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Opening Consultation
Before starting, review the patient’s medical records for relevant musculoskeletal history if available.
Confirm the patient’s identity politely.
Teraz ty powiedz:
Mr. Jones? This way, please.
Ms. Jones? Please come in.
Could I please confirm your full name and date of birth?
Just to confirm, your name and date of birth?
Your full name and date of birth, please.
Introduce yourself warmly, stating your name and role.
Teraz ty powiedz:
Hello, I’m Dr. Jones. How can I help you today?
Good morning/afternoon, I’m Dr. Jones. What brings you in today?
Hi, I’m Dr. Jones. What would you like to discuss today?
Chief Complaint (CC)
The Chief Complaint (CC) refers to the primary symptom or concern that a patient presents with during a medical consultation. Common complaints related to the respiratory system include:
Complaint
Description
Cough
Cough can be dry (non-productive) or wet (productive). A dry cough is often associated with viral infections, asthma, GERD, or irritants like smoke. A productive cough, which brings up mucus, is typically seen in bacterial infections, chronic bronchitis, or bronchiectasis. Chronic cough lasting more than eight weeks warrants further evaluation.
Dyspnea
Dyspnea is the subjective sensation of difficulty breathing or breathlessness. It may be acute or chronic and associated with conditions like asthma, chronic obstructive pulmonary disease (COPD), heart failure, pulmonary embolism, or interstitial lung disease. Dyspnea can occur at rest or with exertion and may worsen when lying down (orthopnea) or at night (paroxysmal nocturnal dyspnea).
Wheezing
Wheezing is a high-pitched whistling sound that occurs during breathing, typically more noticeable during expiration. It indicates airway obstruction, which may be due to asthma, COPD, respiratory infections, or foreign body aspiration. Wheezing may be generalized (as in asthma) or localized to one area (suggesting a possible obstruction).
Chest Pain
Chest pain related to the respiratory system is often pleuritic in nature, meaning it worsens with deep breathing, coughing, or movement. Causes include pleuritis, pneumonia, pulmonary embolism, and pneumothorax. The pain is usually sharp or stabbing and may be accompanied by symptoms like dyspnea or fever.
Hemoptysis
Hemoptysis refers to the coughing up of blood or blood-streaked sputum. It may range from minor blood-streaking to massive bleeding. Common causes include lung infections (e.g., tuberculosis), bronchiectasis, lung cancer, and pulmonary embolism. Hemoptysis should always prompt further investigation.
Sputum Production
Sputum production indicates increased mucus secretion in the respiratory tract. Purulent sputum (yellow or green) suggests infection, while clear, white, or frothy sputum may be seen in viral infections or COPD. The volume, color, and consistency of sputum can provide important diagnostic clues.
Hoarseness
Hoarseness or changes in voice quality, also known as dysphonia, can occur due to laryngeal inflammation, vocal cord lesions, or nerve damage (e.g., recurrent laryngeal nerve). Common causes include laryngitis, GERD, smoking, or tumors affecting the larynx. Persistent hoarseness lasting more than three weeks warrants further evaluation.
Snoring or Sleep Apnea
Snoring and episodes of apnea (temporary cessation of breathing) during sleep may indicate obstructive sleep apnea (OSA). Risk factors include obesity, enlarged tonsils, and alcohol use. OSA is associated with daytime sleepiness, fatigue, and cardiovascular risks like hypertension.
Cyanosis
Cyanosis is a bluish discoloration of the skin or mucous membranes caused by low oxygen saturation in the blood. It may be central (affecting the lips and tongue) in severe cases or peripheral (affecting the extremities). Common causes include severe respiratory distress, COPD, pulmonary edema, or congenital heart defects.
Clubbing
Clubbing is characterized by the bulbous enlargement of the fingertips or toes, often associated with chronic hypoxemia. It is seen in conditions like lung cancer, bronchiectasis, cystic fibrosis, or pulmonary fibrosis. The underlying cause of clubbing is not fully understood, but it is thought to involve vascular and connective tissue changes.
History of Present Illness
The History of Present Illness (HPI) focuses on the patient’s respiratory symptoms and the progression of their condition. Using a structured approach, like OLD CARTS, can help in thoroughly assessing and understanding the nature of the respiratory symptoms
O – Onset: Determining when the cough began is crucial for diagnosis. Acute onset may suggest infections like pneumonia or bronchitis, while a chronic cough often indicates conditions such as asthma, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), or even post-nasal drip.
Teraz ty zapytaj – Onset:
When did the cough start?
Did it come on suddenly or gradually?
Was there any recent illness, exposure, or incident that triggered it?
Has the cough been consistent, or has it changed since it started?
L – Location: While cough generally affects the respiratory tract, identifying any associated areas of discomfort, such as the throat, chest, or upper abdomen, can provide diagnostic clues. Discomfort in these areas may indicate airway irritation, pleurisy, or even a cardiac source.
