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Respiratory history taking

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Breathlessnes

  • How did the breathlessness start?
    • If the onset was instantaneous = pneumothorax, pulmonary embolus or anaphylaxis. Paroxysmal nocturnal dyspnoea (p. 47) may wake a sleeping patient with breathlessness
    • Onset over hours = asthma, acute pulmonary oedema, lobar pneumonia, or acute hypersensitivity pneumonitis, while an insidious onset is more typical of an evolving pleural effusion, chronic obstructive pulmonary disease (COPD), interstitial lung disease and lung tumours.
  • How is your breathing at rest and overnight?
    • Asthma commonly wakes patients, while most patients with COPD are comfortable at rest and when asleep but struggle with exertion.
    • Breathlessness provoked by lying down (orthopnoea) = heart failure , also occurs frequently in patients with severe airflow obstruction or diaphragmatic weakness because the weight of the abdomen displaces the diaphragm cranially on lying down, compromising the vital capacity.

  • Does your breathlessness vary from day to day or week to week?

    • Variable breathlessness is typical of asthma,
    • COPD or interstitial lung disease usually report consistent daily limitation.

  • Can you tell me something you do that would make you breathless? and How far can you walk on a good day?

    • These questions reveal the disability caused by respiratory disease. Record restrictions on normal activity or work and the corresponding MRC breathlessness score.

Wheeze history

  • Is the wheeze worse during or after exercise?
    • If it occurs during exercise and limits it, this suggests COPD;
    • in asthma, wheeze and tightness usually appear after exercise.
    • Do you wake with wheeze during the night? This suggests asthma.
    • Do you have hay fever or other allergies? Atopy is common in allergic asthma. A family history of wheeze or asthma is common

Cough history

  • Duration of the cough.
  • Whether it is present every day.
  • If it is intrusive/irresistible or whether the patient coughs deliberately to clear a perceived obstruction (throat clearing). •
  • Whether it produces sputum. If so, how much, and what colour? • Any haemoptysis?
  • Any triggers (such as swallowing, cold air, during or after exercise, allergens).
  • Smoking. This increases the likelihood of chronic bronchitis or lung cancer.
  • Cough + Associated clinical features: • Wheeze: may signal cough-variant asthma
  • Heartburn or reflux: GERD
  • Altered voice or swallowing: consider laryngeal causes.
  • Drug history, especially angiotensin-converting enzyme (ACE) inhibitors.

Hemptysis

  • blood from cough or Mouth ?

    • Blood in the mouth may be vomited
    • may have come from the nose in epistaxis
    • or may appear on chewing or tooth brushing in patients with gum disease.
    • When did blood appear, how much blood, were there associated symptoms and over what time period was it present?

  • Any fever/symptoms of infection? - Acute or chronic bronchial infections, including tuberculosis, often trigger haemoptysis. •

  • Recurrent blood streaks in clear sputum = lung cancer.
  • Recurrent blood streaks in purulent sputum over years = bronchiectasis.
  • A sudden episode of haemoptysis with pleuritic pain and breathlessness = pulmonary embolism.
  • Large volumes of haemoptysis (> 20 mL) suggest specifc icauses= lung cancer eroding a pulmonary vessel,bronchiectasis (such as in cystic fbirosis) • cavitary disease (e.g., complicating an aspergilloma or cavitary pulmonary tuberculosis). • pulmonary vasculitis • pulmonary arteriovenous malformation.*