How to Take a History in COPD — Long Case

1. Presenting Complaint

• Breathlessness (dyspnoea)
• Chronic cough
• Sputum production
• Wheeze
• Chest tightness

2. History of Presenting Complaint (HPC)

A. Dyspnoea

• Onset — Gradual over years is typical; acute onset suggests exacerbation
• Duration — How long has it been present?
• Progression — Slowly worsening over years (hallmark of COPD)
• Exertional threshold — What activity provokes it? (climbing stairs, walking on flat, dressing, at rest?)
• Orthopnoea/PND — Ask specifically; more typical of heart failure but can coexist
• Quantify disability using the MRC Dyspnoea Scale:

Tip: Ask about the "shopping trolley sign" — less breathless when pushing a trolley/cart than walking freely (due to tripod positioning). This is very specific for COPD.

B. Cough

• Onset and duration — Chronic productive cough for ≥3 months in ≥2 consecutive years = chronic bronchitis
• Character — Productive vs. dry
• Time pattern — Morning cough ("morning ritual"), worse in winter
• Triggers — Cold air, smoke, exercise

C. Sputum

• Volume — How much per day? (teaspoon, tablespoon, egg cup)
• Colour — White/grey (stable), yellow/green (infection/exacerbation), rusty (pneumococcal infection), pink frothy (pulmonary oedema — important differential)
• Haemoptysis — Always ask; if present, consider lung cancer, bronchiectasis, TB. Clubbing is not a feature of COPD — its presence should prompt investigation for malignancy or pulmonary fibrosis

D. Wheeze

• Persistent or episodic?
• Response to bronchodilators (helps differentiate from asthma)

E. Chest Pain/Tightness

• Pleuritic pain? (pneumothorax, pleurisy)
• Central tightness (cor pulmonale, ischaemic heart disease)

3. Exacerbation History

• Frequency — How many exacerbations per year?
• Triggers — URTI, environmental, seasonal
• Symptoms of exacerbation — Increased dyspnoea, increased cough, change in sputum quantity or purulence
• Severity — Treated at home? GP visit? A&E? ICU?
• Hospitalisations — Number, dates, whether intubated or on NIV (BiPAP)
• Steroid/antibiotic courses — Home supply? "Rescue pack"?

4. Risk Factor History (Aetiology)

Smoking History — Most Important

• Type — Cigarettes, cigars, pipe, shisha, e-cigarettes
• Pack-year history = (cigarettes per day ÷ 20) × years smoked

  e.g., 20 cigarettes/day for 30 years = 30 pack-years

• Current smoker or ex-smoker — If ex, when did they stop?
• Passive/secondhand smoke — Childhood exposure, occupational

Occupational Exposure

• Dust — Coal miners, gold miners, cotton textile workers
• Fumes/chemicals — Welding, painting, agriculture
• Duration of exposure — Years, intensity
• Use of protective equipment (PPE)

Indoor/Biomass Fuel Exposure

• Burning of wood, dung, crop residue for cooking/heating (common in low-income settings)
• Poorly ventilated kitchens

Childhood History

• Recurrent lower respiratory tract infections in childhood
• Premature birth (poor lung development = reduced lung reserve)
• Severe asthma

Environmental/Outdoor Pollution

• Urban vs. rural, industrial area

Alpha-1 Antitrypsin (A1AT) Deficiency

• Ask about family history of emphysema, especially in non-smokers
• Young age at onset (<45 years), lower lobe predominant emphysema
• Associated liver disease (cirrhosis)

5. Past Medical History

• Asthma or childhood wheeze (overlap syndrome ACOS)
• Previous tuberculosis — Can cause airflow obstruction
• Recurrent chest infections / bronchiectasis
• Heart disease — Ischaemic heart disease, heart failure (key comorbidity and differential for dyspnoea)
• Pulmonary hypertension / cor pulmonale — Ankle swelling, raised JVP
• Osteoporosis — Common in COPD, worsened by steroids
• Diabetes, metabolic syndrome
• Lung cancer — Strong shared risk factor with smoking
• Anxiety/depression — Very common comorbidity; significantly impairs quality of life

6. Drug History

• Current inhalers — SABA (salbutamol), LABA (salmeterol, formoterol), LAMA (tiotropium, umeclidinium), ICS (fluticasone, budesonide), combination inhalers (LABA/LAMA, LABA/ICS, triple therapy)
• Inhaler technique and compliance — Ask the patient to demonstrate
• Oral medications — Theophylline, roflumilast, azithromycin prophylaxis
• Long-term oral steroids — Doses, duration, side effects
• Home nebulisers
• Home oxygen / NIV
• Medications that can worsen respiratory disease — Beta-blockers (use cardioselective if needed), NSAIDs (avoid), ACE inhibitors (cause cough — may be confused with COPD cough)
• Allergy history