Teraz ty zapytaj – Location:
Do you feel discomfort in your throat, chest, or elsewhere?
Is there any chest pain or tightness with the cough?
Does the cough feel like it originates from deep in your chest or your throat?
D – Duration: The duration of the cough helps determine if it is acute, subacute, or chronic. Acute coughs (less than three weeks) usually indicate respiratory infections. Subacute coughs (three to eight weeks) may follow respiratory infections, while chronic coughs (over eight weeks) often relate to underlying conditions like asthma, GERD, or smoking-related lung diseases.
Teraz ty zapytaj – Duration:
How long have you been coughing?
Is it constant, or does it come and go?
Have you noticed changes in the duration or frequency over time?
C – Character: The nature of the cough—whether dry, productive (wet), hacking, or paroxysmal—can be diagnostic. For example, a productive cough with purulent sputum suggests bacterial infections, while a dry cough may be linked to irritants, asthma, or interstitial lung diseases. Paroxysmal coughing fits can occur with pertussis or asthma.
Teraz ty zapytaj – Character:
How would you describe the cough—dry, wet, or hacking?
Are you coughing up any mucus or blood?
Is the cough deep and rattling, or more of a tickle?
A – Associated Symptoms: Other symptoms such as fever, wheezing, shortness of breath, chest pain, or hemoptysis should be assessed. Fever and chills may suggest an infectious etiology, while wheezing or dyspnea might point towards asthma, COPD, or other airway obstructions.
Teraz ty zapytaj – Associated Symptoms:
Do you have any other symptoms, like shortness of breath or fever?
Is there any chest pain, wheezing, or difficulty breathing?
Have you noticed any unusual fatigue or weight loss?
R – Radiation: Though cough itself does not radiate but associated chest pain or discomfort may spread to the shoulder, upper back, or even down the arm. This could indicate pleuritic pain or a condition with overlapping cardiac symptoms.
Teraz ty zapytaj – Radiation:
Do you feel any pain that moves or radiates with the cough?
Is there tightness in your chest that spreads to your shoulders or back?
T – Timing: Understanding when the cough worsens can provide insights into potential causes. A nighttime cough may be associated with asthma or heart failure, while a morning cough can suggest chronic bronchitis. A cough that worsens with changes in position may indicate GERD.
Teraz ty zapytaj – Timing:
Is the cough worse at certain times, like at night or in the morning?
Do you notice a difference when lying down or being active?
Has there been any change in the cough over time?
S – Severity: The severity of the cough and its impact on the patient’s daily activities, such as sleep disturbances, fatigue, or missed work, should be noted.
Teraz ty zapytaj – Severity:
On a scale of 0-10, how severe is the cough?
Is the cough affecting your sleep or daily activities?
Would you describe the impact as mild, moderate, or severe?
Past Medical History
Understanding the patient’s past medical history is essential for identifying potential respiratory risk factors and comorbidities:
Asthma: A history of asthma is significant, especially if the patient experiences frequent exacerbations or has poor symptom control. It may suggest a need for adjustments in their asthma management plan.
Chronic Obstructive Pulmonary Disease (COPD): This category includes both chronic bronchitis and emphysema. A history of smoking is commonly associated with the development of COPD.
Pneumonia: Recurrent episodes of pneumonia may indicate an underlying immunodeficiency or chronic lung disease, necessitating further investigation.
Tuberculosis (TB): A history of TB raises the risk of lung scarring or the development of bronchiectasis, which can lead to chronic respiratory issues.
Pulmonary Embolism (PE): A personal or family history of PE or deep vein thrombosis increases the risk of future embolic events and may indicate the need for preventive measures.
Lung Cancer: A history of smoking or previous cancer diagnoses increases the risk of lung malignancies. Close monitoring and early screening may be warranted.
Occupational Exposures: Previous jobs with exposure to asbestos, silica, or other harmful substances should be noted, as they increase the risk for diseases like asbestosis, silicosis, or occupational asthma.
Teraz ty zapytaj – Past Medical History:
Do you have a history of asthma, and have you experienced frequent exacerbations?
Have you been diagnosed with COPD, chronic bronchitis, or emphysema?
Have you had pneumonia in the past, especially more than once?
Have you ever been treated for tuberculosis?
Do you or your family have a history of pulmonary embolism or blood clots?
Have you been diagnosed with lung cancer, or do you have a history of smoking?
Did you have any occupational exposure to substances like asbestos, silica, or chemicals?
Medications
Understanding the patient’s current and past medications provides insight into their treatment history and potential drug-related causes for respiratory symptoms:
Current Respiratory Medications Ask about inhalers, bronchodilators, corticosteroids, or other asthma/COPD treatments. Evaluate their effectiveness and adherence to the prescribed regimen.
Recent Antibiotics or Steroids Recent use of antibiotics or steroids may indicate a history of respiratory infections or asthma/COPD exacerbations.
