Intial history
What questions about her symptoms would you like to ask?
Additional Hx
What questions about her past medical history would you ask?
The patient is a 52 years old smoker with history of emphysema in the past and currently presented with worsened dyspnea and frequent cough.
Emphysema is the irreversible collapse of the small air sacks in the lungs causing breathing difficulty to the patient. Dyspnea means difficulty in breathing. smoking is a leading cause of major lung related diseases including cancer. As per the given data, the patient is already having history of lung injury which can be worsened over period of time.
During history collection, it is very important to address the symptoms of the patient and ask more details regarding the characteristics of symptoms are important to know about the disease condition ans its progress.
Questions can be asked about her symptoms include,
| Questions | Rationale |
| Do you have habit of smoking in excess currently? if yes, hoe often and how many packets of cigarettes per day? | To know any underlying life habits which can be preventable by giving education and support |
|
Do you have breathing difficulty while lying down? if yes, Which position it is worsened ? Which position provides you some relief? |
To know the how severe the dyspnea ( dyspnea at rest) and what triggers it. |
| Do you wake up in the night due to difficulty in breathing ? | To kow the severity of her condition and how it affect daily living. |
|
DO you feel chest pain associated with difficulty in breathing? if yes, Where is the exact position? How often do you feel the pain? How can you describe the pain? |
to knoe additional symptoms associated with her condition. |
| Questions | Rationale |
| What kind of work do you do/did you do? | To understand about work related hazards like regular exposure to substances such as asbestos, chemicals, or smoke |
| How does the cough sounds like? | |
|
Do you have any sputum production associated with cough? if yes, What is the color of the sputum? what is the consistency of sputum? Is it foul smelling? |
To know the symptom in detail and know about related disease conditions. |
| Do you feel any relief if you take some measures to reduce cough?( drinking hot fluids, cough medications etc.) | to know the character and severity of the cough |
Dyspnea during daily activities, changes in sputum production, increasing discomfort in left chest while coughing are not included in questions as it is given in additional information.
Questions about her past medical history include,
| Questions | Rationale |
| Do you have a history of asthma, tuberculosis, lung cancer, cystic fibrosis, bronchitis, or any other lung disease other than emphysema? | To know the predisposing factors |
|
Do you have ant allergies in the past?If yes, How does your allergy affect your breathing? When was the last allergic reaction happened? |
To know verify the possible causes of her condition. |
| Do you have any history of cardiac problems in the past? | Cardiac diseases can worsen dyspnea. |
| Have you undergone any cardio thoracic surgical procedures in the past ? | cardio thoracic procedures can cause recurrent lung infections. |
| What medications are you using currently? Did you stated using any medications recently within one year? | Some medications can trigger the symptoms. |
History of fever is not asked as given in the additional history. Family history is not included.
Intial history 52 yof smoker -hx of emphysema One year hx of mild increase in dyspnea...
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