History Taking

When performing an assessment a framework of questions must be developed to help the nurse gather information in a systematic way. Patients must be allowed to tell their story, but this may be unstructured; it is up to the nurse to gather the information in a logical sequence. Some practitioners fi nd it useful to have a template or an assessment form to follow, to ensure that all relevant facts are collected. The key elements of a medical history include: 1- Patient identification 2- Presenting complaint 3- History of presenting complaint 4- Past medical history 5- Current health and medications 6- Family history 7- Psychosocial history 8- Review of systems

The patient’s name, age, date of birth, and computer or hospital number should be recorded. The date and time of the consultation should also be noted.

The patient should be encouraged to explain the problem in their own words. This should be summarized briefly in a few words, such as shortness of breath, cough.

The patient should be encouraged to describe what they think has caused the problem, and what has led them to ask for help. PQRSTU Assessment: They should be asked what impact the symptoms are having on their life. What provokes symptoms and what relieves them? For example, if the patient is complaining of breathlessness, they should be asked what exacerbates the breathlessness, and what treatment they may have tried either pharmacologically or nonpharmacologically to alleviate it. Once the patient has given their account, the nurse can enquire about the presenting symptoms and illness. Patients with respiratory disease may have many chronic symptoms such as breathlessness or cough. The nurse must determine whether the patient is describing an acute worsening of their usual symptoms, and what has led them to seek medical attention. The timing and precipitants of the symptoms should be recorded as well as the impact on daily living.

Details of any previous or other current illnesses, operations or injuries should be recorded. For instance, a past history of tuberculosis is significant where the presenting complaint is haemoptysis and weight loss, particularly if treatment was inadequate or incomplete the fi rst time. Disease affecting other organs than the respiratory system is also signifi cant. For example, a history of cardiac disease may be particularly relevant in an acutely breathless patient, as heart failure may be the cause of the symptoms, rather than respiratory disease.

The patient should be asked to bring a list of any repeat prescriptions to the consultation, as many patients fail to remember drug names and dosages. The patient should also specifically be asked about: 1. What medications they are currently taking, including ‘over the .counter’ medication 2. Any respiratory medications they may have been prescribed in the past, and why that medication had been stopped Whether they use nebulized drugs or are on home oxygen therapy. 3. History of allergic reactions they may have had in the past, and what their symptoms were. This last point is important, as many people confuse common side-effects such as nausea related to starting an antibiotic, for example, as an allergic drug reaction. This may result in the patient being denied drugs in the future that they may benefi t from. Any true allergy should be clearly documented in the consultation notes. Many drugs have pulmonary side effects. ACE inhibitors and beta blockers can cause cough for example. Aspirin, non-steroidal anti-inflammatories and beta blockers can all trigger asthma exacerbations.

Taking a family history will highlight conditions with genetic links which may be the cause of the patients’ symptoms, such as cystic fibrosis or alpha one antitrypsin deficiency. A strong family history of asthma, for example, may lead the nurse to consider this as a possible diagnosis in an individual presenting with nocturnal cough and breathlessness.

This is a crucial part of any respiratory assessment and should include: 1. Occupation A detailed occupational history should be taken. This should include the nature, duration of the employment and what the job entailed. This is especially important for workers who were exposed to environmental hazards, such as passive smoking, silica, asbestos or coal dust. The nurse should enquire whether any respiratory or other protection was worn during the period of employment. If the patient is currently employed, then the nature and timing of the symptoms should be explored, especially if an occupational disease is suspected which is liable to compensation . The patient should also be asked if any time has been taken off work because of respiratory illness. 2. Smoking and illicit drug use Tobacco is a major cause of respiratory disease. The type and amount of tobacco smoked, along with the duration should be recorded and the individuals ‘pack year’ history documented.

Travel history Patients should be asked about any foreign or local travel where they may have been sitting still for long periods; this increases the risk of pulmonary embolism. If patients have visited areas where there are high levels of tuberculosis, HIV or malaria, this should be documented. Ethnicity The ethnic origin of the patient may be relevant. For example, the incidence of tuberculosis is higher in people from the Indian subcontinent. Pets, hobbies and activities Patients should be asked whether they currently or used to keep birds such as pigeons, parrots, or parakeets, as these can be the source of a respiratory condition such as bird-fancier’s lung. Pets, such as dogs, cats and horses can worsen or trigger asthma exacerbations.