History Taking of

Respiratory System
Pulmonology Departement

Activities

Lecture
overview
Demonstration of History Taking
based on symptoms in 3rd semester
small class
Self learning
Evaluation
check list
OSCE

CLINICAL COMPETENCE
3/4

Pernah melakukan atau pernah

menerapkan dibawah supervisi (3)
Mampu melakukan secara mandiri (4)

OBJECTIVES

To address the symptoms of ......

To review the anatomy &
pathophysiology, differential diagnosis,
pathogenesis, complication, guidelines for
evaluating .......
To review the etiology, pathogenesis,
differential diagnosis, diagnosis of ........

The successful student should be

able to :

Perform a complete history for a given

patient
Establish a comfortable rapport with the
patient
Exhibit empathy, tact and compassion,
maintaining a professional & ethical code
of conduct
Concisely communicate the history

DATA COLLECTION

1
0

Chief
complaint

Iterative hypothesis

Diferential diagnosis

1
5

Initial Problem /
Diagnosis

histor
y

Physical
examin
ation

tests

Introductory questions
Good relationship
Logical manner
Listen carefully
Interrupt appropriately
Note non-verbal clues
Correctly interpret

Presenting (principal) symptom

History of presenting illness
Past history
Social history
occupation, education, smoking,
alcohol, analgesic use, overseas travel,
immunisation, marital status, social
support, living conditions
Family history
Systems review

History of presenting illness

details of current illnesses, details of
previous, similar episode, current
treatment & drug history, menstrual &
reproductive history for women, extend
of functional disability

History of presenting illness

Current symptoms
the time of onset & duration; the mode of
onset; the site & radiation; especially of
pain; the character; the severity;
aggravating or relieving factors; associated
symptoms
Current treatment & drug history
tablets or medicines, colour or size, name &
dose, length of use. Treatment for blood
pressure, high cholesterol, diabetes,
arthritis, anxiety or depression, antibiotics,
NSAIDs

Sexual history
urethral discharge, dysuria, vaginal
discharge, a genital ulcer, anorectal
symptoms, type of sexual
practiseAIDS
Menstrual history
last menstrual period, age at which
menstrual began, regular, menopause,
childbearing years

Past history
Past illnesses
serious illnesses or operations or admissions to
the hospital. Childhood illnesses, obstetric or
gynaecological problems.
Past treatments, allergies, blood transfusions
The social & personal history
occupation, education, smoking, alcohol,
analgesic use, overseas travel, immunisation,
marital status, social support, living conditions

Occupation & education

work exposure to dust, chemicals or
disease : mine workers asbestosis.
Hobies bird fanciers and lung disease
Social habits
smoking : how many cigarettes (cigars or
pipe), for how many years . alcohol : how
much, how often ?

Family history
- family disease
- genogram

The systems review

shortness of breath, cough, cough up
anything, coughed up blood, snore
loudly, wheezing, fevers, night sweats,
pneumonia or tuberculosis, chest X-ray,

Detailed history & exploring possible

etiologies of cough :

Character ; what is the cough like ?

- clearing of the throat : GER & post nasal drip
- brassy cough (hard & metallic) : conditions
that narrow the trachea or larynx
- Barking cough (like a seal) : croup
- Hacking cough : pharyngitis,
tracheobronchitis, early pneumonia
- whooping cough : pertusis
- any sputum production ? If so, what collor &
how much ( mucus, blood, pus, pink froth) ?

Onset ; how did it start (sudden versus

gradual) ?
Intensity : at what time of day is your
cough at its worst ? Does it keep you
awake at night (asthma and chronic
bronchitis may be associated with
nocturnal or morning cough ?
Duration : how long has it been going on
(acute versus chronic versus paroxysmal
versus seasonal versus perrenial0? If
cough is chronic, how has it changed
recently ? Is it getting better, worse or
staying the same ?

Event associated :
- Pneumonia : fever, chills, rigors,
increased sputum production
- URTI : malaise, sore throat, rhinotthe,
myalgia, headache, ear pain
- tracheitis : retrosternal pain like a hot
poker
- TB / malignancy : hemoptysis,
costitutional symptoms

Detailed history & exploring possible

etiologies of dyspnea :
Character : describe the nature of your
breathing difficulty
Onset : how did the SOB start ( sudden vs
gradual) ?. What were you doing when
you became SOB ?
Intensity : how severe is your SOB right
now, on a scale of 1 to 10 with 1 being
mild and 10 being the worst ? Has it
gotten worse ?
Duration : how long have you been SOB?

Frequency : Has this ever happened to you

before ? If so, how often does it happen ?
When was the last time you became SOB ?
Palliative factors : Is there anything that
makes your SOB better ? if so, what ?
Provocative factors : Is there anything that
makesyour SOB worse ? If so, what ?
Exertion ?
Position (sitting up versuslying down)?
Exposure to cold air ?
Infection ?
Allergies

Frequency : Has this ever happened to you

before ? If so, how often does it happen ?
When was the last time you became SOB ?
Palliative factors : Is there anything that
makes your SOB better ? if so, what ?
Provocative factors : Is there anything that
makesyour SOB worse ? If so, what ?
Exertion ?
Position (sitting up versuslying down)?
Exposure to cold air ?
Infection ?
Allergies

Even associated
PE : Hemoptysis, pleuritic chest pain, DVT
Pulmonary edema / ACS : Exertional chest

pain (CP), PND, orthopnea, and peripheral

edema.
COPD : Cough, wheeze, and progressively
worsening SOBOE
Pneumonia, other infections : Fever / chills,
rigors, increased sputum production,
cough
Ascities : Abdominal distension

 Anxiety (diagnosis of exclusion) :

Lightheadedness, diaphoresis, trembling,

choking sensation, palpitations, numbness
or tongling in hands/feet, chest pain,
nausea, abdominal pain,
depersonalization/derealization, flushes or
chills, real of dying, fear of going crazy or
doing something uncontrolled
Constitutional symptoms: fever, chills,
night sweats, weight loss, anorexia, and
asthenia.

Thank you