11/13/24, 8\:12 PM Guide | Respiratory history

Respiratory history

Table of contents
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Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
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 o
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Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
Once the patient has
complaints, work with them to establish a shared agenda for the rest of the consultation\:
" O k , s o y o u’ v e m e n t i o n e d t h a t y o u h a v e t h r e e p r o b l e m s t o d a y t h a t y o u’ d l i k e a d d r e s s i n g. A s t h e r e m a y n o t b e t i m e t o a d d r e s s
t h e m a l l t h o r o u g h l y i n t h i s c o n s u l t a t i o n , i t w o u l d b e h e l p f u l t o k n o w w h i c h o f t h e i s s u e s y o u f e e l i s m o s t i m p o r t a n t t o d e a l
w i t h t o d a y . I’ l l t h e n l e t y o u k n o w w h i c h o f t h e s e i s s u e s I f e e l i s t h e p r i o r i t y a n d w e c a n a gr e e o n w h a t t h e f o c u s o f t o d a y’ s
c o n s u l t a t i o n s h o u l d b e . D o e s t h a t s o u n d o k ?"
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
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 di

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 respiratory disease 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
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).
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SOCRATES

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.
Site
Ask about the location of the symptom\:
" W h e r e i s t h e p a i n ?"
" C a n y o u p o i n t t o w h e r e y o u e x p e r i e n c e t h e p a i n ?"
Onset
Clarify how and when the symptom developed\:
" D i d t h e s h o r t n e s s o f b r e a t h c o m e o n s u d d e n l y o r g r a d u a l l y ?"
" W h e n d i d t h e s h o r t n e s s o f b r e a t h
" H o w l o n g h a v e y o u b e e n e x p e r i e n c i n g t h e s h o r t n e s s o f b r e a t h ?"
Character
Ask about the speci
" H o w w o u l d y o u d e s c r i b e t h e s h o r t n e s s o f b r e a t h ?" (e.g.
"tight chest"
,
" I s t h e s h o r t n e s s o f b r e a t h c o n s t a n t o r d o e s i t c o m e a n d go ?"
"can't take a deep breath")
Radiation
Ask if the symptom moves anywhere else\:
" D o e s t h e c h e s t p a i n s p r e a d e l s e w h e r e ?"
Associated symptoms
Ask if there are other symptoms which are associated with the primary symptom\:
" A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e p a i n ?" (e.g. fever in pneumonia, shortness of breath and
haemoptysis in pulmonary embolism)
Time course
Clarify how the symptom has changed over time\:
" H o w h a s t h e s h o r t n e s s o f b r e a t h c h a n g e d o v e r t i m e ?"
Ask if there is diurnal variation of symptoms\:
" A r e y o u r s y m p t o m s w o r s e a t a p a r t i c u l a r t i m e o f d a y ?"
Exacerbating or relieving factors
Ask if anything makes the symptom worse or better\:
" D o e s a n y t h i n g m a k e t h e s h o r t n e s s o f b r e a t h w o r s e ?" (e.g. exertion, exposure to an allergen, cold air)
" D o e s a n y t h i n g m a k e t h e p a i n b e t t e r ?" (e.g. rest, inhaler)
Severity
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10\:
" O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e c h e s t p a i n , i f 0 i s n o p a i n a n d 1 0 i s t h e w o r s t p a i n y o u’ v e e v e r e x p e r i e n c e d ?"
If the symptom is shortness of breath, 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
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 risk factors for respiratory disease as you work through
the patient's history (e.g. past medical history, family history, social history).
Important respiratory risk factors include\:
Pre-existing respiratory disease (e.g. asthma, COPD)
Family history of respiratory disease (e.g. cystic
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Smoking
Vaping/e-cigarette use
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
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.
Ideas
Explore the patient's ideas about the current issue\:
" W h a t d o y o u t h i n k t h e p r o b l e m i s ?"
" W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g?"
" I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u g h t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
"
Concerns
Explore the patient's current concerns\:
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?"
" W h a t’ s y o u r n u m b e r o n e c o n c e r n r e ga r d i n g t h i s p r o b l e m a t t h e m o m e n t ?"
" W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i gh t b e ?"
Expectations
Ask what the patient hopes to gain from the consultation\:
" W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?"
" W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?"
" W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?"

