Respiratory History Taking
Opening the Consultation
Preparation and Introduction
Wash hands and don appropriate personal protective equipment (PPE) if required.
Introduce yourself with your full name and professional role.
Confirm the patient’s full name and date of birth.
Consent and Purpose
Explain the purpose of the consultation:"I’d like to take a history from you to better understand
what’s been going on."
Obtain verbal consent to proceed.
General Communication Skills
These skills apply throughout the consultation to maintain a patient-centred approach:
Empathy: Respond appropriately to verbal and non-verbal cues.
Active listening: Show attentiveness through posture, nodding, and verbal prompts.
Eye contact: Maintain an appropriate level.
Body language: Open and professional (avoid crossed arms/legs, lean slightly forward).
Avoid interruptions while the patient is speaking.
Rapport-building:
"How have you been keeping?"
"Would you like to have a seat?"
Signposting: "First, we’ll talk about your symptoms, then I’ll ask about your medical history."
Summarising: Recap what’s been said at key points to check understanding.
Presenting Complaint
Open Questions
Start with broad, open questions to allow the patient to share their concerns:
"What’s brought you in today?"
"Can you tell me more about the issues you’ve been experiencing?"
Encouraging Expansion
"Could you tell me a bit more about that?"
Identifying Multiple Complaints
If multiple issues are raised, establish a shared agenda:
"Which of these would you like to prioritise today?"
Open vs Closed Questions
Open questions: Allow the patient to narrate their experience in their own words.
Closed questions: Used later to clarify specific details or explore risk factors.
History of Presenting Complaint
Use the SOCRATES mnemonic to explore each symptom in detail.
Key Respiratory Symptoms
Dyspnoea (shortness of breath)
Cough (productive or dry)
Haemoptysis (coughing up blood)
Wheeze
Chest pain (often pleuritic)
Opening the Consultation
Preparation and Introduction
Wash hands and don appropriate personal protective equipment (PPE) if required.
Introduce yourself with your full name and professional role.
Confirm the patient’s full name and date of birth.
Consent and Purpose
Explain the purpose of the consultation:"I’d like to take a history from you to better understand
what’s been going on."
Obtain verbal consent to proceed.
General Communication Skills
These skills apply throughout the consultation to maintain a patient-centred approach:
Empathy: Respond appropriately to verbal and non-verbal cues.
Active listening: Show attentiveness through posture, nodding, and verbal prompts.
Eye contact: Maintain an appropriate level.
Body language: Open and professional (avoid crossed arms/legs, lean slightly forward).
Avoid interruptions while the patient is speaking.
Rapport-building:
"How have you been keeping?"
"Would you like to have a seat?"
Signposting: "First, we’ll talk about your symptoms, then I’ll ask about your medical history."
Summarising: Recap what’s been said at key points to check understanding.
Presenting Complaint
Open Questions
Start with broad, open questions to allow the patient to share their concerns:
"What’s brought you in today?"
"Can you tell me more about the issues you’ve been experiencing?"
Encouraging Expansion
"Could you tell me a bit more about that?"
Identifying Multiple Complaints
If multiple issues are raised, establish a shared agenda:
"Which of these would you like to prioritise today?"
Open vs Closed Questions
Open questions: Allow the patient to narrate their experience in their own words.
Closed questions: Used later to clarify specific details or explore risk factors.
History of Presenting Complaint
Use the SOCRATES mnemonic to explore each symptom in detail.
Key Respiratory Symptoms
Dyspnoea (shortness of breath)
Cough (productive or dry)
Haemoptysis (coughing up blood)
Wheeze
Chest pain (often pleuritic)
