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.
Introduce yourself – name/role
Confirm patient details – name/DOB
Explain the need to take a history
Ensure the patient is comfortable
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)
- Wheeze – Time 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
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 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
Acute hospital admissions / ITU admissions?
Regular medications – often provide useful clues as to patients past medical history
- Inhalers – preventer / reliever
Over the counter drugs / herbal remedies?
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
Respiratory disease? – asthma / atopy / lung cancer / cystic fibrosis
Recent contact with others who were unwell? – viral infections / pneumonia / TB
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)
- 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?
- Shipyard / Construction / Plumber – Asbestos
- Miners – Pneumoconiosis
- Farmer – Allergic extrinsic alveolitis
Hobbies – Bird fancier – Allergic extrinsic alveolitis
High-risk areas for tuberculosis (TB)?
Recent long-haul flights? – pulmonary embolism
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
Respiratory – Dyspnoea / 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
Summarise the history