Ask the patient to tell you about his chief complaint. Use such questions as “When did you first notice you weren’t feeling well?” and “What has happened since then that brings you here today?” Because many respiratory disorders are chronic, be sure to ask him how the latest episode compared with the previous episode, and what relief measures were helpful or unhelpful.

The current health history includes the patient’s biographic data and an analysis of his symptoms. Determine the patient’s age, gender, marital status, occupation, education, religion, and ethnic background. These factors provide clues to potential risks and to the patient’s interpretation of his respiratory condition. Advanced age, for example, suggests physiologic changes such as decreased vital capacity. Alternatively, the patient’s occupation may alert you to problems related to hazardous materials. Ask him for the name, address, and phone number of a relative who can be contacted in an emergency.

After obtaining biographic data, ask the patient to describe his symptoms chronologically. Concentrate on the symptoms’:

Next, ask the patient to characterize his symptoms. Have him describe:

Be sure to document your findings.

A patient with a respiratory disorder may complain of dyspnea, fatigue, cough, sputum production, wheezing, and chest pain. Here are some helpful assessment techniques to gain information about each of these signs and symptoms.

The information gained from the patient’s past health history helps in understanding his current symptoms. It also helps to identify patients at risk for developing respiratory difficulty.

First, focus on identifying previous respiratory problems, such as asthma and COPD. A history of these disorders provides instant clues to the patient’s current condition. Then ask about childhood illnesses.

Obtain an immunization history, especially of influenza and pneumococcal vaccination, which may provide clues about the potential for respiratory disease. A travel history may be useful and should include dates, destinations, and length of stay.

Next, ask what problems in the past caused the patient to see a health care provider or required hospitalization, paying particular attention to respiratory problems. For example, chronic sinus infection or postnasal discharge may lead to recurrent bronchitis, and repeated episodes of pneumonia involving the same lung lobe may accompany bronchogenic carcinoma.

Ask the patient to describe the prescribed treatment, whether he followed the treatment plan, and whether the treatment helped. Determine whether he has suffered any traumatic injuries. If he has, note when they occurred and how they were treated.

The history should also include brief personal details. Ask the patient if he smokes; if he does, ask when he started and how many packs of cigarettes he smokes per day. By calculating his smoking in pack-years, you can assess his risk of respiratory
disease. To estimate pack-years, use this simple formula: number of packs smoked per day multiplied by the number of years the patient has smoked. For example, a patient who has smoked 2 packs of cigarettes per day for 42 years has accumulated 84 pack-years.

Remember to ask about the patient’s alcohol use and about his diet because nutritional status commonly influences a patient’s risk of respiratory infection.

It’s also important to obtain an allergy history. Allergies could include airborne, food, drug, and insect bites. Determine what the allergic reaction is, such as runny nose, sneezing, coughing, or other respiratory complication such as wheezing. Another component of the past health history includes medications the patient is taking. These include prescribed, OTC, herbal, and recreational drugs. All of these have adverse effects, some of them adversely affecting the respiratory system. It’s important to note medications that the patient is allergic to. This information needs to be verified and documented properly.

Obtaining a family history helps determine whether a patient is at risk for hereditary or infectious respiratory diseases. First, ask if any of his immediate blood relatives, such as parents, siblings, and children, have had cancer, sickle cell anemia, heart disease, or a chronic illness, such as asthma and emphysema. Remember that diabetes can lead to cardiac and, possibly, respiratory problems. If an immediate relative has one or more of these disorders, ask for more information about the patient’s maternal and paternal grandparents, aunts, and uncles.

Be sure to determine whether the patient lives with anyone who has an infectious disease, such as influenza or TB.

Ask the patient about his psychosocial history to assess his lifestyle. Be sure to cover his home, community, and other environmental factors that might influence how he deals with his respiratory problems. For example, people who work in mining, construction, or chemical manufacturing are commonly exposed to environmental irritants. Also ask about interpersonal relationships, mental health status, stress management, and coping
style. Keep in mind that a patient’s sexual habits or drug use may be connected with pulmonary disorders related to acquired immunodeficiency syndrome.

To assess respiratory function, determine the rate, rhythm, and quality of the patient’s respirations and inspect his chest configuration, tracheal position, chest symmetry, skin condition, nostrils (for flaring), and accessory muscle use. Accomplish this by observing the patient’s breathing and inspecting his anterior and posterior thorax. Note all abnormal findings.