History Taking in Chronic Lung Diseases

1. Presenting Complaint (Chief Complaint)

2. History of Presenting Illness (HPI)

Dyspnea (Breathlessness)

• Onset and duration: Gradual over years (COPD, ILD, pulmonary fibrosis) vs. episodic (asthma) vs. sudden (pneumothorax)
• Progression: Slowly progressive (COPD, IPF) vs. relapsing-remitting (asthma)
• Functional impact: Grade using MRC Dyspnea Scale (Grade 1-5)
  • Grade 1: Only on strenuous exercise
  • Grade 2: Walking briskly on level ground or up a hill
  • Grade 3: Slower than others on level ground; stops on flat after 100m
  • Grade 4: Stops after a few minutes walking on flat
  • Grade 5: Too breathless to leave house; breathless at rest
• Positional: Orthopnea (heart failure, diaphragm paralysis), platypnea (hepatopulmonary syndrome)
• Exacerbating/relieving factors: Exercise, cold air, allergens, lying flat

Cough

• Duration (chronic = >8 weeks in adults)
• Character: Dry/non-productive (ILD, asthma, ACE inhibitors) vs. productive (COPD, bronchiectasis)
• Timing: Morning predominance (COPD with sputum); nocturnal (asthma, post-nasal drip, GERD)
• Haemoptysis: Amount, frequency - suggests bronchiectasis, malignancy, TB, vasculitis

Sputum

• Daily volume (bronchiectasis can produce >30 mL/day)
• Color: Clear/white (asthma, viral), yellow/green (infection - COPD exacerbation), rust-colored (pneumococcal pneumonia), pink frothy (pulmonary edema)
• Purulence: A key marker in COPD exacerbations - increased purulence + increased dyspnea + increased volume = Anthonisen Type 1 exacerbation

Wheeze

• Is it truly wheeze vs. stridor (inspiratory upper airway)?
• Episodic and reversible (asthma) vs. persistent (fixed obstruction, COPD)

Chest Pain

• Pleuritic (sharp, worse on inspiration - pleuritis, PE, pneumonia)
• Central chest tightness (asthma, cardiac)

3. Smoking History - MANDATORY

• Smoking status: Current / ex-smoker / never-smoker
• Pack-year history: (cigarettes/day ÷ 20) × years smoked
  • e.g., 20/day for 30 years = 30 pack-years
• Type: Cigarettes, cigars, pipe, cannabis, e-cigarettes, hookah (shisha)
• Age started, age stopped (if ex-smoker), reason for stopping
• Passive smoke exposure: At home or workplace
• COPD is uncommon with <10 pack-years; consider alternative diagnoses in never-smokers

4. Occupational and Environmental Exposure History

Key occupations and associated lung diseases:

• "Have you ever worked in any dusty, chemical, or fume-heavy environment?"
• "Have your symptoms improved on weekends or holidays?" (strongly suggests occupational asthma)
• "What is the interval between exposure and onset of symptoms?"
• Indoor environment: molds, damp walls, air conditioning filters, pets (birds especially)

5. Drug and Medication History

• Amiodarone - pulmonary fibrosis (one of the most common)
• Methotrexate - hypersensitivity pneumonitis
• Bleomycin - fibrosing alveolitis
• Nitrofurantoin - acute and chronic pulmonary reactions
• ACE inhibitors - chronic dry cough (in up to 15% of users)
• Beta-blockers - can worsen bronchospasm in asthma/COPD
• NSAIDs, aspirin - exacerbate asthma in NSAID-sensitive patients
• Illicit drugs: Cocaine (pulmonary hemorrhage), heroin, cannabis
• Over-the-counter supplements, herbal remedies (often overlooked)

6. Past Medical History

• Prior respiratory illnesses: childhood asthma, recurrent chest infections, TB, pertussis
• Hospitalizations for chest disease - particularly ICU admissions or intubations (indicates severity)
• Previous pulmonary function tests (spirometry results, trend over time)
• Previous chest X-rays or CT scans
• History of allergies or atopy (eczema, allergic rhinitis, food allergies) - atopic triad suggests asthma
• Connective tissue diseases (RA, SLE, systemic sclerosis, polymyositis) - all can cause ILD
• GERD (can trigger asthma and cough)
• Recurrent sinusitis (granulomatosis with polyangiitis, Kartagener's)
• Immunosuppression (HIV, transplant, long-term steroids) - consider opportunistic infections