7. Oxygen and NIV History

• Long-term oxygen therapy (LTOT) — Prescribed? Hours per day (ideally >15 hours)? Portable vs. concentrator?
• Non-invasive ventilation (BiPAP/CPAP) — For hypercapnic respiratory failure
• Ambulatory oxygen

8. Functional History and Quality of Life

• Activities of daily living (ADLs) — Can they shower, dress, cook independently?
• Exercise tolerance — What is the patient's current maximum walking distance?
• Mobility aids — Wheelchair, rollator?
• Social participation — Work, hobbies, going out

9. Social History

• Smoking status (if not already asked)
• Alcohol — Can affect response to infection and drug compliance
• Occupation — Current or retired; occupational exposure (see above)
• Housing — Stairs, heating, dampness/mould, rural vs. urban
• Social support — Lives alone? Who are the carers?
• Benefits/income — Disease impact on employment
• Travel — Air travel (requires oxygen if PaO₂ borderline)

10. Family History

• COPD or emphysema in relatives — Especially early-onset or non-smokers → suspect A1AT deficiency
• Asthma — First-degree relatives
• Lung cancer
• Maternal tobacco use during pregnancy — Increases childhood risk

11. Systems Review (Relevant Positives/Negatives)

12. Key Differential Diagnoses to Screen For in History

13. Closing the History — Summarise the GOLD Classification Context

• Symptoms: CAT score or MRC grade
• Exacerbation history: ≥2 moderate or ≥1 hospitalisation = high-risk group E
• Spirometry: Confirm with FEV₁/FVC <0.7 post-bronchodilator; then GOLD 1–4 by % predicted FEV₁

Quick Summary Checklist for COPD Long Case History

• Presenting symptoms (dyspnoea, cough, sputum, wheeze) — onset, severity, progression
• MRC dyspnoea grade
• CAT score questions
• Exacerbation history (frequency, hospitalisations, NIV/intubation)
• Smoking — pack-year history, current vs. ex-smoker
• Occupational, indoor, environmental exposures
• Childhood history (infections, premature birth)
• Family history (A1AT, asthma, lung disease)
• Past medical history (especially cardiac disease, asthma, TB)
• Drug history (inhalers with compliance, oxygen, steroids)
• Functional and QoL impact
• Social history (living situation, support, occupation)
• Systems review (cor pulmonale symptoms, depression, weight loss)
• Differentials excluded by history

Excluding Cor Pulmonale in a COPD Long Case

1. HISTORY — Symptoms That Suggest Cor Pulmonale

2. EXAMINATION — Signs to Look For

Vital Signs

• SpO₂ — Hypoxia (SpO₂ <88%) is the main driver; chronic hypoxia must be present
• Tachycardia — RV compensation / hypoxia / arrhythmia
• Cyanosis — Central (lips/tongue) from hypoxia; peripheral (extremities) from low cardiac output

JVP (Jugular Venous Pressure)

• Elevated JVP — the single most reliable bedside sign of raised right atrial pressure
• Look for prominent 'a' wave (RVH, decreased RV compliance)
• Look for prominent 'v' wave + pulsatile liver → tricuspid regurgitation (TR), a complication of longstanding cor pulmonale

Precordial Examination

• Parasternal heave — RV hypertrophy (hand over left sternal edge)
• Loud P₂ — Pulmonary hypertension (listen at pulmonary area 2nd ICS left)
• Right ventricular S₃ — RV failure
• TR murmur — Pansystolic at left sternal edge, louder on inspiration (Carvallo's sign)

Abdomen

• Hepatomegaly — tender, pulsatile (if TR present)
• Ascites — late sign of severe RHF

Peripheries

• Pitting ankle/leg oedema — bilateral, pitting, dependent
• Look up to the sacrum (if patient is bed-bound)

• Raised JVP
• Parasternal heave
• Loud P₂
• TR murmur
• Hepatomegaly + pulsatile liver

3. INVESTIGATIONS — How to Confirm/Exclude

Bedside

Bloods

Imaging

Definitive Diagnosis

• Right heart catheterisation (RHC) — the gold standard; demonstrates mean pulmonary artery pressure (mPAP) ≥25 mmHg at rest (or ≥20 mmHg by updated ESC criteria 2022). Required when echocardiogram is inconclusive or before specific PAH-targeted therapy.

Summary: Practical Approach in Long Case

History: Ankle oedema, worsening dyspnoea, syncope, abdominal distension
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Examination: Elevated JVP, parasternal heave, loud P₂, TR murmur,
             hepatomegaly, pitting oedema
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ECG: Right axis deviation, P pulmonale, RVH pattern
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CXR: Prominent pulmonary arteries, RV enlargement
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Echo: RV hypertrophy, TRJV, estimated RVSP
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ABG: Confirm hypoxia/hypercapnia (the primary driver)
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RHC (if needed): mPAP ≥20–25 mmHg = confirmed