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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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