A thorough history is valuable in the diagnosis of symptoms such as cough, dyspnoea and chest pain, and can be used to understand a patient's baseline respiratory function.
History of Presenting Complaint
When asking for more information about a patient’s symptoms, start by asking general questions such as “could you please tell me more about that”, and then narrow down the questions as more information is provided.
- Generally speaking, the following questions are a good starting point for any type of pain, and may be useful in gaining information about other symptoms:
- Site - localised or generalised; unilateral or bilateral
- Onset - sudden or gradual, and what the situation was (e.g. following trauma)
- Character - sharp, dull, burning or pressure-like
- Radiation - e.g. down the arm or across the back
- Associated symptoms - e.g. fevers, nausea / vomiting, bony pain
- Timing - duration of symptoms, frequency of episodes, changes through the day
- Exacerbating & alleviating factors - e.g. exacerbation with exertion and alleviation with rest
- Severity - on a scale of 1 to 10, with 10 being the worst
Past Medical History
Ask about any medical conditions the patient has previous been diagnosed with, the management of these conditions, and any complications they may have.
In any patient with chronic respiratory disease, ask about exercise tolerance. How long the patient can walk without getting short of breath, and how long it takes them to recover following exertion. Patients with severe pulmonary disease (such as COPD, cystic fibrosis or other causes of bronchiectasis) may have intensive pulmonary rehabilitation regimens.
Ask about allergies and whether the patient gets hay fever or eczema; these suggest atopy which is associated with asthma.
Ask about what medications the patient takes regularly, what they take them for, and what side effects they have had.
In patients with airways disease, ask about what inhalers they use and whether they have an action plan in place.
Certain medications may cause respiratory symptoms. ACE inhibitors may cause cough by increasing levels of bradykinin; beta blockers may worsen airways disease; and aspirin-induced respiratory disease is an condition to consider in patients with nasal polyps and sinus symptoms. Certain medications, such as methotrexate and bleomycin, may cause interstitial lung disease.
Finally, ask about oxygen therapy. Patients with severe, end-stage chronic obstructive pulmonary disease or bronchiectasis may be on home oxygen, twenty-four hours a day or only intermittently.
Ask about whether any conditions run in the family. In particular, ask about family history of atopy - eczema, food allergies, allergic rhinitis and asthma.
Patients with cystic fibrosis (autosomal recessive) or alpha-1 antitrypsin deficiency (autosomal co-dominant) often report family members with the disease.
Ask about a family history of cancer, and particularly lung cancer - how old at the time of diagnosis and whether they were a smoker.
It is important to understand any patient’s social situation when taking their history. This includes key aspects such as their occupation (or previous occupation, if retired), living situation, mobility, ability to perform activities of daily living, diet and exercise.
Ask about occupational exposures - to asbestos, silica dust, coal-mining or industrial chemicals - as these predispose to respiratory disease.
In patients with hypersensitivity pneumonitis, consider other exposures such as birds (bird-fancier’s lung), spa baths (hot tub lung due to mycobacterium avium complex) or mouldy hay (farmer’s lung).
A major aspect of the respiratory history is the smoking history, as smoking is associated with chronic obstructive pulmonary disease and lung cancer. Identify how many years the patient has smoked for, how many they smoked per day, and how long since they quit (if applicable).
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