OnExam

Identifying Information

Gather the patient's general identifying data.

Chief Complaint

Elicit the patient's chief complaint.

History of Presenting Illness (HPI)

Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.

Cough

  • Duration
    • Acute: < 3 weeks
    • Sub-acute: 3-8 weeks
    • Chronic: > 8 weeks
  • Productive vs. non-productive
    • Volume
    • Colour (mucoid, purulent, clear, bloody, brown)
    • Viscosity
    • Smell
  • Hemoptysis
  • Change in nature from chronic cough
    • Increase in sputum
    • Change in colour
  • Aggravating factors
    • Extreme temperatures
    • Animal contact
    • Exertion
    • Pollutants
    • Cigarette smoke
    • Dust
  • Postural clues suggestive of CHF
    • Orthopnea
    • PND
  • Sinus pressure, post-nasal drip, preceding URTI, rhinitis

Dyspnea

  • At rest or with exertion
    • If with exertion, what is their exercise tolerance
    • ≥4 METS if can walk up one flight of stairs without dyspnea
  • Changes with position
    • Orthopnea (dyspnea when lying horizontally)
    • Trepopnea (dyspnea when lying on one side)
    • Platypnea (dyspnea when seated)
  • Relation to stress or anxiety
  • Slow, insidious onset (i.e., with fibrosis) or rapid onset (i.e., asthma attack)
  • Environmental triggers (cold temperature, cigarette smoke, pollutant, animals, dust, pollen)

PE/DVT Risk Questions:

  • Prior DVT or PE
  • Clinical signs/symptoms of DVT
  • Leg swelling, pain with palpation of deep veins of leg
  • Current or previous malignancy
  • Hypercoaguable states (Factor V Leiden, prothrombin mutations)
  • Recent immobilization
    • Bed rest (≥3 days)
    • Long flights or car rides
  • Recent surgery (within 4 weeks)
  • Hemoptysis
  • Concurrent tachycardia
  • Chest Pain
    • Pleuritic chest pain
  • Wheezing
  • Snoring
  • Sleep apnea
    • STOP BANG: Snoring, tired (daytime), observed apneas, high BMI, neck circumference, age ≥50, gender male
    • Positive response to 3 criteria is 86% sensitive and 56% specific for presence of OSA
  • Fever, night sweats, or chills
  • Weight loss
  • Smoking (pack/years)
    • If quit, when and for how long had they smoked prior
    • Exposure to second-hand smoke
  • Sick contacts
  • Travel history/birthplace
    • Tuberculosis exposure
  • Environmental/occupational exposures

Past Medical History (PMHx)

Specifically ask about:

  • General history of previous illnesses, conditions, and hospitalization
  • Asthma
    • Last visit to hospital, previous hospitalizations, prior intubations, triggers, frequency of rescue inhaler use
  • COPD
    • Previous hospitalizations, previous steroid use, home oxygen use
  • Pneumonia
  • Interstitial lung disease
  • HIV
  • Congestive heart failure
  • Lung cancer
  • DVT or PE
  • Autoimmune disease

Family History (FmHx)

Specifically ask about:

  • Asthma
  • Atopy (asthma, atopic dermatitis, allergic rhinitis)
  • COPD
  • Pulmonary fibrosis
  • Cystic fibrosis
  • Alpha-1 antitrypsin deficiency
  • Lung cancer
  • Cardiac disease

Social History (SocHx)

Specifically ask about:

  • Occupational exposures (e.g., asbestos, silica)
  • Potential hazards related to housing
    • Prisons, mold, pets, dust, carpets

Substance Use History (SubHx)

Specifically ask about:

Medications

  • Ask about all medications patient is currently taking, and whether they are taken as prescribed
  • Particularly important medications pertaining to the Respiratory System include, but are not limited to:
    • Beta Blockers
    • ACE Inhibitors
    • Oral Contraception
    • Inhalers (Past and present)
      • Adherence and frequency of use
    • Anticoagulants
    • Diuretics
    • Steroids and other immunosuppressants
    • Recent antibiotic prescriptions

    Allergies

    Note allergies and ensure they concord with those listed in the EMR

    Immunizations

    Note immunization history as described in the immunization history section.

    Review of Systems

    Conduct a review of systems, keeping other etiologies from your differential in mind.

    References

    1. Bickley LS. The head and neck. In: Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:153-239.
    2. Wells PS, Anderson DR, Bormanis J, et. al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997 Dec 20-27;350(9094):1795-8.