HISTORY TAKING

in
RESPIRATORY DISORDERS

Lecture Presentation by;

Anatomy Department
Faculty of Medicine
HISTORY TAKING

Employ your eyes, ears, nose, hands

Start by telling the patient your name and who you are proper
greeting and introduction (a warm welcome)

Guide the conversation

HISTORY TAKING

Treat the pts. as the rational human being they are

Explain what and why you are doing

All questions should leave the patient with a free choice of answers
HOW TO TAKE HISTORY

Always record the pts name, age, sex, ethnic group, marital status,
job, place

Record the date and time of exam.

Note the way of admission, who referred the pt. to surgery

HOW TO TAKE HISTORY

The assessment of the surgical pt. aims to:

confirm the diagnosis
detect associated medical illnesses
assess fitness for anesthesia
 CHIEF COMPLAINTS

What brought the patient to you?

ONE Main complaint
Followed by other related complaints
Latest one on the top
Duration of each complaint v.important
Elaborate the c/c in H/O Present illness
 THE PRESENT COMPLAINT

What is the problem ?

Note the answer in the pts own words

Associated complaints
Events Leading to APPROACH Dr.

Get as much information as you can

What happened, what were you doing
Has anything unusual happened?
If this is a chronic problem, whats different this time?
Final SAMPLE notes

Try to ask open ended questions (avoid yes/no questions)

Wait for the patient to respond
5-10 seconds is not out of line
Note pertinent negatives
Write everything down
HISTORY OF THE PRESENT COMPLAINT

Full details of the history of the main complaint/complaints

Get back to the beginning of the trouble (point no. 1 onwards)
Onset: sudden or gradual
Progression till now
Related complaints more or less significant
HOW TO TAKE HISTORY

Remaining questions about of the abnormal system

Systematic direct questions

PAST MEDICAL HISTORY

OTHER ILLNESSES

ACCIDENTS

OPERATIONS
Past Medical History

Underlying medical problems

Recent visits to hospitals/doctors
Recent medical procedures
Recent accidents/falls/trauma
Medic Alert tags may be useful
Medical equipment in the house
DRUG HISTORY

DRUGS AND DOSES

ALLERGIES
Prescription and OTC
Including vitamins, herbal remedies
Birth Control Pills
Illicit Drugs
Always get a list of medicines
Home O2 rate is also important
What did you take, when, how much?
H/O Allergies

Environmental and Medical allergies are important

Medic Alert tags are also useful
FAMILY HISTORY

Parents alive or dead?

Medical conditions of parents & siblings.
E.g. D.M, T.B, HTN, CVS disorders etc.
DISEASES
CAUSES OF DEATH
Spouse and children any significant illness
SOCIAL HISTORY

TYPE AND PLACE OF DWELLING

OCCUPATION
CONTACT WITH HAZARDS
LEISURE ACTIVITIES
TRAVELS ABROAD
HABITS

SMOKING

ALCOHOL
APPETITE

Has the appetite increased, decreased or remained

unchanged ?
If decreased: anorexia or eating causes pain
Anorexia= lack or loss of appetite
Anorexia nervosa= prolonged refusal to eat, resulting in
emaciation (fear of becoming obese)
What are your new likes and dislikes ?
DIET

What type of food do you eat ?

When do you eat your meals ?

How long do the meals take ?

WEIGHT

Has your weight changed ?

How much ?

How quickly ?

Clothes have got tighter or looser ?

VOMITING

How often do you vomit ?

Is the vomiting preceded by nausea?

What is the nature and volume of the vomits?

What other symptoms are associated?
QUESTIONS OF THE RESPIRATORY SYSTEM

Cough

Hemoptysis

Dyspnea

Chest pain
COUGH

Sudden audible expulsion of air from the lungs

Coughing is preceded by inspiration, glottis partially closed, accessory

EM contract to expel the air forcibly from the resp. passages
COUGH

Protective response to clear the lungs, bronchi and trachea of

secretions

Chronic coughing- TBC, lung cancer

Episodes of chronic coughing- subphrenic irritation, CHF.

HEMOPTYSIS

Coughing up of blood from the respiratory tract

Blood-streaked sputum- minor URI

More profuse bleeding- lung abscess, TBC, lung cancer

DYSPNEA

Breathlessness- distressful sensation of uncomfortable breathing

Causes- heart conditions, strenuous exercise or anxiety

Wheeze= a whistling respiratory sound- COAD

CHEST PAIN

Site
Severity
Nature
Aggravating factors
Relieving factors
BREATHLESSNESS

Orthopnoea- breathlessness when lying down

Paroxysmal nocturnal dyspnoea- sudden attack in the middle of the

night that awakes the patient.
Dyspnoea shortness of breath
Summarize your case

c/c till end

Make Differential diagnosis
Start ruling out the DDs one by one
List only the relevant ones
Most probable diagnosis
Diagnosis & further management

Management plan begins now;

Investigations (non-invasive first)
Base lines
Chest x-ray
Perfusion scan
Tuberculin test (T.B)
Bronchoscopy (invasive)
Management

Plan further treatment with options