- • Goals of the history are to develop a probable
diagnosis or limited differential diagnosis and to assess severity
- • Important features of symptoms include severity,
chronicity, moderating and aggravating factors, and associated systemic
- • Risk factors for lung disease are identified in
past medical, family, social, occupational, environmental, and drug
- • Physical examination should be directed to narrow
the differential diagnosis or confirm a specific diagnosis.
- • Pulmonary examination emphasizes assessing the
quality of normal breath sounds as well as the presence and nature
of adventitious sounds.
Most patients present for pulmonary evaluation because they either
have respiratory-related symptoms or signs or have a physical, radiographic,
or physiological abnormality detected during routine health screening,
evaluation of an unrelated medical problem, or through epidemiological surveys.
This chapter describes the initial evaluation of these patients,
focusing on interpretation of specific symptoms and physical findings.
Evaluation begins with a thorough history and physical examination,
with the goal of developing a specific diagnosis or narrowing the
differential diagnosis. This is accomplished by characterizing the
symptoms specific to the presenting illness and then searching for
risk factors for the specific pulmonary conditions suggested by
the history. Important qualities that help characterize presenting
symptoms include their severity, chronology, aggravating or moderating
factors, and associated systemic symptoms. Risk factors for pulmonary
disease are sought through family, social, occupational, environmental,
and drug histories. Determining previous or concurrent nonpulmonary
medical conditions that could impact the lungs is also important.
Performing a directed physical examination enhances the history
and focuses the diagnostic process by searching for specific signs
that either confirm the diagnosis or differentiate between various
conditions that might explain the symptoms. Although the chest examination
is primary, the importance of performing a complete examination
cannot be overemphasized. Examination of nonpulmonary systems helps
identify whether the symptoms originate from a primary pulmonary process
or are pulmonary manifestations of nonpulmonary or systemic conditions
such as cancer or connective tissue disorders. The physical examination
also aids in assessing disease severity.
The history and physical examination are not always performed
in a sequential fashion in a single interview. Although it is important
to be systematic and complete in the diagnostic approach, the seasoned
clinician learns to perform the directed examination as the history
is obtained. Specific symptoms prompt an active search for physical
findings while additional history is obtained. The evaluation also
often takes place during several meetings. The first visit focuses
on characterizing the history of the presenting illness, performing
a broad search for risk factors, and completing a physical examination
to identify the pathophysiology suggested by the history. Additional
specific historical and physical clues are sought at subsequent
interviews, directed by the results of tests ordered after the initial
Some patients referred for pulmonary evaluation are asymptomatic.
They are referred because of abnormalities detected on chest radiograph ...