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Respiratory history taking is an important skill that is often assessed in the OSCE setting. It’s important to have a systematic approach to ensure you don’t miss any key information. The guide below provides a framework to take a thorough respiratory history.

Check out the respiratory history mark scheme here.


Introduction

Introduce yourself – name/role

Confirm patient details – name/DOB

Explain the need to take a history

Gain consent

Ensure the patient is comfortable


Presenting complaint

It’s important to use open questioning to elicit the patient’s presenting complaint.

“So what’s brought you in today?”   or  “Tell me about your symptoms”

Allow the patient time to answer, trying not to interrupt or direct the conversation.

Facilitate the patient to expand on their presenting complaint if required.

“Ok, so tell me more about that”  “Can you explain what that pain was like?”


History of presenting complaint

Onset – When did the symptom start? / Was the onset acute or gradual?

Duration – minutes / hours / days / weeks / months / years

Severity – e.g. if the symptom is shortness of breath – are they able to talk in full sentences?

Course – is the symptom worsening, improving, or continuing to fluctuate?

Intermittent or continuous? – Is the symptom always present or does it come and go?

Precipitating factors – are there any obvious triggers for the symptom?

Relieving factors – does anything appear to improve the symptoms e.g. an inhaler

Associated features – are there other symptoms that appear associated e.g. fever/malaise 

Previous episodes – has the patient experienced this symptom previously?

 

Key respiratory symptoms:

  • Dyspnoea – Only on exertion or at rest? / Determine severity
  • Cough –  Dry vs productive / Sputum (volume, colour, consistency)
  • WheezeTime of day / Triggers
  • Haemoptysis  – Volume 
  • Chest pain – Site / Radiation / Character
  • Systemic symptoms – Fever / Night sweats / Weight loss

If any of these symptoms are present, gather further details as shown above (Onset / Duration / Course / Severity / Precipitating factors / Relieving factors / Associated features / Previous episodes)

 

Pain – if pain is a symptom, clarify the details of the pain using SOCRATES

  • Site – where is the pain 
  • Onset – when did it start? / sudden vs gradual?
  • Character – sharp / dull ache / burning
  • Radiation – does the pain move anywhere else? 
  • Associations – other symptoms associated with the pain 
  • Time course – worsening / improving / fluctuating / time of day dependent
  • Exacerbating / Relieving factors – does anything make the pain worse or better?
  • Severity – on a scale of 0-10, how severe is the pain?

 

Ideas, Concerns and Expectations

Ideas – what are the patient’s thoughts regarding their symptoms?

Concerns – explore any worries the patient may have regarding their symptoms

Expectations – gain an understanding of what the patient is hoping to achieve from the consultation

 

Summarising

Summarise what the patient has told you about their presenting complaint.

This allows you to check your understanding regarding everything the patient has told you.

It also allows the patient to correct any inaccurate information and expand further on certain aspects.

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

Signposting involves explaining to the patient:

  • What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
  • What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”

Past medical history

Respiratory conditions – asthma / pneumonia / COPD / pulmonary embolism / malignancy / tuberculosis

Other medical co-morbidities – cardiovascular disease / neuromuscular disease / malignancy

Surgical history 

Acute hospital admissions / ITU admissions? 


Drug history

Regular medications – often provide useful clues as to patients past medical history

  • Inhalers – preventer / reliever 
  • Steroids
  • Diuretics

Antibiotics

Over the counter drugs / herbal remedies? 

Home oxygen? 

 

Medications with respiratory side effects:

  • Beta-Blockers / NSAIDS – bronchoconstriction
  • ACE inhibitors – dry cough
  • Cytotoxic agents –  interstitial lung disease
  • Oestrogen – e.g. contraceptive pill / HRT – increased risk of PE
  • Amiodarone / Methotrexate – pleural effusions / interstitial lung disease

 

ALLERGIES – document these clearly


Family history

Respiratory disease? – asthma / atopy / lung cancer / cystic fibrosis

Recent contact with others who were unwell? – viral infections / pneumonia / TB


Social history

Smoking – How many cigarettes a day? How long have they smoked for? 

Alcohol – How many units a week? – be specific about type / volume / strength of alcohol

Recreational drug use – e.g. Cannabis (increased risk of lung cancer)

 

Living situation:

  • House / Flat  – stairs / adaptations / home oxygen
  • Who lives with the patient? – important when considering discharge from hospital
  • Any carer input? – what level of care do they receive?

 

Activities of daily living:

  • Is the patient independent / able to fully care for themselves?
  • Can they manage self-hygiene/housework/food shopping?

 

Occupation:

  • Shipyard / Construction / Plumber – Asbestos
  • Miners – Pneumoconiosis
  • Farmer – Allergic extrinsic alveolitis

 

Hobbies – Bird fancier – Allergic extrinsic alveolitis


Travel history

High-risk areas for tuberculosis (TB)? 

Recent long-haul flights?pulmonary embolism


Systemic enquiry

Systemic enquiry involves performing a brief screen for symptoms in other body systems.

This may pick up on symptoms the patient failed to mention in the presenting complaint.

Some of these symptoms may be relevant to the diagnosis (e.g. calf pain in pulmonary embolism).

Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.

 

Cardiovascular – Chest pain / Palpitations  / Dyspnoea /  Syncope / Orthopnoea  / Peripheral oedema 

RespiratoryDyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain

GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit 

Urinary –  Volume of urine passed / Frequency / Dysuria  / Urgency / Incontinence

CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion

Musculoskeletal – Bone and joint pain / Muscular pain 

Dermatology – Rashes / Skin breaks / Ulcers / Lesions


Closing the consultation

Thank patient

Summarise the history


 

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