HISTORY TAKING for the CHEST & LUNGS

Caesar L. Mendoza, M.D.,FPCP,FPCCP SECTION OF PULMONARY MEDICINE MEDICAL CENTER MANILA

80% of clinical information comes from the history

Accurate and detailed chronologic events

medical interview : patient-centered

Set the Stage o Welcome the patient ensure comfort & privacy o Know & use the patient's name introduce & identify yourself

Set the Agenda

o
o

Use open-ended questions initially Negotiate a list of all issues avoid detail! Chief complaint(s) & other concerns

Chief complaint

Main problem Prioritize among problems

History of Present Illness (HPI)

Story behind the present illness

main respiratory symptoms

Dyspnea Cough Hemoptysis Chest pain wheezing

HPI
Interview with "WH" questions
what?

when? where?

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

Address as many of these details as appropriate

Location

Quality Duration Aggravating Factors Relieving Factors Effect on Function Associated Symptoms

Radiation Quantity Frequency

Secondary History expands on the primary history a focused review of systems interpretation (& experience) is necessary.

Secondary History
Shortness of breath Ask about effort intolerance

Ask if it happens even while at rest

Is it associated with chest pain Cough

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

HPI
CC: Shortness of breath Onset of symptom/s: when? Acute/sudden, subacute, chronic Sudden Anaphylaxis AMI PE

Acute exacerbation of asthma Anxiety Long term onset of shortness of breath

COPD Asthma Heart failure Fibrotic lung disease Pulmonary hypertension Lung cancer

HPI

Sub-acute presentations Infection bacterial/viral pneumonia Diurnal variation

Asthma

Sleep apnea

Positional variation Orthopnea Medication Inhalers Nebulisers O2 at home Prednisolone / long term ABs

HPI CC: Cough Asthma

COPD (productive sputum)

Infection (productive sputum) What is the sputum like? Green infection Brown infection, can contain blood

Blood
Pink frothy sputum orthopnea

HPI
Frequency Volume quantify in terms of teaspoons / cups

HPI
CC: Chest pain

Respiratory pain due to pneumonia, cancer, musculoskeletal

Radiation arm, jaw, & neck back dissecting aortic aneurysm leaning forwards pericarditis cardiac

Alleviating factors

REVIEW OF SYSTEMS (ROS)

Series of questions grouped by organ system

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

General/Constitutional Skin/Breast Eyes/Ears/Nose/Mouth/Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Neurologic/Psychiatric allergic/Immunologic/Lymphatic/Endocrine

Past Medical History

background information related to the patient's health & well being Allergies and Reactions to Drugs What happened?

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

OTC drugs
Surgeries/Injuries/Hospitalizations (Appendectomy, Car Accident, etc.) Immunizations

Occupational and social history

Occupational Asthma
Industrial Dust Diseases Asbestos-related Diseases Extrinsic Allergic Alveolitis Sick Building Syndrome

Occupational and social history

Hobbies and pets

Lifestyle: alcohol consumption illicit drugs Smoking history: type & number of
cigarettes smoked

passive smoking
Sexual history HIV and AIDS

Family history
Respiratory diseases with a genetic component

Infectious diseases

Respiratory problems may be caused by disorders of other 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

EXERCISE MYTH
If walking/cycling is good for your health, the postman would be immortal. A rabbit runs and hops A tortoise and only lives 15 years.

doesn't run, barely walks & does nothing ..yet lives for 450 years!!!

And you want me to Exercise?

END
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