7. Family History

• Asthma or atopy in first-degree relatives (strong genetic component)
• Alpha-1 antitrypsin deficiency (autosomal co-dominant) - suspect in early-onset COPD, non-smokers, or lower lobe emphysema
• Cystic fibrosis (autosomal recessive) - bronchiectasis in young adults
• Familial IPF (rare but recognized)
• Pulmonary arterial hypertension (BMPR2 mutations)

8. Social History

• Alcohol: Can cause aspiration pneumonia, risk for TB
• Housing: Damp, mould exposure; housing type (inner city vs. rural)
• Pets: Birds (HP), cats, dogs (allergens)
• Travel: TB endemic areas, histoplasmosis/coccidioidomycosis (endemic mycoses)
• Hobbies: Pigeon racing, mushroom growing, hot tub use
• Exercise capacity: Specifically, what activities are now limited that were not before? (functional decline)
• Nutrition: Weight loss suggests malignancy, advanced COPD, or systemic disease

9. Systems Review Relevant to Chronic Lung Disease

10. Specific Points for Common Chronic Lung Diseases

COPD

• Smoking history (almost always present; >10 pack-years)
• Onset of symptoms: typically after age 40
• Chronic productive cough, especially in morning (chronic bronchitis component)
• Exercise-limiting dyspnea, progressive
• Exacerbation history: frequency per year, what triggers them, hospital admissions
• Ask about "blue bloater" vs. "pink puffer" features historically

Asthma

• Episodic wheeze and breathlessness - diurnal variation (worse at night/early morning)
• Identifiable triggers: allergens, exercise, cold air, NSAIDs, aspirin, stress
• Symptom-free intervals between attacks
• Personal/family history of atopy
• Response to bronchodilators
• Seasonal variation

Bronchiectasis

• Chronic productive cough - large volumes of sputum, often purulent
• Postural drainage (sputum production increases on lying down)
• Recurrent chest infections requiring antibiotics
• Underlying cause: childhood infections, TB, immune deficiency, cystic fibrosis, PCD

Interstitial Lung Disease / IPF

• Insidious onset, usually >50 years
• Dry, non-productive cough
• Progressive exertional dyspnea
• No identifiable trigger in IPF; extensive exposure history critical for secondary ILD
• Duration >4 weeks distinguishes from acute HP or infection
• Symptoms <4 weeks with fever suggest cryptogenic organizing pneumonia, acute HP, or drug reaction

Pulmonary Hypertension

• Progressive exertional dyspnea as earliest symptom
• Syncope or pre-syncope on exertion (a red flag)
• Ankle edema, fatigue
• Features of underlying cause: CTD, HIV, portal hypertension, chronic PE

Summary: The Structured Approach

CHRONIC LUNG DISEASE HISTORY - CHECKLIST
==========================================
1. Chief complaint + characterize each symptom (SOCRATES approach)
2. Dyspnea: onset, progression, MRC grade, functional impact
3. Cough: duration, character, haemoptysis
4. Sputum: volume, colour, purulence
5. Wheeze/chest tightness: pattern, triggers
6. SMOKING: pack-year history (MANDATORY)
7. Occupational/environmental history: lifelong, latency noted
8. Drug history: amiodarone, MTX, bleomycin, ACE-i, beta-blockers
9. Past medical history: childhood illness, hospitalisations, PFTs
10. Family history: atopy, AAT deficiency, CF
11. Social history: housing, pets, travel, hobbies
12. Systems review: extrapulmonary clues to systemic disease

• Goldman-Cecil Medicine - Chapter 80: Interstitial Lung Disease (History section)
• Fishman's Pulmonary Diseases and Disorders, 2-Volume Set - COPD pathophysiology
• Goldman-Cecil Medicine, Chapter 80, p. 936 - ILD diagnostic approach