Taking a Respiratory History

Every non-emergent assessment should begin by introducing yourself to the patient; provide your name, credentials and your role within the care team. Verify the identity of the patient and her reason for seeking care. Communicate the purpose and value of a thorough respiratory history and elicit the patient's consent. During the history, you will be gathering information about the patient's current and any previous respiratory problems, this may require input from family members or significant others. Provide comfort measure for the patient/family.

Your assessment will seek to identify the: What, When, How much, What time of day, What makes it better, What makes it worse, for the following symptoms:

• cough,
• sputum production,
• dyspnea,
• hemoptysis,
• chest pain, and 
• wheezing.

The following questions may be useful in taking a respiratory history:

• Please describe the problem that caused you to come in today?
• How has this condition impacted your activities?
• How often does this occur?
• How long has this been occuring?
• Do you have any chest pain with breathing? If so, what is the pain like, when does it occur, and what relieves it?
• Do you have a cough? If yes, what does the cough sound like, when does it occur, do you bring up any phlegm (sputum) when you cough, what does the phlegm look like? Normal sputum is thin, clear to white in color, and tasteless and odorless. Yellow-green colored sputum may indicate a bacterial infection and rust-colored sputum is characteristic of pneumonia.
• Are you ever short of breath? If so, does your shortness of breath occur at rest or with activity? Ask the patient specific questions about shortness of breath that impacts daily living, such as being able to carry groceries from a car, or being able to clean floors or do laundry.
• Do you have any problems breathing at night? If so, do you use pillows to help you get in a position to breathe easier?
• Do you have any allergies? If yes, how does your allergy affect your breathing?
• Do you smoke now or have you ever smoked? If yes, how many years did you smoke and how many packs of cigarettes did you smoke daily?
• What kind of work do you do/did you do? In your work are/were you exposed to substances such as asbestos, chemicals, or cigarette smoke?
• Do you have a personal or family history of asthma, tuberculosis, lung cancer, cystic fibrosis, bronchitis, emphysema, or any other lung disease?

Answers to these questions provide you with important information about the patient's current problem and background data that could be contributing factors to respiratory disease. Conduct the assessment in a comfortably warm room. Ask the patient to sit upright. During all aspects of the assessment, observe for fatigue or discomfort. Allow the patient time to rest if necessary.

In taking a history for an infant, ask the parents about any episodes of respiratory distress, cyanosis, apnea, sudden infantdeath syndrome (SIDS) in a sibling or other family member, exposure to passive smoke, or a history of prematurity or mechanical ventilation. In taking a history for a child, ask parents about any asthma history, including factors related to asthma epidoses, adequacy of asthma treatment, and whether or not the child has a history of night coughing, swollen lymph nodes, sore throat, or facial pain.

If the patient is an older adult, ask the patient whether or not he or she has had an annual flu immunization and pneumonia vaccine. Ask about any recent changes in exertional capacity, fatigue, a change in the number of pillows needed to sleep at night, any significant weight change, or a history of night sweats, or hand or leg swelling.

After the interview is completed, proceed in an orderly fashion by following the steps of respiratory physical assessment: 

• Inspection, 
• Palpation, 
• Percussion, and 
• Auscultation.

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