STANDARDIZED HISTORY TAKING OF A RESPIRATORY PATIENT

2.

RT comes to your clinic for muscle pain, headache and cough. When you ask her what made her decide to see you, she answered, "dahil po inuubo ako". What is RT's chief complaint?

Explanation
RT's chief complaint is cough. This is evident from her statement "dahil po inuubo ako" which translates to "because I am coughing". This indicates that her main reason for seeking medical attention is her cough.

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3.

You want to know RT's chief complaint. What question will help you get her answer?

What happened?
What is your illness?
When did you have symptoms?
What brought you to the clinic for consultation?

Correct Answer

A. What brought you to the clinic for consultation?

Explanation

The question "What brought you to the clinic for consultation?" is the most appropriate to ask in order to know RT's chief complaint. This question specifically asks about the reason for RT's visit to the clinic, which will provide information about the main issue or symptom she is experiencing. The other options, such as "What happened?" and "When did you have symptoms?" are more general and may not directly address the chief complaint. Similarly, asking "What is your illness?" assumes that RT already knows her diagnosis, which may not be the case.

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4.

RT smokes 10 cigarettes a day since she was 18 years old. What is her smoking history? (GIVE ANSWER IN PACK YEARS)

Correct Answer
6 PACK YEARS

Explanation
The answer of 6 PACK YEARS suggests that RT has been smoking an average of 10 cigarettes per day since she was 18 years old. Pack years is a unit used to measure the cumulative exposure to smoking over time. It is calculated by multiplying the number of packs smoked per day by the number of years smoked. In this case, since RT has been smoking 10 cigarettes per day for 6 years, the total pack years would be 6.

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5.

You want to ask regarding RT's alcohol intake. What information must you elicit from her?

Type of alcohol consumed
Brand of alcohol consumed
Number of units/glasses/bottles consumed in a day/week/month/year
Location where alcohol was consumed

Correct Answer(s)

A. Type of alcohol consumed
A. Number of units/glasses/bottles consumed in a day/week/month/year

Explanation

To assess RT's alcohol intake, it is important to elicit information about the type of alcohol consumed and the number of units/glasses/bottles consumed in a specific time frame (day/week/month/year). This information will help determine the quantity and frequency of alcohol consumption, which is essential in evaluating the potential health risks and identifying any alcohol-related issues. The brand of alcohol consumed and the location where it was consumed may provide additional insights but are not as crucial as the type and quantity of alcohol consumed.

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6.

Review of systems is done to be able to identify patient problems not related to the chief complaint.

True
False

Correct Answer

A. True

Explanation

Review of systems is a comprehensive assessment of the patient's body systems, which is done to identify any potential health problems that may not be directly related to the chief complaint. It helps healthcare providers to gather information about the patient's overall health, detect any underlying conditions, and provide appropriate treatment or referrals. Therefore, the statement that review of systems is done to identify patient problems not related to the chief complaint is true.

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7.

RT tells you that her cough has greenish phlegm. Which among the following information listed below should you ask regarding sputum production? Tick all that apply

Volume
Consistency
Color
Taste

Correct Answer(s)

A. Volume
A. Consistency
A. Color

Explanation

When a patient reports greenish phlegm, it indicates the presence of an infection. Asking about the volume of sputum production would help determine if the cough is productive or not. Inquiring about the consistency would provide information about the thickness or viscosity of the phlegm, which can indicate the severity of the infection. Lastly, asking about the color of the phlegm is essential as it can further indicate the type of infection or the presence of blood. Taste is not relevant in this context as it does not provide any useful information about the sputum production.

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8.

Which key systemic symptoms should you ask regarding RT's chief complaint? Tick all that apply

Fever
Night sweats
Weight loss
Palpitations

Correct Answer(s)

A. Fever
A. Night sweats
A. Weight loss

Explanation

The key systemic symptoms that should be asked regarding RT's chief complaint are fever, night sweats, and weight loss. These symptoms can be indicative of underlying medical conditions or infections that may be causing RT's chief complaint. Palpitations, on the other hand, are not directly related to systemic symptoms and may require further investigation for a separate issue.

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9.

Which of the following information should you ask to help you in establishing RT's history of present illness? Tick all that apply.

Onset and duration of cough
Severity of cough and course of disease
Exacerbating and relieving factors
Presence of dyspnea, hemoptysis, wheezing, chest pain or fever
Previous illnesses

Correct Answer(s)

A. Onset and duration of cough
A. Severity of cough and course of disease
A. Exacerbating and relieving factors
A. Presence of dyspnea, hemoptysis, wheezing, chest pain or fever

Explanation

To establish RT's history of present illness, it is important to ask about the onset and duration of cough, as this can provide information about the progression of the illness. Asking about the severity of the cough and the course of the disease can help in understanding the severity and progression of the symptoms. Inquiring about exacerbating and relieving factors can provide insights into what triggers or alleviates the cough. Asking about the presence of dyspnea, hemoptysis, wheezing, chest pain, or fever can help in identifying any additional symptoms that may be indicative of underlying conditions. Previous illnesses should also be asked about as they can provide information about any pre-existing conditions that may be relevant to the current illness.

