TB , PNEUMONIA , ASTHMA history taking

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CDC tuberculosis symptoms risk factors pneumonia asthma symptom history clinical assessment

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Respiratory history-taking format

Start with: Name, age, sex, occupation, residence, presenting complaints and duration.

For all three conditions, ask about:

Cough: onset, duration, dry/productive, amount and colour of sputum
Breathlessness: onset, progression, at rest/exertion, wheeze
Fever, chest pain, hemoptysis
Weight loss, appetite, fatigue
Past respiratory illness, TB treatment, hospital/ICU admissions
Drug and allergy history
Smoking/vaping, biomass-fuel or occupational dust exposure
Contact history, travel, living conditions
Comorbidities: diabetes, HIV/immunosuppression, heart disease, COPD
Family history of asthma, TB, allergy
Immunization history: influenza, pneumococcal, BCG where relevant

1. Tuberculosis history taking

Presenting complaints

Ask specifically:

Cough for how long? Persistent cough, usually over 2 weeks, dry or productive?
Sputum: quantity, colour, foul smell?
Hemoptysis: streaks or frank blood? Quantity? Episodes?
Fever: low-grade, evening rise, duration?
Night sweats
Loss of weight and appetite
Fatigue, weakness, reduced daily activity
Chest pain or breathlessness

Pulmonary TB commonly develops gradually, with cough, fever, weight loss, fatigue and night sweats. Ask actively about blood in sputum. The CDC clinical overview distinguishes latent TB, which is asymptomatic and non-infectious, from active TB disease.

History of present illness

Onset and progression: gradual or rapid?
Prior evaluation for the same symptoms?
Previous antibiotics and whether symptoms persisted
Any prior chest X-ray, sputum examination, GeneXpert/NAAT, Mantoux/TST or IGRA result?
Previous diagnosis of TB?
Was anti-TB treatment taken before?
- Date and duration
- Regularity/adherence
- Drug side effects
- Completion, cure, default, relapse, or treatment failure
- Known drug resistance or contact with drug-resistant TB patient

Contact and exposure history

Household contact with cough, diagnosed TB, or TB treatment
Close contact at work, hostel, prison, shelter, school, hospital
Overcrowding and poor ventilation
Previous residence/travel in a high-TB-burden area
Exposure to cattle or unpasteurized dairy products, if relevant

TB spreads through airborne particles generated when a person with pulmonary or laryngeal TB coughs, speaks or sings, as summarized by the CDC transmission guidance.

Risk factors

Ask about:

HIV status or risk factors, previous HIV test
Diabetes mellitus
Steroid use, chemotherapy, biologics, transplant medication
Chronic kidney disease, malnutrition
Smoking, alcohol dependence, substance use
Silica/dust exposure, mining
Previous TB or untreated latent TB infection

Extrapulmonary symptoms

Ask for symptoms based on sites:

Neck/axillary swelling or lymph nodes
Headache, vomiting, altered behavior, seizures
Back pain, deformity, weakness/numbness in legs
Abdominal pain/distension, diarrhea
Joint pain/swelling
Urinary symptoms
Menstrual or infertility history when genital TB is possible

Example summary

A 28-year-old man presents with cough with sputum for 1 month, low-grade evening fever, night sweats, loss of appetite and 5-kg weight loss. He reports close household contact with a person receiving treatment for pulmonary TB. There is no previous TB treatment history.

2. Pneumonia history taking

Presenting complaints

Ask about:

Fever: abrupt or gradual, chills/rigors, maximum temperature
Cough: dry or productive
Sputum: purulent, rusty, green, foul-smelling, blood-stained
Dyspnea: at rest or exertion, worsening?
Pleuritic chest pain: worse on deep breath or coughing?
Malaise, myalgia, headache, confusion, poor oral intake
In older adults: new confusion, falls, weakness or reduced functioning

Pneumonia may present with cough, fever, dyspnea or malaise, and sputum may be absent, purulent, or blood-stained. Textbook of Family Medicine, p. 321.

