11/13/24, 8\:12 PM Guide | Shortness of breath history

Shortness of breath history

Table of contents

Background

Shortness of breath, or dyspnoea, is a symptom characterised by di1
with a wide variety of pathologies with multiple aetiologies.
It can be associated
Dyspnoea is commonly reported by patients and accounts for 12% of medical admissions.
2

Causes of shortness of breath (dyspnoea)

Dyspnoea can be caused by a number of respiratory and non-respiratory conditions. These causes can be divided into four
primary categories\: respiratory, cardiac, neuromuscular, or systemic illness.
3
Respiratory diseases
Asthma\: a chronic disease characterised by episodic and recurrent bronchial in
4
Chronic Obstructive Pulmonary Disease (COPD)\: an umbrella term comprising chronic bronchitis and emphysema. Patients
may experience worsened dyspnoea and coughing due to an acute exacerbation of COPD associated with a respiratory
infection.
Interstitial lung disease\: an umbrella term describing a large number of respiratory disorders characterised by progressive
scarring of the lung tissue. 5
Disorders include pulmonary
Pulmonary embolism
Pulmonary tuberculosis\: a bacterial infection caused by m y c o b a c t e r i u m t u b e r c u l o s i s .
Whooping cough (pertussis)\: a highly contagious upper respiratory tract infection caused by the bacteria B o r d e t e l l a
p e r t u s s i s .
6
Pneumonia\: a lower respiratory infection caused by a viral or bacterial infection.
Pneumothorax\: a collection of air outside of the lung but within the pleural cavity.
7
Neoplastic causes
Laryngeal or pharyngeal carcinoma
Lung cancer
Pleural carcinoma
Cardiac causes
Atrial and other arrhythmias
Pulmonary oedema (secondary to congestive heart failure)
Acute coronary syndrome
Valvular heart disease (e.g. aortic stenosis)
Neuromuscular causes
Kyphoscoliosis
Phrenic nerve paralysis
Systemic causes
Anaemia\: reduces oxygen-carrying capacity
Acute renal failure
Metabolic acidosis
Liver cirrhosis
Sepsis
Alternative causes of dyspnoea
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Medications\: see drug history below
Recreational drugs\: cocaine, codeine, heroin, methadone, and propoxyphene
Hyperventilation syndrome
Myasthenia gravis\: causes muscle weakness

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
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 a y , c a n y o u t e l l m e m o r e a b o u t y o u r d i
Tip\: avoid using the term “dyspnoea” when speaking with patients. Instead, use patient-friendly synonyms such as shortness of
breath, di
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
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History of presenting complaint

Gather further details about the patient’s shortness of breath using the SOCRATES acronym.

