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 patientâ€™s symptoms, start by asking general questions such as â€œcould you please tell me more about thatâ€, 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 patientâ€™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-fancierâ€™s lung), spa baths (hot tub lung due to mycobacterium avium complex) or mouldy hay (farmerâ€™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).
Want more info like this?
- Your electronic clinical medicine handbook
- Guides to help pass your exams
- Tools every medical student needs
- Quick diagrams to have the answers, fast
- Quizzes to test your knowledge
Ainslie G. Assessment of cough. Continuing Medical Education. 2009 Mar 19;27(2):68.Antoniou KM, Margaritopoulos GA, Tomassetti S, Bonella F, Costabel U, Poletti V. Interstitial lung disease. European Respiratory Review. 2014 Mar 1;23(131):40-54.Badran M, Ayas N, Laher I. Cardiovascular complications of sleep apnea: role of oxidative stress. Oxidative medicine and cellular longevity. 2014;2014.Beasley R, Semprini A, Mitchell EA. Risk factors for asthma: is prevention possible?. The Lancet. 2015 Sep 12;386(9998):1075-85.Braman SS, Davis SM. Wheezing in the elderly. Asthma and other causes. Clinics in geriatric medicine. 1986 May;2(2):269-83.Cano-JimÃ©nez E, HernÃ¡ndez GonzÃ¡lez F, Peloche G. Comorbidities and Complications in Idiopathic Pulmonary Fibrosis. Medical Sciences. 2018 Sep;6(3):71.Committee on Rating of Mental and Physical Impairment. The Respiratory System. JAMA. 1965 Nov; 194(8): 919-932.Cushman M. Epidemiology and risk factors for venous thrombosis. InSeminars in hematology 2007 Apr 1 (Vol. 44, No. 2, pp. 62-69). WB Saunders.del Giudice MM, Allegorico A, Parisi G, Galdo F, Alterio E, Coronella A, Campana G, Indolfi C, Valenti N, Di Prisco S, Caggiano S. Risk factors for asthma. InItalian journal of pediatrics 2014 Dec (Vol. 40, No. 1, p. A77). BioMed Central.Feierabend R. Hoarseness in adults. Am Fam Physician. 2009;80:363.Gordon BR. Asthma History and Presentation. Otolaryngeal Clin N Am. 2008; 41: 375-385.Harding SM. Complications and consequences of obstructive sleep apnea. Current opinion in pulmonary medicine. 2000 Nov 1;6(6):485-9.Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'fallon WM, Melton LJ. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Archives of internal medicine. 2000 Mar 27;160(6):809-15.Ho WK. Deep vein thrombosis: risks and diagnosis. Australian family physician. 2010 Jul;39(7):468.Holzinger F, Beck S, Dini L, StÃ¶ter C, Heintze C. The diagnosis and treatment of acute cough in adults. Deutsches Ã„rzteblatt international. 2014;111:356.Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006;129:1S-23S.Kilgore D, Najm W. Common Respiratory Diseases. Prim Care Clin Office Pract. 2010; 37: 297-324.Krieger BP. When wheezing may not mean asthma: other common and uncommon causes to consider. Postgraduate medicine. 2002 Aug 1;112(2):101-11.Mannino DM, Buist AS. Global burden of COPD: risk factors, prevalence, and future trends. The Lancet. 2007 Sep 1;370(9589):765-73.Mathews KP. Respiratory Atopic Disease. JAMA. 1982 Nov; 248(20): 2587-2610.Molina JR, Yang P, Cassivi SD, Schild SE, Adjei AA. Non-small cell lung cancer: epidemiology, risk factors, treatment, and survivorship. InMayo Clinic Proceedings 2008 May 1 (Vol. 83, No. 5, pp. 584-594). Elsevier.O'Donnell AE. Bronchiectasis. Chest. 2008 Oct 1;134(4):815-23.Osann KE. Lung Cancer in Women: The Importance of Smoking, Family History of Cancer, and Medical History of Respiratory Disease. Cancer Research. 1991 Sep; 51: 4893-4897.Papiris S, Kotanidou A, Malagari K, Roussos C. Clinical review: severe asthma. Critical Care. 2001 Feb;6(1):30.Prakash UBS. Uncommon Causes of Cough. Chest. 2006;129:206S.Pratter MR. Overview of common causes of chronic cough: ACCP evidence-based clinical practice guidelines. CHEST Journal. 2006 Jan 1;129(1_suppl):59S-62S.Samama MM. An epidemiologic study of risk factors for deep vein thrombosis in medical outpatients: the Sirius study. Archives of internal medicine. 2000 Dec 11;160(22):3415-20.Sethi GR, Batra V. Bronchiectasis: causes and management. The Indian Journal of Pediatrics. 2000 Feb 1;67(2):133-9.Travis, W.D., Costabel, U., Hansell, D.M., King Jr, T.E., Lynch, D.A., Nicholson, A.G., Ryerson, C.J., Ryu, J.H., Selman, M., Wells, A.U. and Behr, J., 2013. An official American Thoracic Society/European Respiratory Society statement: update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. American journal of respiratory and critical care medicine, 188(6), pp.733-748.Troy L, Corte T. Interstitial lung disease in 2015: where are we now?. Australian family physician. 2015 Aug;44(8):546.Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. Jama. 2004 Apr 28;291(16):2013-6.