterial/viral pneumonia

Diurnal variation

Asthma Sleep apnea

Positional variation

Orthopnea

Medication

Inhalers Nebulisers O2 at home

Prednisolone / long term ABs


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HPI

CC: Cough

Asthma

COPD (productive sputum)

Infection (productive sputum)What is the sputum like?

Green infection

Brown infection, can contain blood

Pink frothy sputum orthopnea

Blood


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Frequency

Volume quantify in terms of teaspoons / cups

HPI


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HPI

CC: Chest pain

Respiratory pain due to pneumonia, cancer,

musculoskeletal

Radiation cardiac arm, jaw, & neck

backdissecting aortic aneurysm

Alleviating factors leaning forwards pericarditis


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REVIEW OF SYSTEMS (ROS)

Series of questions grouped by organ system

1. General/Constitutional

2. Skin/Breast

3. Eyes/Ears/Nose/Mouth/Throat

4. Cardiovascular

5. Respiratory

6. Gastrointestinal

7. Genitourinary8. Musculoskeletal

9. Neurologic/Psychiatric

10. allergic/Immunologic/Lymphatic/Endocrine


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Past Medical History

background information related to the

patient's health & well being

Allergies and Reactions toDrugs

What happened?


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- Current Medications

Medical/Psychiatric Illnesses (Diabetes,Hypertension, Depression, etc.)

Surgeries/Injuries/Hospitalizations

(Appendectomy, Car Accident, etc.)

OTC drugs

Immunizations


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Occupational and social history

Occupational Asthma

Industrial Dust Diseases

Asbestos-related Diseases

Extrinsic Allergic Alveolitis

Sick Building Syndrome


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Hobbies and petsLifestyle: alcohol consumption

illicit drugs

Smoking history: type & number ofcigarettes smoked

passive

smoking

Occupational and social history

Sexual history

HIV and AIDS


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Family history

Respiratory diseases with a

genetic component

Infectious diseases


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Respiratory problems may be caused by disorders ofother organ systems

Loss of appetite is a common feature whenever people are unwell.

It suggests that the disease is having a significant effect on

wellbeing

Significant loss of weight may well be indicative of serious illness,

e.g. malignancy or tuberculosis

gastro-oesophageal reflux is a common cause of chronic cough.

Heart disease may cause respiratory symptoms

Severe anaemia may cause breathlessness

Neuromuscular diseases may cause respiratory symptoms,

particularly dyspnea


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EXERCISE MYTH

If walking/cycling is good for your health,

the postman would be immortal.

A rabbit runs and hops and only lives 15 years.

A tortoise doesn't run, barely walks & does nothing ..yet

lives for 450 years!!!

And you want me to Exercise?


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END

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1 history taking of chest & lungs

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