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 can be applied to other symptoms, although some of the elements of SOCRATES may not
be relevant to all symptoms.
Onset, associated symptoms, time course, exacerbating or relieving factors, and severity are relevant to dyspnoea history
taking.
Site
N/A
Onset
Clarify when the dyspnoea developed\:
“ W h e n d i d t h i s d i
“ H o w l o n g h a s t h i s b e e n g o i n g o n f o r ?”
“ W h a t w e r e y o u d o i n g w h e n i t
The period of time that the patient has been experiencing dyspnoea, in conjunction with the development of the dyspnoea,
can help to determine the cause.
It is also important to determine if the dyspnoea occurs on exertion or at rest, as this helps to determine the severity of the
di
Episodic dyspnoea is de8
It is most commonly associated
with asthma exacerbations, especially if these episodes are severe and associated with wheezing.
Chronic dyspnoea is de9
Depending on the aetiology, this form of
dyspnoea may worsen over weeks, months, or years. Patients may not present until their dyspnoea has worsened and is
impacting their daily lives. Dyspnoea developing over a few months may indicate infective tuberculosis. Dyspnoea
worsening over multiple years may indicate COPD or interstitial lung disease.
Sudden, severe dyspnoea is a red-
and haemoptysis may indicate a pulmonary embolism. A pneumothorax or tension pneumothorax is often associated with a
traumatic cause, with features including pleuritic chest pain, tachycardia, peripheral cyanosis, and hypotension.
Character
N/A
Radiation
N/A
Associated symptoms
Ask if there are other symptoms which are associated with the dyspnoea.
“ H a v e y o u n o t i c e d a n y o t h e r c h a n ge s s i n c e y o u r t r o u b l e b r e a t h i n g b e g a n ?”
Infective causes of dyspnoea may be associated with\:
Fever (+/- rigours)
Productive cough
Wheeze
Chest tightness or pain (bronchitis, pulmonary tuberculosis)
Pleuritic chest pain (pneumonia)\: occasionally, patients with lower lobe pneumonia may also report upper abdominal pain
Night sweats (pulmonary tuberculosis)
Sudden weight loss (pulmonary tuberculosis)
Haemoptysis
Vomiting after a paroxysm of coughing and/or sweating/facial whooping cough)
Chronic respiratory diseases causing dyspnoea may be associated with\:
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Progressively reduced exercise tolerance
Chronic, non-productive cough (note\: a non-productive cough may become productive during an acute exacerbation of
COPD)
Wheezing
Chest tightness or pain
Fatigue
Finger clubbing (pulmonary
Cachexia
Central cyanosis (associated with hypoxaemia)
Tachypnea (emphysema)
Frequent respiratory infections
Headache (hypersensitivity pneumonitis)
Myalgia (hypersensitivity pneumonitis)
Neoplastic causes of dyspnoea may be associated with\:
Weight loss & appetite loss
Fatigue
Night sweats
Hoarseness (laryngeal carcinoma or bronchial carcinoma)
Shortness of breath (bronchial or pleural carcinoma)
Chest wall pain (bronchial or pleural carcinoma)
Pain in the shoulder and inner aspect of the arm (known as Pancoast’s syndrome and caused by bronchial carcinoma)
Wheeze (bronchial carcinoma)
Enlarged cervical or supraclavicular lymph nodes
A pulmonary embolism may be associated with\:
Tachycardia
Dry cough
Haemoptysis
Pleuritic chest pain
Current or recent symptoms of deep vein thrombosis (unilateral leg pain, swelling and erythema)
Pulmonary oedema secondary to congestive heart failure may be associated with\:
Shortness of breath
Bilateral leg oedema
Orthopnoea
Finger clubbing
Traumatic causes may be associated with\:
Wheeze and/or stridor (inhaled foreign body)
Shortness of breath and/or pleuritic chest pain (pneumothorax)
Tachypnea and tachycardia (pneumothorax)
Lightheadedness or fainting (pneumothorax)
Lung cancer red
Unexplained haemoptysis is a red
haemoptysis should be referred urgently (urgent suspected cancer referral).
NICE advise an urgent chest X-ray (within two weeks) in patients aged 40 years and over with two or more of the
following unexplained symptoms\:
Cough
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Fatigue
Shortness of breath
Chest pain
Weight loss
Appetite loss
needed.
If they have ever smoked or been exposed to asbestos, then only one unexplained symptom from the list above is
Time course
Clarify how the dyspnoea changes over time\:
“ I s i t h a r d t o b r e a t h e a l l t h e t i m e , o r d o e s i t c o m e a n d g o d u r i n g t h e d a y ?”
H a s t h e d i
Diurnal variation in dyspnoea symptoms may indicate the underlying aetiology\:
Symptoms worse at night and in the morning, with improvement during the day, suggests asthma
Paroxysms of coughing and dyspnoea in whooping cough are worse at night
COPD patients typically experience worsened dyspnoea in the early morning
Paroxysmal nocturnal dyspnoea refers to the patient waking up at night feeling short of breath. This is typically relieved by
sitting upright. This may indicate congestive cardiac failure.
Exacerbating or relieving factors
Ask if anything makes breathing easier or harder for the patient\:
“ D o e s a n y t h i n g m a k e i t h a r d e r t o b r e a t h e ?”
“ D o e s a n y t h i n g h e l p y o u b r e a t h e e a s i e r ?”
Certain medications can worsen dyspnoea (see drug history section).
Mild shortness of breath on exertion is common and generally not concerning. However, severe and progressively worsening
exercise intolerance may indicate underlying respiratory or cardiac disease.
Orthopnoea is a symptom when the patient experiences shortness of breath when lying down. The patient may describe using
multiple pillows at night to improve their symptoms. Clinically, the number of pillows used serves as a means to classify the
patient’s dyspnoea (e.g. three-pillow orthopnoea). Orthopnoea is associated with a number of conditions, including asthma,
chronic bronchitis, sleep apnoea, or pulmonary oedema.
Worsening dyspnoea in certain locations suggests an environmental trigger. Common exacerbating factors for respiratory
diseases include dust, animal fur, pollen, pollution, changes in weather, and mouldy hay. Sensitivity to any of these may indicate
asthma, COPD, or hypersensitivity pneumonitis.
Severity
Speak with the patient to understand how much their dyspnoea is impacting their quality of life.
mMRC Dyspnoea Scale
The mMRC (Modi
associated with dyspnoea.
11
Score Description
0 I only get breathless with strenuous exercise
1 I get short of breath when walking uphill
2
I walk slower than people my age because of breathlessness, or I have to stop for breath
when walking with people my age.
3 I stop for breath after walking 100 metres on level ground
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4 I am too breathless to leave the house or I am breathless when dressing/undressing
A useful method to remember the scale is\:
0 = Zero di
1 = Dyspnoea walking ↑
2 = Dyspnoea when walking in a pair
3 = Cannot walk 100 metres (three digits)
4 = Number four, you’re on the

