History Taking: The Respiratory System

Question 1

What is the history taking structure?

Answer 1

Presenting complaint (PC)
History of presenting complaint (HPC)
Past medical history (PMH)
Medication/allergies (DH)
Family history (FH)
Social history (SH)
Systems enquiry/review (SE)

Question 2

What symptoms should you ask the patient about/ whether they have had any of the said symptoms?

Answer 2

• Chest pain - Dyspnoea - Cough
• Sputum
• Haemoptysis
• Wheeze
• Systemic upset

Question 3

If yes to chest pain, what ‘clarifying’ questions need to be asked?

Answer 3

SOCRATES
Site
Onset
Character
Radiation
Associated symptoms 
Timing
Exacerbators / relievers 
Severity (1-10 rating scale)

Question 4

If central chest pain, what can be potential causes?

Answer 4

Tracheitis
Angina/ MI
Aortic dissection
Massive PE
Oesophagitis
Lung tumour / metastases 
Mediastinal tumour/ mediastinitis

Question 5

If pleural chest pain, what can be potential causes?

Answer 5

Pneumonia / Bronchiectasis / TB
Lung tumour/ metastases/ mesothelioma
PE
Pneumothorax

Question 6

If chest wall chest pain, what can be potential causes?

Answer 6

Muscular / rib injury
Costochondritis
Lung tumour / bony metastases/ mesothelioma
Shingles (herpes zoster)

Question 7

What questions should be asked if patient is experiencing dyspnoea?

Answer 7

 Is there anything that brings it on?
 Does anything make it better or worse?
 Are you always breathless? Is it when you walk/ exercise?
 Do you get breathless lying down?
– Orthopnoea/ PND (cardiac causes)
 How far can you walk normally? How far can you walk now? i.e. exercise tolerance
 How do you manage walking uphill / up stairs?
 Is there anything it stops you from doing?
 Have you noticed any other symptoms?
– Consider – cough, sputum, chest pain, palpitations, wheeze, stridor

Question 8

If dyspnoea onset is in minutes, what could be potential diagnoses?

Answer 8

PE
Pneumothorax 
Acute LVF
Acute asthma 
Inhaled foreign body

Question 9

If dyspnoea onset is in hours to days, what could be potential diagnoses?

Answer 9

Pneumonia
Asthma
Exacerbation of COPD

Question 10

If dyspnoea onset is in weeks to months, what could be potential diagnoses?

Answer 10

Anaemia
Pleural effusion
Respiratory neuromuscular disorders

Question 11

If dyspnoea onset is in months to years, what could be potential diagnoses?

Answer 11

COPD
Pulmonary fibrosis
Pulmonary TB

Question 12

What questions should be asked of a patient suffering with a cough?

Answer 12

 How long have you had it?
 Is it a new problem?
 When does it occur?
 Is there anything that makes it better or worse?
 Is it a dry cough? Do you cough anything up?
 Do you smoke?
 Has your medication changed recently?
 Do you experience any other symptoms?
– Consider - dyspnoea, weight loss, stridor, pain, syncope, vomiting

Question 13

If the cough is productive, what could be potential diagnoses?

Answer 13

Infection

Bronchiectasis

Question 14

If the patient is presented with a persistent ‘moist’ cough worst in morning, what could be potential diagnoses?

Answer 14

COPD

Question 15

If the cough is associated with wheeze, what could be potential diagnoses?

Answer 15

Asthma / COPD

Question 16

If the cough is painful, what could be potential diagnoses?

Answer 16

Tracheitis

Question 17

If the cough is harsh or barking, what could be potential diagnoses?

Answer 17

Laryngitis/ laryngeal tumour

Question 18

If the cough is chronic and dry, what could be potential diagnoses?

Answer 18

Interstitial lung disease

Question 19

If the cough is Bovine (non-explosive), what could be potential diagnoses?

Answer 19

Left recurrent laryngeal nerve invasion (secondary to malignancy) Neuromuscular disorders

Question 20

If the cough is persistent with haemoptysis, what could be potential diagnoses?

Answer 20

Bronchial carcinoma

Question 21

If the patient has been producing sputum, what questions do you need to ask?

Answer 21

 How often do you produce sputum when you cough?
 How much sputum do you cough up? Has this changed?
 What colour is it? Has the colour changed?
 Is there any blood?
 Is it frothy or thick?
Is there any abnormal smell or taste?
Have you been experiencing any other symptoms?
E.g. fever, dyspnoea, pain

Question 22

If serous sputum is produced, what could be some potential diagnoses?

Answer 22

Acute pulmonary oedema

Question 23

If mucoid sputum is produced, what could be some potential diagnoses?

Answer 23

COPD/ asthma

Question 24

If purulent sputum is produced, what could be some potential diagnoses?

Answer 24

Infection

Question 25

If rusty sputum is produced, what could be some potential diagnoses?

Answer 25

Pneumococcal pneumonia

Question 26

If the patient is presented with haemoptysis (coughing up blood), what questions do you need to ask?

Answer 26

 When did you first notice blood in your sputum?  How many times has it happened?  How much blood is there?  Are there any other colours in the sputum apart from the blood?  Have you noticed bleeding or bruising anywhere else?  Are you taking any medication to thin the blood?  Have you noticed any other symptoms? – E.g. breathlessness / chest pain / cough / weight loss (pleuritic chest pain and hemoptysis is a red flag)

Question 27

If the cause of haemoptysis is malignant, what potential diagnosises can be reached?

Answer 27

Bronchial carcinoma Metastatic lung disease

Question 28

If the cause of haemoptysis is infective, what potential diagnosises can be reached?

Answer 28

Acute infection Bronchiectasis TB

Question 29

If the cause of haemoptysis is vascular, what potential diagnosises can be reached?

Answer 29

Pulmonary infarction or pulmonary embolus

Question 30

If the cause of haemoptysis is cardiac, what potential diagnosises can be reached?

Answer 30

Mitral valve disease | Acute LVF

Question 31

If the cause of haemoptysis is vasculitis, what potential diagnosises can be reached?

Answer 31

Wegener’s granulomatosis | Good pasture’s syndrome

Question 32

If the cause of haemoptysis is of other origin, what potential diagnosises can be reached?

Answer 32

Trauma Anticoagulation (consider warfarin) Clotting disorder

Question 33

What are some other question that should be asked in a taking a pulmonary system history?

Answer 33

Change in appetite Weight loss Fever Tiredness / lethargy