History Taking
Overview
With each symptom, always (if relevant) ask about:
- When did it start?
- Did it come on suddenly or gradually?
- Is it continuous or intermittent?
- Has this ever happened before?
Cough
- Onset:
- How did it start?
- Did it suddenly come on?
- Character:
- Dry or productive?
- What are they coughing up?
- Blood?
- Fresh/bright red blood?
- Dark clots or ground-up coffee?
- What is the sputum like?
- Offensive smell?
- Colour? – may be white, yellow, green, or pink
- Blood?
- Timeline:
- How long has it been ongoing?
- Exacerbating/alleviating factors:
- Severity – how much are they coughing?
- Variability:
- Diurnal variation – is it worse at night or early in the morning?
- Is it continuous or intermittent?
- Does it change in different environments? (e.g. work, indoors, or outdoors)
- Have they noticed anything else?
- Has this ever happened before?
- Have they been ill recently?
Review of systems
- Screen for other respiratory symptoms:
- Shortness of breath, orthopnoea, paroxysmal nocturnal dyspnoea
- Sputum – as above
- Wheezing
- Chest pain – use SOCRATES
- Peripheral oedema
- Screen for features of infection:
- Fever
- Productive cough
- Screen for red flags:
- Haemoptysis
- Unexplained weight loss
- Night sweats
- Hoarse voice
- Screen for gastro-oesophageal reflux disease (GORD):
- Heartburn, regurgitation
- Screen for ENT symptoms:
- Runny nose, nasal drip, itching
- Sore throat
Past Medical History
Questions include:
- Do they have any other medical conditions?
- Have they ever had any previous surgery?
- Do they take any regular medications?
- Do they take any over-the-counter medications, herbal remedies, or supplements?
Family History
- Is there any family history of anything similar?
Allergy History
- Are they allergic to anything?
- What happens during the allergic reaction?
Social History
- Do they smoke?
- If so, how much and how long?
- Do they drink alcohol?
- If so, how much and how long?
- Do they use any illicit drugs?
- If so, how much and how long?
- Do they have any pets?
- What is their occupation?
- Are they exposed to dust?
- Are they exposed to asbestos?
- Who’s at home?
- What support do they have?
- How has this impacted their activities of daily living?
- Has there been any recent foreign travel?
Investigations
Overview
When suggesting investigations in an OSCE, the BOXES (Blood tests, orifice tests, x-rays, ECGs, special tests) mnemonic is useful for deciding the order of investigations:
- Blood tests:
- Full blood count:
- Anaemia may be seen in malignancy
- Leukocytosis suggests an infection
- Urea and electrolyte (U&Es) and calcium:
- Hyponatraemia may be seen in Legionella pneumonia and small-cell lung cancer
- Hypercalcaemia may be seen in squamous cell lung cancer
- Full blood count:
- Orifice tests:
- Sputum microscopy, culture, and sensitivity:
- To identify the underlying cause of a chest infection
- Sputum cytology:
- If lung cancer suspected
- Sputum microscopy, culture, and sensitivity:
- X-rays:
- Chest x-ray:
- May show abnormal opacification and areas of consolidation
- Chest x-ray:
- ECGs:
- ECG:
- If a cardiac cause (e.g. heart failure) is suspected
- ECG:
- Special tests:
- Spirometry and bronchodilator reversibility:
- For asthma/COPD
- High-resolution CT scan:
- For lung cancer, pulmonary fibrosis, and bronchiectasis
- Bronchoscopy:
- Obtain a biopsy to diagnose lung cancer
- Echocardiogram:
- If a cardiac cause (e.g. heart failure) is suspected
- Nasoendoscopy:
- For ENT-related causes
- 24-hour pH manometry:
- For GORD
- Spirometry and bronchodilator reversibility:
Differential Diagnoses
Asthma
- A history may reveal:
- Wheezing, cough, chest tightness
- Increased use of reliever inhaler
- History of atopy (e.g. eczema/hayfever)
- A physical exam may reveal:
- Wheezing, tachycardia, tachypnoea, difficulty completing sentences, cyanosis, accessory muscle use, altered consciousness, coma depending on severity
- Investigations may reveal:
- Peak expiratory flow rate (PEFR):
- Decreased compared to best or predicted
- Spirometry with bronchodilator reversibility:
- FEV1/FVC ratio 0.7 or less with reversibility
- Fractional exhaled nitric oxide test (FeNO):
- Increased
- Peak expiratory flow rate (PEFR):
COPD
- A history may reveal:
- Shortness of breath, cough, and wheezing
- Sputum production
- A history of smoking
- A physical exam may reveal:
- Fever, crackles, wheezing, hypoxaemia
- Cyanosis, chest hyper-expansion, facial plethora
- Investigations may reveal:
- Spirometry with bronchodilator reversibility:
- FEV1/FVC ratio 0.7 or less without reversibility
- Spirometry with bronchodilator reversibility:
Bronchiectasis
- A history may reveal:
- Chronic cough productive of foul, offensive, copious amounts of sputum
- Shortness of breath
- Recurrent infection
- Severe infection in childhood
- A physical exam may reveal:
- Crackles, wheezing, clubbing
- Investigations may reveal:
- Chest x-ray:
- Thickened airways
- High-resolution CT chest:
- Tram-tracking and bronchial dilation
- Chest x-ray:
Pneumonia
- A history may reveal:
- Subacute onset of fever, cough, shortness of breath, pleuritic chest pain