History of present illness

Clarify:

Acute onset over hours to days, or more prolonged illness?
Symptoms after influenza/COVID-like illness?
Recent upper respiratory infection?
Any worsening despite antibiotics?
Severity:
- Can the patient speak full sentences?
- Breathlessness at rest?
- Cyanosis?
- Reduced urine output?
- Drowsiness or confusion?

Exposure and aspiration history

Sick contacts, recent viral outbreak exposure
Recent hospitalization, surgery, ICU admission
Residence in nursing home/long-term care facility
Recent antibiotics
Travel, hotel/cruise stay, contaminated water exposure
Bird exposure, animal exposure
Aspiration risk: vomiting, dysphagia, stroke, seizure, alcohol intoxication, reduced consciousness
Tuberculosis contact if symptoms are prolonged

Risk factors and comorbidity

Age extremes
COPD/asthma/bronchiectasis
Heart failure, diabetes, kidney/liver disease
HIV, cancer, steroid/immunosuppressant use
Smoking and alcohol use
Poor dentition or swallowing difficulty
Vaccination: influenza, pneumococcal, COVID-19 as locally recommended

Differentiate from important alternatives

Ask for:

Wheeze and episodic variability: asthma
Orthopnea, PND, leg swelling: heart failure
Sudden dyspnea, pleuritic pain, leg swelling: pulmonary embolism
Chronic cough, weight loss, night sweats: TB
Reflux, choking, dysphagia: aspiration

Example summary

A 65-year-old woman with diabetes presents with 3 days of high fever with chills, productive cough with yellow sputum, right-sided pleuritic chest pain and progressive breathlessness. There is no history of aspiration or recent hospitalization.

3. Asthma history taking

Presenting complaints

Ask about the four cardinal symptoms:

Wheeze
Breathlessness
Chest tightness
Cough, especially dry cough at night or early morning

Then establish variability:

Are symptoms episodic or recurrent?
Worse at night or early morning?
Better spontaneously or after inhaler use?
Symptoms-free periods between attacks?
Seasonal variation?

Trigger history

Ask whether symptoms are triggered by:

Dust, smoke, perfumes, incense
Cold air/weather changes
Exercise
Viral respiratory infections
Pollen, pets, mold
Occupational exposure: flour, chemicals, paint, dust, fumes
Emotional stress/laughter
Aspirin/NSAIDs or beta-blockers
Food allergy, if there is a suggestive history

Severity and control

Ask:

How often are daytime symptoms present?
Night waking due to asthma?
How often is a reliever inhaler used?
Limitation in school, work, exercise, or sleep?
Any emergency visit, admission, ICU admission, NIV/intubation?
Any oral steroid courses in the past year?
Previous life-threatening or near-fatal attack?

A prior intubation, ED/hospital attendance in the preceding year, recent oral corticosteroid use, excessive short-acting beta-agonist use, and poor adherence to inhaled corticosteroids indicate higher risk. ROSEN's Emergency Medicine: Concepts and Clinical Practice, Asthma History section.

Medication history

Ask the patient to show inhalers if possible:

Name/colour of inhaler and dose
Reliever use: how many puffs/day or canisters/month?
Preventer inhaled corticosteroid use and adherence
Correct inhaler technique, spacer use
Recent oral steroids
Side effects
Written asthma action plan and peak-flow monitoring, if used

Atopy and family history

Ask for:

Allergic rhinitis: sneezing, nasal blockage, itchy/watery eyes
Eczema
Food/drug allergy
Family history of asthma, allergy, eczema

Occupational history

Symptoms worse at work and improve on weekends/holidays?
New work exposure before symptoms began?
Dust, fumes, chemical sprays, animals, flour, latex exposure?

Example summary

A 20-year-old student has recurrent episodes of wheeze, chest tightness and nocturnal cough for 6 months. Symptoms are triggered by dust and exercise and improve after a salbutamol inhaler. She has allergic rhinitis and a family history of asthma. There is no previous ICU admission or oral steroid use.

Red-flag questions needing urgent assessment

Ask and act promptly if there is:

Severe breathlessness at rest, inability to speak full sentences
Cyanosis, drowsiness, confusion, exhaustion
Large-volume or recurrent hemoptysis
Chest pain with severe dyspnea
Low oxygen saturation, if available
In asthma: poor response to reliever, silent chest, prior ICU/intubation
In suspected TB: significant hemoptysis or severe respiratory compromise

For suspected infectious pulmonary TB, use local infection-control procedures and arrange prompt clinical assessment rather than waiting for routine follow-up.

Differentials for each of it

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Differentials for TB, pneumonia, and asthma

These diagnoses often overlap because all can cause cough and breathlessness. Use the time course, fever pattern, sputum, wheeze, systemic symptoms, risk factors, examination, chest X-ray, and appropriate microbiology/spirometry to distinguish them.

1. Differential diagnosis of pulmonary tuberculosis

Consider these in a patient with chronic cough, weight loss, fever, night sweats, hemoptysis, or an upper-lobe infiltrate/cavity.

Differential	Clues favoring it over TB
Bacterial pneumonia	Acute illness over hours to days, high fever with chills, purulent sputum, pleuritic pain.
Lung cancer / bronchogenic carcinoma	Older age, smoking history, persistent cough or hemoptysis, weight loss, focal mass, non-resolving consolidation. Can coexist with TB.
Chronic pulmonary aspergillosis / aspergilloma	Chronic cough, weight loss and hemoptysis, particularly with pre-existing cavities from previous TB.
Non-tuberculous mycobacterial disease	Chronic cough with nodular or cavitary lung disease, often in bronchiectasis, COPD, or immunosuppression. Requires mycobacterial culture/speciation.
Fungal lung infections	Histoplasmosis, coccidioidomycosis, etc., depending on geographical and exposure history. May closely mimic TB with chronic constitutional symptoms and cavities.
Bronchiectasis	Long-standing daily productive cough, large-volume purulent sputum, recurrent infections and hemoptysis.
Chronic bronchitis / COPD	Smoking or biomass exposure, chronic productive cough, progressive exertional dyspnea and persistent airflow limitation.
Lung abscess	Fever, toxic appearance, foul-smelling sputum, aspiration risk, cavity often with an air-fluid level.
Sarcoidosis	Dry cough, dyspnea, bilateral hilar lymphadenopathy, skin/eye manifestations; constitutional symptoms may occur.
Lymphoma	Fever, drenching night sweats, weight loss, enlarged lymph nodes, mediastinal mass.
Pulmonary embolism/infarction	Sudden pleuritic pain, acute dyspnea, tachycardia, possible hemoptysis, DVT risk factors.

A chronic cavitary lesion can result from TB, non-tuberculous mycobacteria, fungal infection, malignancy, or lung abscess. The CDC review on chronic pulmonary aspergillosis highlights that aspergillosis, endemic fungal disease and NTM infection can mimic pulmonary TB.

2. Differential diagnosis of pneumonia

Consider these in a patient with fever, cough, sputum, pleuritic pain, breathlessness, and an infiltrate on chest X-ray.

Differential	Clues favoring it over pneumonia
Acute bronchitis / viral upper respiratory infection	Cough dominates; often viral prodrome, wheeze or sore throat; usually no focal chest signs or new infiltrate.
Influenza / COVID-19 / other viral pneumonitis	Myalgia, sore throat, coryza, headache, viral exposure; may have bilateral diffuse rather than focal chest changes.
Pulmonary tuberculosis	Symptoms for weeks or months, weight loss, night sweats, TB contact, hemoptysis, upper-zone/cavitary lesion.
Aspiration pneumonitis / aspiration pneumonia	Vomiting, dysphagia, stroke, seizure, alcohol intoxication or reduced consciousness; dependent-lobe involvement.
Acute exacerbation of COPD	Known COPD, increased dyspnea and sputum volume/purulence, wheeze; X-ray may not show new consolidation.
Acute asthma exacerbation	Episodic wheeze/chest tightness, trigger exposure, variable symptoms, improvement with bronchodilator; no focal consolidation unless infection coexists.
Acute heart failure / pulmonary edema	Orthopnea, paroxysmal nocturnal dyspnea, leg edema, raised JVP, diffuse crackles, cardiomegaly or bilateral edema.
Pulmonary embolism	Abrupt dyspnea, pleuritic pain, tachycardia, syncope or hemoptysis; fever may be low-grade.
Lung cancer with post-obstructive collapse/consolidation	Persistent or recurrent pneumonia in the same location, smoking history, weight loss, hilar mass.
Pleural effusion / empyema	Pleuritic pain and dyspnea, decreased breath sounds and stony dullness; ultrasound/X-ray clarifies.
Interstitial lung disease	Usually chronic progressive breathlessness and dry cough, bilateral fine crackles, diffuse interstitial imaging pattern.

Pneumonia can cause acute cough, fever, dyspnea, malaise, and productive or blood-stained sputum. Textbook of Family Medicine, p. 321. Confirmation commonly requires clinical assessment plus chest imaging, with microbiological testing selected according to severity and setting.

3. Differential diagnosis of asthma

Consider these in a patient with wheeze, episodic dyspnea, cough, and chest tightness.

Differential	Clues favoring it over asthma
COPD	Usually age over 40, smoking/biomass exposure, persistent rather than variable symptoms, chronic sputum, less complete reversibility on spirometry.
Vocal cord dysfunction / inducible laryngeal obstruction	Inspiratory noise or stridor, throat tightness, sudden attacks, often exercise/stress-related, poor response to bronchodilator.
Acute bronchitis or bronchiolitis	Acute infective illness, fever/coryza, new wheeze rather than recurrent variable episodes. Bronchiolitis is especially relevant in infants.
Pneumonia	Fever, purulent sputum, pleuritic pain, focal crackles/bronchial breathing or consolidation on X-ray.
Heart failure, especially cardiac asthma	Orthopnea, PND, edema, raised JVP, cardiac disease, basal crackles and pulmonary edema.
Pulmonary embolism	Sudden onset dyspnea and pleuritic pain, tachycardia, thromboembolic risk factors.
Upper-airway obstruction	Stridor, voice change, focal wheeze, symptoms unresponsive to bronchodilator. Causes include tumor, goiter, tracheal stenosis and tracheomalacia.
Foreign-body aspiration	Sudden cough/wheeze after choking, unilateral decreased air entry, particularly in children.
GERD with aspiration or reflux-related cough	Heartburn, regurgitation, cough when lying down or after meals; may worsen asthma too.
Postnasal drip / upper-airway cough syndrome	Nasal blockage, rhinorrhea, throat clearing, sensation of mucus dripping.
Bronchiectasis	Chronic productive cough, recurrent infections, large sputum volume and possible hemoptysis.
Cystic fibrosis or primary ciliary dyskinesia	Childhood onset, recurrent chest/sinus infections, poor growth, chronic wet cough.
Anaphylaxis	Sudden wheeze with urticaria, facial/tongue swelling, hypotension or GI symptoms after allergen exposure.

In adults, common asthma mimics include COPD, heart failure, GERD, mechanical airway obstruction, and vocal cord dysfunction. In children, also consider foreign-body aspiration, bronchiolitis/pneumonia, cystic fibrosis, bronchopulmonary dysplasia, and primary ciliary dyskinesia, as summarized in the CDC/ATSDR asthma differential guide.

Key clinical distinction

TB: chronic, constitutional symptoms, TB contact, hemoptysis, possible upper-zone/cavitary disease.
Pneumonia: acute fever with cough, sputum, pleuritic pain and focal consolidation.
Asthma: recurrent, variable wheeze/cough/chest tightness, triggers, nocturnal symptoms, bronchodilator response.

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