The Respiratory History

Wash Hands  Introduce yourself  Patient Data [Name & Age]  Explain & Gain Consent
“Today I’ve been asked to take a respiratory history from you - I’ll be asking you some questions about your current
medical issue, your past medical history, your family medical history and some questions about your social history - would
that be okay?

To Complete the History-Taking:

History of Presenting Illness Past Medical History 
T
 Major Symptoms  Allergies - Hayfever? Eczema?
- Dyspnoea & Wheeze  Vaccinations
- Cough, Sputum, Haemoptysis  Medications
- Chest pain - What are you currently taking?
 DYSPNOEA - Puffers: Relievers [B2 agonists] & Preventers
- How long have you been SOB? Has it come on [inhaled corticosteroids]
quickly? Insidiously? How has it evolved over - Anticholinergics: [IpraBrom - atrovet]
time? - ACE inhibitors
- How much exercise can you do before your - OTC: NSAIDs, paracetamol
SOB stops you or slows you down?  Asthma? Emphysema?
- Can you walk up a flight of stairs? Distance you
can walk?
 Bronchitis, Pneumonia, Tuberculosis?
- Have you been woken at night by  Previous hospitalisations & investigations;
breathlessness? Do you have to sleep sitting up sick as a child?
[PND/orthopnea]; Do you snore?  Have you ever had a CXR before?
- New York Heart Association Classification  Surgical history
(1) Disease present but NO dyspnoea or  Diabetes? Blood pressure? Cholesterol?
dyspnoea only on heavy exertion
(2) Dyspnoea on moderate exertion
(3) Dyspnoea on minimal exertion
(4) Dyspnoea at rest
 CHEST PAIN
- Is there a feeling of tightness in the chest when Family Medical History
you feel SOB?
- Is there pain when you breathe in? Is it painful  History of respiratory/heart issues
to take a deep breath? Cough?  History of cancer?
 COUGH & SPUTUM  Atopy
- How long have you had the cough? Did it  Cystic Fibrosis
develop slowly or quickly?  TB & Other infections recently
- Dry cough?
- Do you cough up anything? What does it look Social History
like? Smell like? Thick/thin?  Smoking, Alcohol, Diet
- What colour? Clear or discoloured? Blood?
- Does the cough get better or worse? When?  Occupation: What do you do?
[Nighttime - GORD], exercise? - What the job involves; exposures?
 Weight loss/appetite, fever, sweats, fatigue  Travel? Overseas recently?
 Associated symptoms? Ankle swelling?  Partner? Kids?
 Social supports?
 Living conditions & exposures:
- Dust mites, Pets, Smoking family members

hank the patient & Wash hands

 Summarise: “Today, I took a history from [patient], a [#] year old male/female; They presented with [presenting
symptoms] on a background of [previous symptoms]; their past medical history is […] and there is a history of [in the
family]; provide social history