- Cough may be productive
- A physical exam may reveal:
- Fever, tachycardia, crackles
- Focal consolidation and dullness of percussion
- Investigations may reveal:
- Full blood count:
- May show leukocytosis
- Legionella urinary antigen:
- For Legionella pneumonia
- Blood cultures:
- Identifies likely pathogen
- Urea and electrolytes (U&Es):
- Prognosis is worse if urea is elevated (CURB-65)
- Chest x-ray:
- Shows opacification
- Full blood count:
Acute bronchitis
- A history may reveal:
- >2 weeks of cough which may or may not be productive, may be associated with a runny nose and sore throat
- Symptoms are less severe than that of pneumonia
- A physical exam may reveal:
- Low-grade fever
- No dullness to percussion, no crackles
- Investigations may reveal:
Post-nasal drip
- A history may reveal:
- Frequent throat clearing, a ‘dripping’ or ‘trickling’ sensation down the back of the throat, nasal discharge, nasal congestion, sneezing, halitosis
- A physical exam may reveal:
- Mucus secretions in the nasopharynx/oropharynx
- Investigations may reveal:
- Clinical diagnosis
Gastro-oesophageal reflux disease (GORD)
- A history may reveal:
- Epigastric burning pain, regurgitation, trigger foods that may worsen symptoms
- Associated with posture such as lying down
- A physical exam may reveal:
- n/a
- Investigations may reveal:
- Therapeutic trial of proton pump inhibitor:
- Relieves symptoms
- 24-hour oesophageal pH monitoring:
- Diagnostic
- Therapeutic trial of proton pump inhibitor:
Drug-induced cough
- A history may reveal:
- The use of angiotensin-converting enzyme inhibitors (ACE inhibitors) associated with a tickly, dry cough
- A physical exam may reveal:
- n/a
- Investigations may reveal:
- Stopping ACE inhibitor resolves cough
Pulmonary tuberculosis (TB)
- A history may reveal:
- Cough, fever, weight loss, night sweats, haemoptysis
- HIV/immunosuppression
- Travel to an endemic area
- A physical exam may reveal:
- Fever, tachypnoea
- Investigations may reveal:
- Chest x-ray:
- May show bilateral hilar lymphadenopathy, may show upper lobe cavitation
- Sputum culture:
- Diagnostic
- Chest x-ray:
Whooping cough (pertussis)
- A history may reveal:
- Paroxysms of cough followed by inspiratory whoop that may lead to post-tussive vomiting
- A physical exam may reveal:
- Subconjunctival haemorrhages
- Investigations may reveal:
- Nasopharyngeal culture or PCR:
- Identifies Bordetella pertussis
- Nasopharyngeal culture or PCR:
Lung cancer
- A history may reveal:
- Cough, haemoptysis, unexplained weight loss, hoarseness, chest pain
- Features of paraneoplastic syndromes
- A physical exam may reveal:
- Focal wheezing, dullness, decreased breath sounds
- Investigations may reveal:
- Chest x-ray:
- Mass present
- CT chest:
- Mass present
- Biopsy:
- Histologically confirms lung cancer
- Chest x-ray:
Laryngeal cancer
- A history may reveal:
- A persistent hoarse voice, a lump in the neck, sore throat or feeling something is stuck in the throat, stridor
- Investigations may reveal:
- Refer to ENT
- CT with contrast of neck and chest:
- Identifies tumour
- Fine-needle aspiration:
- Allows for histological diagnosis
Foreign body aspiration
- A history may reveal:
- Coughing and choking, ingestion of food
- Recurrent pneumonia
- A physical exam may reveal:
- Unilateral wheezing, stridor, focal dullness to percussion
- Investigations may reveal:
- Chest x-ray:
- May identify object
- Chest x-ray:
Interstitial lung disease (including idiopathic pulmonary fibrosis)
- A history may reveal:
- Slow, progressive shortness of breath and dry cough
- There may be a history of exposure to chemicals, radiotherapy, chemotherapy, some drugs (e.g. nitrofurantoin, methotrexate, amiodarone), asbestos, tuberculosis, ankylosing spondylitis, silicosis, sarcoidosis
- A physical exam may reveal:
- Dry crackles, clubbing
- Investigations may reveal:
- Pulmonary function tests:
- Shows restrictive pattern
- High-resolution CT scan:
- Ground glass appearance
- Pulmonary function tests:
Hypersensitivity pneumonitis
- A history may reveal:
- May present acutely within 4-8 hours after exposure with fever, chills, cough (may be productive)
- May present more slowly weeks-months after exposure with lethargy, productive cough, weight loss
- A causative trigger many be identified such as pet birds
- A physical exam may reveal:
- Crackles
- Investigations may reveal:
- Chest x-ray:
- May show fibrosis
- CT chest:
- May show fibrosis
- Chest x-ray:
Sarcoidosis
- A history may reveal:
- Fever, arthritis, erythema nodosum, weight loss, malaise
- A physical exam may reveal:
- Wheezing, dry crackles
- Investigations may reveal:
- Chest x-ray:
- Bilateral hilar lymphadenopathy
- Serum ACE:
- Elevated
- Serum calcium:
- Elevated
- Lung biopsy:
- Non-caseating granuloma
- Chest x-ray:
Pharyngeal pouch (Zenker’s diverticulum)
- A history may reveal:
- Usually seen in older men
- Regurgitation of undigested food, gurgling, halitosis, aspiration
- A physical exam may reveal:
- Halitosis, gurgling neck swelling
- Investigations may reveal:
- Barium swallow with fluoroscopy:
- Identifies pharyngeal pouch
- Barium swallow with fluoroscopy: