Breathlessness history

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Here is a structured clinical guide to taking a history of breathlessness (dyspnoea):

History of Breathlessness

1. Definition & Opening

Dyspnoea is the subjective, uncomfortable awareness of breathing. Patients use varied terms — "tightness," "suffocating," "can't get enough air," "heavy breathing," "unable to take a deep breath." Always use the patient's own language to confirm you are discussing the same symptom.

2. Onset & Duration

Feature	Details to Elicit
Onset	Sudden vs. gradual
Duration	Hours, days, weeks, months
Course	Progressive, intermittent, or stable

Acute dyspnoea suggests: pulmonary oedema, pulmonary embolism, pneumothorax, pneumonia, acute asthma, foreign body, vocal cord dysfunction
Chronic progressive dyspnoea suggests: COPD, left ventricular failure, interstitial fibrosis, pulmonary vascular disease, pleural effusion, severe anaemia

3. Severity — Functional Grading

Quantify exercise tolerance carefully. Patients often adapt by slowing down without realising it.

Ask:

How far can you walk on the flat at your own pace before stopping?
How many stairs before you must stop?
Does dressing, eating, or talking on the phone cause breathlessness?
Are you breathless at rest?

MRC Dyspnoea Scale (commonly used):

Grade	Description
1	Only on strenuous exercise
2	Hurrying on level ground or walking up slight hill
3	Slower than most on level, or stops after ~100 m
4	Stops after ~100 yards; unable to leave the house
5	Too breathless to leave house / breathless when dressing

Modified Borg Scale (0–10) may also be used to rate intensity of sensation at a given moment.

4. Precipitating & Relieving Factors

Factor	Implication
Exercise	Universal; assess threshold
Lying flat (orthopnoea)	Left ventricular failure, bilateral diaphragm palsy, COPD
Waking from sleep (PND)	Left ventricular failure (classically); also COPD (pooling of secretions), nocturnal aspiration
Upright position (platypnoea)	Pulmonary vascular shunting (hepatopulmonary syndrome, PFO)
Lateral decubitus (trepopnea)	Unilateral lung or pleural disease
Triggers: smoke, dust, moulds, perfumes	Asthma, occupational/hypersensitivity disease
Relieved by bronchodilator	Asthma / COPD
Relieved by sitting up	Cardiac failure

Key questions:

How many pillows do you sleep on? (orthopnoea — quantify)
Do you ever wake at night fighting for breath? (PND)

5. Character / Quality of Sensation

Descriptors can narrow the differential:

Descriptor	Likely Cause
"Chest tightness"	Asthma, myocardial ischaemia
"Air hunger / suffocation"	Pulmonary oedema, severe hypoxia
"Can't take a deep breath"	COPD with hyperinflation
"Heavy breathing"	Deconditioning
"Throat closing"	Anaphylaxis, vocal cord dysfunction

(No single descriptor is pathognomonic — use in context.)

6. Associated Symptoms

Symptom	Suggests
Wheeze	Asthma, COPD, cardiac asthma (pulmonary oedema)
Productive cough	Infection, bronchiectasis, COPD
Haemoptysis	PE, malignancy, TB, bronchiectasis
Ankle swelling / orthopnoea	Cardiac failure
Fever / rigors	Pneumonia, infective exacerbation
Chest pain (pleuritic)	PE, pneumothorax, pleurisy
Chest pain (central/crushing)	Acute coronary syndrome
Palpitations	Arrhythmia driving dyspnoea
Dizziness / light-headedness	Hyperventilation, anaemia, arrhythmia
Weight loss	Malignancy, severe COPD

7. Background History

Past medical history:

Cardiac disease (heart failure, IHD, valve disease)
Respiratory disease (asthma, COPD, TB, previous PE/DVT)
Anaemia (Hb <6–7 g/dL can cause exertional dyspnoea)
Neuromuscular disease (respiratory muscle weakness)
Renal disease (pulmonary oedema, anaemia)

Drug history:

Amiodarone, methotrexate, nitrofurantoin → pulmonary fibrosis
Beta-blockers → worsen asthma/COPD
ACE inhibitors → cough (may be confused with breathlessness)
Aspirin, progesterone → increased minute ventilation
NSAIDs → aspirin-sensitive asthma

Smoking history: Pack-years (COPD, malignancy risk)

Occupational / environmental history: Asbestos, coal, silica, birds, fungi → asbestosis, COPD, hypersensitivity pneumonitis

Family history: Asthma, alpha-1 antitrypsin deficiency, pulmonary hypertension

8. Functional Impact

Impact on daily activities, work, sleep
Anxiety or panic (psychogenic dyspnoea / hyperventilation syndrome — consider if symptoms at rest improve with activity, or are accompanied by paraesthesiae, light-headedness, palpitations)

9. Systems Review Pointers

Diabetic → Kussmaul breathing / DKA (metabolic dyspnoea)
Thyrotoxicosis, fever, pregnancy → increased ventilatory drive
Generalised muscle weakness → neuromuscular respiratory failure

Summary of Key Differentials by Pattern

Pattern	Think of
Acute, sudden onset	PE, pneumothorax, acute LVF, asthma attack
Subacute (days–weeks)	Pneumonia, pleural effusion, exacerbation of COPD/CCF
Chronic progressive	COPD, heart failure, IPF, pulmonary hypertension, malignancy, anaemia
Episodic/paroxysmal	Asthma, arrhythmia, hyperventilation, PND
Postural	Orthopnoea → LVF; platypnoea → shunt; trepopnea → unilateral lung disease

Sources: Fishman's Pulmonary Diseases and Disorders, 2-Volume Set, pp. 430–437; Murray & Nadel's Textbook of Respiratory Medicine, 2-Volume, pp. 3486–3497

Chest pain history

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I now have comprehensive content from Goldman-Cecil Medicine, Fuster & Hurst's The Heart, and Murray & Nadel's Respiratory Medicine. Here is a full structured guide:

History of Chest Pain

1. Introduction

Chest pain is one of the most important symptoms in clinical medicine — the clinician's primary task is to determine whether myocardial ischaemia is present, while simultaneously not missing other life-threatening causes (aortic dissection, pulmonary embolism, tension pneumothorax). Carefully gathering the history avoids unnecessary over-investigation and prevents missing critical diagnoses.

"Not uncommonly, clinicians forego the description of patient symptoms, essentially jumping from the chief complaint to laboratory testing and imaging." — Fuster & Hurst's The Heart

2. Site & Radiation

Site	Suggests
Substernal / central	Angina, MI, pericarditis, oesophageal spasm, GERD
Anterior chest → back / interscapular	Aortic dissection
Sternal / parasternal (point tender)	Costochondritis, Tietze syndrome
Localised, unilateral, intercostal distribution	Pleurisy, rib fracture, herpes zoster
Ipsilateral to affected lung	Pulmonary embolism
Epigastric	GERD, peptic ulcer, cholecystitis

Radiation:

Neck, jaw, left (or both) arm(s) → down ulnar aspect → ischaemic (angina/MI)
Left shoulder → pericarditis (diaphragmatic component)
Ipsilateral shoulder + neck → diaphragmatic pleurisy
Back / between shoulder blades → aortic dissection

3. Character / Quality

Descriptor	Likely Cause
Pressure, heaviness, tightness, squeezing, constriction	Angina / MI
"Pressure" — may also improve with nitrates	Oesophageal spasm (can mimic angina)
Tearing / ripping, severe from onset	Aortic dissection
Sharp, pleuritic (worse with inspiration/cough)	Pleurisy, PE, pericarditis, pneumothorax
Positional, relieved by sitting forward	Pericarditis
Burning, postprandial, worse supine	GERD
Lancinating, electric-shock-like, dermatomal	Intercostal neuritis / herpes zoster
Dull ± reproducible by pressure	Musculoskeletal (costochondritis)
Vague, variable, associated with anxiety	Psychogenic / psychiatric

Important: Many patients with angina do NOT use the word "pain." They say "pressure," "ache," "discomfort," "uneasy feeling." Never dismiss a symptom because the patient denies "pain."

4. Onset & Duration

Pattern	Implication
Sudden, maximal from onset	Aortic dissection, pneumothorax
Builds over several minutes	Angina / ACS
Insidious over days	Pericarditis, musculoskeletal, malignancy
<10 min (typically 2–5 min)	Stable angina
>30 min, not relieved by rest/nitrate	MI until proven otherwise
Hours to days without troponin rise or ECG change	Argues strongly against ischaemia
Episodic / recurrent	Angina, oesophageal spasm, anxiety

5. Precipitating & Relieving Factors

Factor	Suggests
Exertion, emotion, cold, heavy meal	Angina (increased myocardial O₂ demand)
Relief with rest	Stable angina
Relief with GTN / nitrates	Angina (also oesophageal spasm)
Rest pain, no precipitant	Unstable angina, MI, Prinzmetal (variant) angina
Worse supine, relieved by antacids	GERD
Worse on deep inspiration / coughing / sneezing	Pleurisy, pericarditis, rib fracture
Relieved by sitting forward	Pericarditis
Reproduced by palpation	Musculoskeletal, costochondritis
Worse after long flights / immobility	PE (consider DVT)

Diamond–Forrester classification of angina:

Substernal pressure-like pain
Precipitated by exertion or emotional stress
Relieved by rest or nitrates and lasting <30 minutes

All 3 criteria = typical angina
2 criteria = atypical angina
1 criterion = non-cardiac chest pain

(Note: atypical presentations are equally common in women — the "atypical in women" concept can be misleading.)

6. Severity

Use a numeric scale (0–10) or verbal descriptors
Severity does NOT correlate reliably with the seriousness of the underlying cause
A "mild" chest discomfort may still represent ACS

7. Associated Symptoms

Symptom	Suggests
Diaphoresis (profuse sweating)	MI, aortic dissection
Nausea / vomiting	MI (especially inferior)
Syncope / presyncope	MI, massive PE, aortic dissection, aortic stenosis
Dyspnoea	ACS, PE, pneumothorax, heart failure, pleuritis
Haemoptysis	PE, malignancy, TB
Palpitations / arrhythmia	MI, ACS
Cough ± fever / productive sputum	Pneumonia, pleuritis
Wheezing	Asthma, cardiac asthma (LVF)
Acid regurgitation / waterbrash	GERD
Dysphagia	Oesophageal disease
Rash (dermatomal vesicles)	Herpes zoster (pain precedes rash by 1–2 days)
Leg swelling / tenderness	DVT → PE

8. Background History

Past medical / cardiac history:

Prior angina, MI, PCI, CABG — pattern change? (new/worse = unstable)
Aortic valve disease (AS → ischaemic-type pain without CAD)
Pericarditis, myocarditis, PE/DVT
Hypertension → risk factor for dissection and IHD
Marfan syndrome / connective tissue disease → aortic dissection

Cardiovascular risk factors (for ischaemia):

Hypertension, diabetes mellitus, hyperlipidaemia
Smoking (pack-year history)
Obesity, physical inactivity
Family history of premature CAD (<55 M, <65 F first-degree relative)

Drug history:

Cocaine / amphetamines → coronary vasospasm, MI (even in young patients)
Oral contraceptive pill / HRT → PE risk
NSAIDs → peptic ulcer disease
Anticoagulants / antiplatelets (relevant to bleeding risk and dissection)
Previous nitrate or antacid response

Family history:

Premature coronary artery disease
Aortic disease, Marfan syndrome
PE/clotting disorders

9. Specific Patterns by Cause (Summary Table)

Condition	Quality	Onset/Duration	Site / Radiation	Key Associations
Stable angina	Pressure, tightness	<10 min; on exertion	Substernal → arm, jaw	Relieved by rest/GTN
Unstable angina / NSTEMI	Same as angina	>10–20 min; at rest	Same	Not relieved by rest
STEMI	Crushing, severe	>30 min	Substernal → arm, jaw	Sweat, nausea, haemodynamic compromise
Variant (Prinzmetal) angina	Pressure	Intermittent, at rest	Substernal	Young, often smoker, nocturnal
Aortic dissection	Tearing/ripping	Sudden, maximal	Anterior chest → back	Hypertension, pulse deficit
PE	Sharp, pleuritic	Sudden	Ipsilateral	Dyspnoea, haemoptysis, DVT risk
Pericarditis	Sharp, positional	Insidious; hours–days	Substernal → left shoulder	Relieved by leaning forward; friction rub
Pleurisy	Sharp, catching	Varies	Localised, unilateral	Worse inspiration/cough; fever if infective
Pneumothorax	Sharp	Sudden	Unilateral	Young male, tall; dyspnoea
GERD	Burning	10–60 min; postprandial	Substernal, epigastric	Worse supine; relieved by antacids
Oesophageal spasm	Pressure (mimics angina)	<30 min; sudden	Substernal	May respond to nitrates
Costochondritis	Dull/sharp	Insidious; days	Sternal/parasternal	Reproduced by palpation
Herpes zoster	Lancinating, burning	Precedes rash 1–2 d	Dermatomal	Vesicular rash follows
Psychogenic	Vague, variable	Variable; hours–days	Variable	Anxiety, no objective correlate

10. Social & Occupational History

Smoking: pack-years (IHD, malignancy, PE risk)
Cocaine / recreational drug use
Occupational: asbestos (mesothelioma — chronic pleuritic pain), dust
Recent immobility, long-haul travel, hospitalisation → PE
Stress, anxiety, panic disorder

Sources: Goldman-Cecil Medicine, pp. 2503–2511; Fuster & Hurst's The Heart (15th ed.), pp. 1383–1405; Murray & Nadel's Textbook of Respiratory Medicine, pp. 3517–3555

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