Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include:
Demonstrating empathy in response to patient cues: both verbal and non-verbal.
Active listening: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and offering them a seat).
Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.
Use open questioning to explore the patient’s presentingcomplaint:
“What’s brought you in to see me today?”
“Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presentingcomplaint if required:
“Ok, can you tell me more about that?”
Once the patient has finished speaking, it is helpful to check if there are any other issues. If the patient has multiple presenting complaints, work with them to establish a shared agenda for the rest of the consultation:
“Ok, so you’ve mentioned that you have three problems today that you’d like addressing. As there may not be time to address them all thoroughly in this consultation, it would be helpful to know which of the issues you feel is most important to deal with today. I’ll then let you know which of these issues I feel is the priority and we can agree on what the focus of today’s consultation should be. Does that sound ok?”
Open vs closed questions
History taking typically involves a combination of open and closedquestions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.
History of presenting complaint
Patients with respiratory pathology can present with a wide variety of symptoms including but not limited to, cough, chest pain and dyspnoea. The SOCRATES acronym (explained below) is a useful tool that you can use to explore each of the patient’s presenting symptoms.
Key respiratory symptoms
Symptoms that are typically associated with respiratorydisease include:
Dyspnoea: shortness of breath associated with a wide range of respiratory pathology including pneumonia, asthma and chronic obstructive pulmonary disease (COPD).
Cough: can be productive (e.g. pneumonia, COPD, bronchiectasis) or dry (e.g. pulmonary fibrosis, side effect of ACE inhibitors).
Haemoptysis: the coughing up of blood originating from the respiratory tract below the level of the larynx. Haemoptysis is typically associated with lung cancer but can be a rare clinical feature of pulmonary embolism.
Wheeze: a continuous, coarse, whistling sound produced in the respiratory airways during breathing. It is commonly associated with conditions such as asthma, COPD and anaphylaxis.
Chest pain: typically worsened by deep inspiration due to being pleuritic in nature (e.g. pulmonary embolism, pleurisy).
Systemic symptoms: these can include fatigue (e.g. lung cancer, COPD), fever (e.g. pneumonia), and weight loss (e.g. end-stage COPD, lung cancer).
The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to most other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.
Ask about the location of the symptom:
“Where is the pain?”
“Can you point to where you experience the pain?”
Clarify how and when the symptom developed:
“Did the shortness of breath come on suddenly or gradually?”
“When did the shortness of breath first start?”
“How long have you been experiencing the shortness of breath?”
Ask about the specificcharacteristics of the symptom:
“How would you describe the shortness of breath?” (e.g. “tight chest”, “can’t take a deep breath”)
“Is the shortness of breath constant or does it come and go?”
Ask if the symptom movesanywhere else:
“Does the chest pain spread elsewhere?”
Ask if there are other symptoms which are associated with the primary symptom:
“Are there any other symptoms that seem associated with the pain?” (e.g. fever in pneumonia, shortness of breath and haemoptysis in pulmonary embolism)
Clarify how the symptom has changed over time:
“How has the shortness of breath changed over time?”
Exacerbating or relieving factors
Ask if anything makes the symptom worse or better:
“Does anything make the shortness of breath worse?” (e.g. exertion, exposure to an allergen, cold air)
“Does anything make the pain better?” (e.g. rest, inhaler)
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:
“On a scale of 0-10, how severe is the chest pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”
If the symptom is shortnessofbreath, the severity can be bluntly assessed by assessing if the patient is able to speak in full sentences without having to take a breath. You can also ask how far a patient is able to walk (either on the flat or at an incline) without having to stop to take a breath to get an idea of their current performance status.
Respiratory risk factors
When taking a respiratory history it’s essential that you identify riskfactors for respiratorydisease as you work through the patient’s history (e.g. past medical history, family history, social history).
Family history of respiratory disease (e.g. cystic fibrosis, alpha-1 antitrypsin deficiency)
Occupational exposure (e.g. coal mining, farming)
Hobbies (e.g. bird keeping)
Ideas, concerns and expectations
A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.
Explore the patient’s ideas about the current issue:
“What do you think the problem is?”
“What are your thoughts about what is happening?”
“It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”
Explore the patient’s current concerns:
“Is there anything, in particular, that’s worrying you?”
“What’s your number one concern regarding this problem at the moment?”
“What’s the worst thing you were thinking it might be?”
Ask what the patient hopes to gain from the consultation:
“What were you hoping I’d be able to do for you today?”
“What would ideally need to happen for you to feel today’s consultation was a success?”
“What do you think might be the best plan of action?”
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.
Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”
What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”
A systemicenquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include:
Neurological: visual changes, motor or sensory disturbances, headache, confusion
Musculoskeletal: chest wall pain, trauma
If the patient’s symptoms are suggestive of an infectiveaetiology, particularly tuberculosis (TB), take a travel history to assess exposure risk (e.g. travel through areas of high TB prevalence).
Past medical history
Ask if the patient has any medicalconditions:
“Do you have any medical conditions?”
“Are you currently seeing a doctor or specialist regularly?”
If the patient does have a medical condition, you should gather more details to assess howwellcontrolled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospitaladmissions (e.g. if asthmatic, ask if they have ever been admitted to ITU with an exacerbation).
Ask if the patient has previously undergone any surgery or procedures (e.g. lobectomy, bronchoscopy):
“Have you ever previously undergone any operations or procedures?”
“When was the operation/procedure and why was it performed?”
Ask the patient if they have been vaccinated against respiratory diseases such as:
You should also clarify when the patient received these vaccinations.
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
Examples of relevant medical conditions
Medical conditions relevant to respiratorydisease include:
Neuromuscular conditions (e.g. motor neurone disease)
Congestive heart failure
Alpha-1 antitrypsin deficiency
Ask if the patient is currently taking any prescribedmedications or over-the-counterremedies:
“Are you currently taking any prescribed medications or over-the-counter treatments?”
If the patient is taking prescribed or over the counter medications, document the medicationname, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any sideeffects from their medication (e.g. dry cough with ACE inhibitor):
“Have you noticed any side effects from the medication you currently take?”
Commonly prescribed respiratory medications
Medications commonly prescribed to patients with respiratory disease include:
Ask the patient if they use recreationaldrugs and if so determine the type of drugs used and their frequency of use. Smoking drugs such as cannabis regularly increases the risk of lung cancer.
Ask the patient if they gamble and if they feel this is a problem.
Gambling is causative of several decrements to health directly, such as increased sedentary behaviour during the time spent gambling, poor sleep, reduced levels of self-care and anxiety. Patients with a gambling problem are also more likely to have substance misuse issues.1