Summarising

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

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 di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
"
" O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u' r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
"
" N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l
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Systemic enquiry

A systemic enquiry 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\:
Systemic\: fevers, weight change, fatigue
Cardiovascular\: chest pain, palpitations, oedema, syncope, orthopnoea
Gastrointestinal\: nausea, vomiting, dysphagia, abdominal pain
Genitourinary\: oliguria, polyuria
Neurological\: visual changes, motor or sensory disturbances, headache, confusion
Musculoskeletal\: chest wall pain, trauma
Dermatological\: rashes

Travel history

If the patient's symptoms are suggestive of an infective aetiology, 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 medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
If the patient does have a medical condition, you should gather more details to assess how well controlled 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 hospital admissions (e.g. if asthmatic, ask if they have ever been admitted to ITU with an exacerbation).
If you suspect the patient is presenting with asthmatic features, it is helpful to know if they have other atopic conditions (e.g.
eczema or hayfever).
Ask if the patient has previously undergone any surgery or procedures (e.g. lobectomy, bronchoscopy)\:
" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?"
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?"
Immunisation history
Ask the patient if they have been vaccinated against respiratory diseases such as\:
In
Pneumococcus
COVID-19
Tuberculosis
You should also clarify when the patient received these vaccinations.
Allergies
anaphylaxis).
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
Examples of relevant medical conditions
Medical conditions relevant to respiratory disease include\:
Asthma
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COPD
Lung cancer
Bronchiectasis
Pulmonary
Pulmonary embolism
Tuberculosis
Neuromuscular conditions (e.g. motor neurone disease)
Congestive heart failure
Cor pulmonale
Cystic
Alpha-1 antitrypsin de

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form
and route.
If the patient is using inhalers, check the device type, whether they use a spacer and if they have any problems using the
inhaler. If there is time in the consultation, you could ask them to demonstrate their inhaler technique.
Ask the patient if they're currently experiencing any side e
" H a v e y o u n o t i c e d a n y s i d e e
Commonly prescribed respiratory medications
Medications commonly prescribed to patients with respiratory disease include\:
Short-acting beta-2-agonist inhalers (e.g. salbutamol, terbutaline)
Long-acting beta-2-agonist inhalers (e.g. salmeterol, formoterol, vilanterol)
Inhaled corticosteroid inhalers (e.g.
Short-acting antimuscarinic inhalers (e.g. ipratropium)
Long-acting antimuscarinic inhalers (e.g. tiotropium, glycopyrronium, umeclidinium)
Oral steroids (e.g. prednisolone)
Theophylline
Antibiotics (e.g. co-amoxiclav, doxycycline, azithromycin)
Anticoagulants (e.g. warfarin, apixaban)
Many inhalers contain a combination of medications (e.g. LABA/ICS or LABA/LAMA), and patients are typically more
familiar with the brand name. It is helpful to familiarise yourself with commonly prescribed combination inhalers in your
area.
Some over the counter drugs which may impact the respiratory system include\:
Aspirin (may worsen haemoptysis if already present)
St John's Wort (an enzyme inducer which may reduce the e
Medications with respiratory side e
Medications with respiratory side e
Beta-blockers and NSAIDs (bronchoconstriction)
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ACE inhibitors (dry cough)
Oestrogen-containing medication (increased risk of pulmonary embolism)
Amiodarone and methotrexate (pleural e
Nitrofurantoin (pulmonary reactions, pulmonary

Family history

Ask the patient if there is any family history of respiratory disease (e.g. asthma, eczema, hay fever, cystic
" D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y l u n g p r o b l e m s ?"
If one of the patient's close relatives are deceased, sensitively determine the age at which they died and the cause of death\:
" I' m r e a l l y s o r r y t o h e a r t h a t , d o y o u m i n d m e a s k i n g h o w o l d y o u r m o t h e r w a s w h e n s h e d i e d ?"
" D o y o u r e m e m b e r w h a t m e d i c a l c o n d i t i o n w a s f e l t t o h a v e c a u s e d h e r d e a t h ?"

Explore the patient's social history to both understand their social context and identify potential respiratory risk factors.
General social context
Explore the patient's general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift, home oxygen)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient's smoking history, including the type and amount of tobacco used.
Calculate the number of 'pack-years' the patient has smoked for to determine their cardiorespiratory risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
Ask the patient if they vape or use e-cigarettes, even if they are an ex- or non-smoker.
See our smoking cessation guide for more details.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history taking guide for more information.
Recreational drug use
Ask the patient if they use recreational drugs 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.
Exercise
Ask if the patient regularly exercises (including frequency and exercise type).
Occupation
disease\:
Explore the patient's current and previous occupations to identify potential exposure to agents which can lead to respiratory
Coal mining is associated with the development of pneumoconiosis.
Farmers are at increased risk of developing allergic extrinsic alveolitis.
Those working in shipyards, construction and plumbing may have been exposed to asbestos increasing their risk of
mesothelioma. Household members are also at risk, as exposure can occur through washing/contact with contaminated
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clothing.
Ask the patient if their symptoms change when they are away from work to help establish a link to potential occupational
exposures.
Pets and hobbies
Ask if the patient has any pets\: allergies to pets are common and may not be immediately obvious (e.g. the patient has a
wheezy chest when at home, but not when outside).
Hobbies such as bird-keeping can increase a patient's risk of developing allergic extrinsic alveolitis (often referred to as 'bird
fancier's lung').

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

Dr Elizabeth Ferguson
General Practitioner
Source\: geekymedics.com
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