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. For example, if the patient
remarks how their mobility has been diminished by their dyspnoea, this may be an appropriate time to demonstrate empathy
and ask how this has been a
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 gh 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 g a 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 g h 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
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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

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\: fever, fatigue, loss of appetite, night sweats, unintentional weight loss
Cardiovascular\: chest pain, leg swelling
Respiratory\: shortness of breath, pleuritic chest pain
Gastrointestinal\: dyspepsia, altered bowel habits
ENT\: rhinorrhoea, nasal obstruction, anosmia
Skin\: eczema (associated with asthma and allergic rhinitis)
Rheumatological\: joint pain/swelling (rheumatoid arthritis is associated with pulmonary
Neurological\: dysphagia

Past medical history

Ask if the patient has any medical conditions, especially pre-existing respiratory diseases\:
“ 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 gu l a r l y ?”
“ D o y o u h a v e a n y c o n d i t i o n s w h i c h a
Ask if the patient has previously undergone any surgery (e.g. thoracic surgery, ENT surgery). It’s important to note that any
surgery or subsequent bedrest is a risk for a pulmonary embolism.
“ 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 ?”
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.
Examples of relevant medical conditions
Patients may present with dyspnoea due to a
Heart failure
Asthma
COPD
Interstitial lung disease
Bronchiectasis
Other relevant medical conditions in the context of dyspnoea include\:
For infective causes\:
Conditions which cause immunosuppression\: diabetes mellitus, HIV, end-stage renal failure, haematological
malignancies and malnutrition.
Neurological disorders which cause dysphagia and increase the risk of aspiration pneumonia\: Parkinson’s disease,
stroke and motor neurone disease.
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For neoplastic causes\:
Primary malignancies which metastasise to the lungs\: adenocarcinomas of the colon/breast/kidney/testicle,
melanoma, thyroid carcinoma, oesophageal cancer and sarcomas.
For vascular causes\:
Conditions which increase the risk of pulmonary embolism\: previous venous thromboembolism, current or recent
pregnancy, recent surgery, recent air travel, leg fractures, malignancy, or any condition which has caused signi
reduced mobility.
Conditions which increase the risk of cardiac failure\: ischaemic heart disease, atrial .
For in
Eczema and allergic rhinitis (associated with asthma).
Other autoimmune conditions, such as rheumatoid arthritis and systemic lupus erythematosus (SLE).
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

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.
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
“ D o y o u t h i n k y o u r t r o u b l e b r e a t h i n g s t a r t e d a f t e r y o u b e g a n t a k i n g a n y o f y o u r c u r r e n t m e d i c a t i o n s ?”
Medication examples
Patients with pre-existing cardio-respiratory disease will take medications to manage these conditions\:
Asthma/COPD\: salbutamol (SABA/LABA), antimuscarinics (SAMA/LAMA) and corticosteroids (inhaled)
Heart failure\: diuretics, SGLT2 inhibitors, ACE inhibitors
Beta-blockers (e.g. propranolol) and NSAIDS (e.g. ibuprofen, naproxen) can precipitate asthma.
Drugs which may cause pulmonary

