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  • • Goals of the history are to develop a probable diagnosis or limited differential diagnosis and to assess severity of illness.
  • • Important features of symptoms include severity, chronicity, moderating and aggravating factors, and associated systemic symptoms.
  • • Risk factors for lung disease are identified in past medical, family, social, occupational, environmental, and drug histories.
  • • 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 evaluation.


Clinical Manifestations


General Considerations


Some patients referred for pulmonary evaluation are asymptomatic. They are referred because of abnormalities detected on chest radiograph ...

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