Respiratory History and Physical Exam
Patients with lung disease often complain of the following symptoms: dyspnea/shortness of breath, cough, sputum production, fatigue, exercise intolerance, chest tightness or chest pain. A thorough history and physical exam is required to identify other signs and symptoms to lead to a diagnosis.
- History
- Physical Exam
History
The respiratory history draws on standard components of the history
- Identifying Data
- Chief Concern
- History of Presenting Illness
- Past Medical History
- Social History
- Occupational History
- Family History
- Functional Inquiry
Chief Concern
History of Presenting Illness
along with standard HPI questions, ask about:
- cough - time of day, severity, dry and hacking or productive
- sputum - quantity, colour, consistency, time of day
- hemoptysis - source, colour, quantity
- dyspnea - orthopnea, PND, severity
- pain
- wheezing
Past Medical History
ask especially about prior illnesses, including:
- childhood respiratory illnesses
- asthma
- pneumonia
- TB
Social History
ask about travels
environmental history:
- home - animals, humidifiers, heating
- occupation - exposure to chemicals or other agents
- personal - smoking, alcohol, drugs, hobbies
Environmental Factors
CH2OPD2 mnemonic (Community, Home, Hobbies, Occupation, Personal habits,
Diet and Drugs)
Occupational history
- chronological listing of all jobs
- precise job activities
- all materials used in job, with MSDS if possible
- duration and intensity of exposure
- protective measures used, or breached
- ventilation of workplace
- timing relationship of symptoms with shift or vacation
- other workers similarly affected