- Respiratory System History
Chief Complaint
Elicit the patient's chief complaint.
History of Presenting Illness (HPI)
Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.
Cough
- Duration
- Acute: < 3 weeks
- Sub-acute: 3-8 weeks
- Chronic: > 8 weeks
- Productive vs. non-productive
- Volume
- Colour (mucoid, purulent, clear, bloody, brown)
- Viscosity
- Smell
- Hemoptysis
- Change in nature from chronic cough
- Increase in sputum
- Change in colour
- Aggravating factors
- Extreme temperatures
- Animal contact
- Exertion
- Pollutants
- Cigarette smoke
- Dust
- Postural clues suggestive of CHF
- Sinus pressure, post-nasal drip, preceding URTI, rhinitis
Dyspnea
- At rest or with exertion
- If with exertion, what is their exercise tolerance
- ≥4 METS if can walk up one flight of stairs without dyspnea
- Changes with position
- Orthopnea (dyspnea when lying horizontally)
- Trepopnea (dyspnea when lying on one side)
- Platypnea (dyspnea when seated)
- Relation to stress or anxiety
- Slow, insidious onset (i.e., with fibrosis) or rapid onset (i.e., asthma attack)
- Environmental triggers (cold temperature, cigarette smoke, pollutant, animals, dust, pollen)
PE/DVT Risk Questions:
- Prior DVT or PE
- Clinical signs/symptoms of DVT
- Leg swelling, pain with palpation of deep veins of leg
- Current or previous malignancy
- Hypercoaguable states (Factor V Leiden, prothrombin mutations)
- Recent immobilization
- Bed rest (≥3 days)
- Long flights or car rides
- Recent surgery (within 4 weeks)
- Hemoptysis
- Concurrent tachycardia
- Chest Pain
- Wheezing
- Snoring
- Sleep apnea
- STOP BANG: Snoring, tired (daytime), observed apneas, high BMI, neck circumference, age ≥50, gender male
- Positive response to 3 criteria is 86% sensitive and 56% specific for presence of OSA
- Fever, night sweats, or chills
- Weight loss
- Smoking (pack/years)
- If quit, when and for how long had they smoked prior
- Exposure to second-hand smoke
- Sick contacts
- Travel history/birthplace
- Environmental/occupational exposures
Past Medical History (PMHx)
Specifically ask about:
- General history of previous illnesses, conditions, and hospitalization
- Asthma
- Last visit to hospital, previous hospitalizations, prior intubations, triggers, frequency of rescue inhaler use
- COPD
- Previous hospitalizations, previous steroid use, home oxygen use
- Pneumonia
- Interstitial lung disease
- HIV
- Congestive heart failure
- Lung cancer
- DVT or PE
- Autoimmune disease
Family History (FmHx)
Specifically ask about:
- Asthma
- Atopy (asthma, atopic dermatitis, allergic rhinitis)
- COPD
- Pulmonary fibrosis
- Cystic fibrosis
- Alpha-1 antitrypsin deficiency
- Lung cancer
- Cardiac disease
Social History (SocHx)
Specifically ask about:
- Occupational exposures (e.g., asbestos, silica)
- Potential hazards related to housing
- Prisons, mold, pets, dust, carpets
Substance Use History (SubHx)
Specifically ask about:
Medications
Ask about all medications patient is currently taking, and whether they are taken as prescribed
Particularly important medications pertaining to the Respiratory System include, but are not limited to:
- Beta Blockers
- ACE Inhibitors
- Oral Contraception
- Inhalers (Past and present)
- Adherence and frequency of use
- Anticoagulants
- Diuretics
- Steroids and other immunosuppressants
- Recent antibiotic prescriptions
Allergies
Note allergies and ensure they concord with those listed in the EMR
Review of Systems
Conduct a review of systems, keeping other etiologies from your differential in mind.
References
- Bickley LS. The head and neck. In: Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:153-239.
- Wells PS, Anderson DR, Bormanis J, et. al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997 Dec 20-27;350(9094):1795-8.