Family history

Ask the patient if there is any family history of lung disease, cardiovascular disease, thromboembolic disease, autoimmune
disease or malignancy.
“ 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 m e d i c a l c o n d i t i o n s ?”
Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic
factors).
If one of the patient’s close relatives is 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 d a d w a s w h e n 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 i s d e a t h ?”
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Social history

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); this is especially important for patients with severe dyspnoea.
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).
It is important to ask about exposure to allergens, such as animal dander or bird feathers, in the home environment and about
passive smoking.
Patients using homeless shelters or hostels are at increased risk of tuberculosis.
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 cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
See our smoking cessation guide for more details.
Cigarette smoking is a primary cause of early exertional dyspnoea and is considered responsible for 90% of cases of COPD.
12,13
These patients may experience gradually worsening dyspnoea which progresses over multiple years.
Smoking is also a major risk factor for developing malignancy and cardiovascular disease.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history taking guide for more information.
Excessive alcohol use is a risk factor for tuberculosis.
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.
Intravenous drug use is a risk factor for tuberculosis.
Occupation
A thorough occupational history (covering all jobs the patient has done throughout their working life) is essential when taking a
history from a patient with chronic dyspnoea.
Focus particularly on\:
Exposure to allergens, such as animal dander, pollen, dust
Exposure to mouldy straw or hay (hypersensitivity pneumonitis)
Exposure to asbestos (pulmonary
Exposure to infectious diseases, such as tuberculosis

Travel history

If the patient’s symptoms suggest an infective aetiology, take a travel history to assess exposure risk.
Ask about whether the patient was born outside of the UK and/or whether they have travelled outside of the UK. Countries
such as India, Pakistan, Romania, Bangladesh and Somalia have particularly high rates of tuberculosis. If a patient was born in,
or has travelled to, an area of high tuberculosis prevalence, ask about their vaccination status.
Legionella pneumonia can also be associated with foreign travel. It can be contracted by inhaling bacteria from poorly
maintained plumbing systems, which may be found in hotels.
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Sitting for long periods during

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

1. National Cancer Institute. DeLINK]
2. Stevens JP, Dechen T, Schwartzstein R, O’Donnell C, Baker K, Howell MD, et al. Prevalence of Dyspnea Among Hospitalized
Patients at the Time of Admission. Journal of Pain and Symptom Management. 2018 Jul;56(1)\:15-22.e2.
3. Deepa Rawat, Hajira Basit, Sandeep Sharma. Dyspnea. StatPearls Publishing; 2023. Available from\: [LINK]
4. National Cancer Institute. DeLINK]
5. Mayo Clinic. Interstitial lung disease - Symptoms and causes. Mayo Clinic. 2017. Available from\: [LINK]
6. Mayo Clinic. Whooping cough\: symptoms and causes. Mayo Clinic. 2022. Available from\: [LINK]
7. McKnight CL, Burns B. Pneumothorax. Nih.gov. StatPearls Publishing; 2023. Available from\: [LINK]
8. Simon ST, Weingärtner V, Higginson IJ, Voltz R, Bausewein C. De
Breathlessness\: Consensus by an International Delphi Survey. Journal of Pain and Symptom Management. 2014 May;47(5)\:828–
38.
9. Karnani NG, Reis
10. GP Notebook. FEV1 / FVC ratio – GPNotebook [Internet]. gpnotebook.com. 2021. Available from\: [LINK]
11. Primary Care Respiratory Society. MRC Dyspnoea Scale. Pcrs-uk.org. 2019. Available from\: [LINK]
12. Elbehairy AF, Guenette JA, Faisal A, Ciavaglia CE, Webb KA, Jensen D, et al. Mechanisms of exertional dyspnoea in symptomatic
smokers without COPD. European Respiratory Journal [Internet]. 2016 Aug 4;48(3)\:694–705.
13. Health Service Executive. Chronic obstructive pulmonary disease (COPD) - Causes. HSE.ie. 2021. Available from\: [LINK]

Reviewer

Dr Derek Casey
General Practitioner
Source\: geekymedics.com
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