Medications with Respiratory Side Effects Some medications, such as ACE inhibitors, can cause chronic cough, while beta-blockers may exacerbate asthma.
Over-the-Counter and Herbal Supplements These can interact with prescribed medications or have effects on respiratory symptoms (e.g., supplements that cause allergic reactions or worsen asthma).
Teraz ty zapytaj – Medications:
Are you currently using any inhalers or other respiratory medications?
Have you recently taken antibiotics or steroids for a respiratory problem?
Are you taking any medications that could cause side effects like cough or wheezing?
Do you use any over-the-counter drugs or herbal supplements?
Have you had any changes in your medication regimen recently?
Family History
Family history can help uncover hereditary respiratory conditions. Important conditions to inquire about include:
Asthma: Asthma often has a genetic predisposition, and a family history may increase the likelihood of diagnosis.
Cystic Fibrosis: This genetic condition causes chronic respiratory infections and pancreatic insufficiency.
Alpha-1 Antitrypsin Deficiency: A genetic condition that predisposes individuals to early-onset emphysema, especially in the presence of smoking or occupational exposures.
Teraz ty zapytaj – Family History:
Is there a family history of asthma or other respiratory conditions?
Do any of your family members have cystic fibrosis?
Is there a known history of alpha-1 antitrypsin deficiency in your family?
Social History
A detailed social history is crucial for identifying modifiable risk factors for respiratory diseases:
Smoking: Smoking is the leading cause of COPD and lung cancer. Assess the patient’s smoking history in pack-years (packs per day multiplied by years of smoking).
Secondhand Smoke: Exposure to secondhand smoke can increase the risk of respiratory illnesses even in non-smokers.
Occupational Hazards: Consider exposure to chemicals, dust, or asbestos, particularly in jobs such as construction, mining, or manufacturing.
Substance Use: Recreational drug use, such as smoking crack or inhaling other toxic substances, can cause significant lung damage, including pneumonitis or chronic bronchitis.
Travel: Recent travel, particularly to regions endemic to infections like tuberculosis or fungal diseases (e.g., histoplasmosis), can guide differential diagnosis.
Teraz ty zapytaj – Social History:
Do you smoke, or have you smoked in the past? If so, how many pack-years?
Are you exposed to secondhand smoke at home or work?
Have you ever worked in environments with dust, chemicals, or asbestos exposure?
Do you use recreational drugs, such as smoking substances or inhaling chemicals?
Have you traveled recently, particularly to areas with a higher risk of tuberculosis or fungal infections?
Allergies
Assessing allergies helps identify potential triggers and guides management, especially in asthma or allergic respiratory conditions:
Drug Allergies: Identify any medications that cause allergic reactions, especially antibiotics, which could be used for treating respiratory infections.
Environmental Allergies: Common triggers like pollen, dust mites, animal dander, or mold can exacerbate asthma or other respiratory symptoms.
Food Allergies: While less commonly linked to respiratory issues, some severe food allergies can cause anaphylaxis with respiratory distress.
Occupational Allergies: Exposure to certain substances at work (e.g., chemicals, dust) can lead to occupational asthma or hypersensitivity pneumonitis.
Teraz ty zapytaj – Allergies:
Do you have any known drug allergies, especially to antibiotics or respiratory medications?
Are you allergic to common environmental triggers like pollen, dust mites, or pets?
Have you experienced respiratory symptoms related to food allergies?
Do you have any known allergies linked to your workplace or specific substances you handle at work?
Have you noticed any allergic reactions to recent medications or environmental changes?
Environmental and Occupational Exposures
In addition to social history, environmental and occupational exposures significantly impact respiratory health:
Home Environment: Poor ventilation, mold, or exposure to dust mites and other indoor allergens can exacerbate asthma and other chronic lung diseases.
Occupational Exposure: Jobs involving exposure to chemicals, fumes, or particulate matter increase the risk of occupational lung diseases such as silicosis, asbestosis, and pneumoconiosis.
Teraz ty zapytaj – Environmental and Occupational Exposures:
Do you have mold, poor ventilation, or other indoor air quality issues at home?
Does your job involve exposure to chemicals, fumes, or dust?
Have you been exposed to any known respiratory hazards at work?
Closing the Consultation
Summarize the main points discussed during the history-taking to confirm understanding and ensure no details were missed.
Teraz ty powiedz:
Let me summarize what we’ve discussed so far to make sure I have everything correct.
To confirm, you’ve mentioned [key symptoms or points]. Does that sound accurate?
Is there anything important that we haven’t covered?
Before we proceed, is there anything else you’d like to add or clarify?
Thank you for sharing all these details; it will help us plan the next steps effectively.
Ask the patient if they have any remaining questions or concerns before moving forward with the examination.
Teraz ty powiedz:
Do you have any other questions or concerns before we start the examination?
Is there anything else you’d like to discuss before we begin the physical exam?
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