History Taking for Respiratory Case in General Medicine

- Dr. Ankit Chandra

1. Patient details
• Name –
• Age –
• Gender -
• Hailing from (Address)_____
• Educated up to ___
• Working as a (Occupation)- ______
• Family’s Monthly income / Socio-economic status – (*TB MC In low socio-economic
status)

2. Chief complain (with duration & Chronological order)

A. Cough
B. Chest pain
C. Breathlessness
D. Hemoptysis

3. History of presenting illness (HOPI)

• Patient was apparently well ___ months back , when she/he noticed _____
• Elaborate symptoms – duration, chronological order
• Etiology/ cause/ risk factors –
• Complications -
• h/o DM/HTN -

a) History of Dyspnea
• Onset – sudden, insidious
• Progression –
• MRC class –
• Postural variation – Diaphragmatic palsy ,
• PND –
• Orthopnea / trepopnea -

Dr. Ankit Chandra

 b) History in Wheeze
• Onset
• Duration
• Progress – constant / intermittent
• Aggravating factors – seasonal, diurnal, postural
• Relieving factor – rest, drugs
• Associated skin rashes
• Dust , food allergy

c) History in cough
• Duration - acute (<3wk) , chronic (>8wks)
• Dry / productive
• Aggravating & relieving factor –
• Postural variation –
• Diurnal variation –
• Cough syncope

d) History in cough with expectoration

• Onset, Duration, Progress
• Quantity – scanty / copious
• Variation – diurnal /postural
• Colour
• Consistency –
• Foul smelling -
• Blood stain -

E) History in chest pain

• Site –
• Onset
• Duration
• Severity
• Pleuritic or not ?? – rib mets
• Radiation

Dr. Ankit Chandra

• Progressive or not ?
• Aggravating & relieving factor – by changing position ??
• Associated with nausea, vomiting, sweating ??

F ) History in Hemoptysis
*Differentiate from Hemoptysis
• Duration
• No. of episode –
• Fresh/altered blood/colour (coffee brown)
• Amount & severity
• Association with – purulent sputum, food particles

G ) History in Fever
• onset –
• Duration & progression –
• Associated with chills & rigor ?
• Evening Rise of temperature ?
• Associated with vomiting , abdomen pain, loose motion ?

I) History of other systems (*Important)

• CNS -
• Renal –
• CVS –

4. Personal History
• h/o smoking – bidi/cigarrete, no./day, age started (COPD/ lung ca)
• Pack years = years of smoking X no. of cigarrete packet/day (1 pack = 20 cig)
• Alcohol intake
• h/o marked weight loss –
• Pets in home
• Recent travel history –
• h/o any drug intake or allergy -

Dr. Ankit Chandra

 5. Past history
• H/o similar episodes –
• Previous history of TB, Aspiration (anaesthesia, coma, drowning)
• h/o allergy, fever, whooping cough, tooth extraction, tonsillectomy,
• h/o HTN, DM, recurrent respiratory infections

6. Family history
• Any history of such illness in family?

8) Social history
• Martial status & No. of children –
• Lives with family or alone ?
• Current Martial status? ant h/o of infertility ?

Summary of History
• ____ age of patient, presented with ____________
• Acute/ chronic
• Congenital/ acquired disease
• Parenchymal / pleural/ bronchial pathology
• Probable diagnosis

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Dr. Ankit Chandra