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10.

You want to check RT's family history. Which among the following diseases should you ask if RT has a family history of? (TICK ALL THAT APPLY)

Asthma
Lung cancer
Recent viral or bacterial lung infections
TB
Cardiovascular diseases

Correct Answer(s)

A. Asthma
A. Lung cancer
A. Recent viral or bacterial lung infections
A. TB
A. Cardiovascular diseases

Explanation

The question asks which diseases you should ask if RT has a family history of. The correct answer includes asthma, lung cancer, recent viral or bacterial lung infections, TB, and cardiovascular diseases. These diseases are relevant to RT's family history because they are all respiratory or cardiovascular conditions that may have a genetic component. By asking about these diseases, you can gather information about RT's family history and potentially identify any inherited risk factors or patterns.

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11.

You now want to review RT's past medical history. Which among the following history of past diseases should be ALWAYS asked if the patient has a respiratory complaint? (TICK ALL THAT APPLY)

Bronchial Asthma
Hyperthyroidism
COPD
Pneumonia
Malignancy
Ulcers
Pulmonary Embolism
Cardiovascular disease

Correct Answer(s)

A. Bronchial Asthma
A. COPD
A. Pneumonia
A. Malignancy
A. Pulmonary Embolism
A. Cardiovascular disease

Explanation

Patients with respiratory complaints should always be asked about their history of Bronchial Asthma, COPD, Pneumonia, Malignancy, Pulmonary Embolism, and Cardiovascular disease. These conditions can directly or indirectly affect the respiratory system and may be relevant to the current complaint. Hyperthyroidism and ulcers are not directly related to respiratory complaints and may not be as relevant to the assessment.

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12.

What other information would you want to know for RT's personal and social history?

History of recreational drug use
Anamnesis
Occupation
Level of functionality

Correct Answer(s)

A. History of recreational drug use
A. Occupation
A. Level of functionality

Explanation

To fully understand RT's personal and social history, it would be important to know their history of recreational drug use. This information can provide insights into their past behaviors, potential addiction issues, and overall lifestyle choices. Additionally, knowing RT's occupation can shed light on their daily activities, level of stress, and potential exposure to certain environments or substances. Lastly, understanding RT's level of functionality can help gauge their overall physical and mental capabilities, which can further inform their personal and social history.

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13.

You want to evaluate the type of cough that RT has. What will you ask her?

Correct Answer(s)
Is your cough dry or productive? (with sputum)

Explanation
The question asks about the type of cough that RT has, specifically whether it is dry or productive (with sputum). This is an important distinction because a dry cough typically indicates irritation or inflammation in the respiratory tract, while a productive cough with sputum suggests the presence of mucus or phlegm that needs to be expelled. By asking this question, the healthcare professional can gather information about the nature of RT's cough, which can help in determining the underlying cause and appropriate treatment options.

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14.

RT tells you that she had asthma during childhood and does not remember her medications. She was previously hospitalized for pneumonia 5 years ago, has undergone an appendectomy 2 years ago and has develops erythematous, transient rashes to Amoxicillin. How will you record and report your findings for her past medical history?

Standardized History Taking Of A Respiratory Patient

You see RT a 30 year old female in your clinic. What should be the first thing you should do upon seeing RT?

Quiz Preview

RT comes to your clinic for muscle pain, headache and cough. When you ask her what made her decide to see you, she answered, "dahil po inuubo ako". What is RT's chief complaint?

You want to know RT's chief complaint. What question will help you get her answer?

RT smokes 10 cigarettes a day since she was 18 years old. What is her smoking history? (GIVE ANSWER IN PACK YEARS)

You want to ask regarding RT's alcohol intake. What information must you elicit from her?

Review of systems is done to be able to identify patient problems not related to the chief complaint.

RT tells you that her cough has greenish phlegm. Which among the following information listed below should you ask regarding sputum production? Tick all that apply

Which key systemic symptoms should you ask regarding RT's chief complaint? Tick all that apply

Which of the following information should you ask to help you in establishing RT's history of present illness? Tick all that apply.

You want to check RT's family history. Which among the following diseases should you ask if RT has a family history of? (TICK ALL THAT APPLY)

You now want to review RT's past medical history. Which among the following history of past diseases should be ALWAYS asked if the patient has a respiratory complaint? (TICK ALL THAT APPLY)

What other information would you want to know for RT's personal and social history?

You want to evaluate the type of cough that RT has. What will you ask her?