This slideshare is to guide the beginners on "what to ask" while taking clinical history while in Respiratory medicine.

1. Dr. Prashant Shukla
Junior Resident
Dept of Pharmacology

2.  Name
 Age
 Sex
 Chief Complaints:
 Breathlessness:
I. Since
II. Worse on lying down/ standing/ working/ no effect at all
III. Medications for the same
IV. Diurnal variations
V. Seasonal variations
VI. Associated skin rash
VII. Associated leg pain
VIII. Associated chest pain
IX. Associated pregnancy
X. Associated OCP intake
XI. Any known allergy
XII. Ankle swelling
XIII. Breathlessness on inspiration / expiration

3.  Cough
i. Since
ii. Severity
iii. Type :
• Serous
• Mucoid
• Mucopurulent
• Rusty
iv. Color
v. Amount
vi. Expectoration( productive/ non-productive)
vii. Postural variations
viii. Diurnal variation
ix. Seasonal variation
x. Blood in sputum
xi. Associated chest pain
xii. Sneezing
xiii. Associated medications for the same
xiv. Loss of appetite
xv. Loss of weight
xvi. Evening rise of temperature
xvii. Haematemesis

4.  Chest pain
I. Since
II. Site/ side
III. Radiation to
IV. Associated perspiration
V. Loss of consciousness
VI. Sense of impending doom
VII. Any medications/ hospitalization
VIII. Exacerbating factors
IX. Relieving factors
X. Onset exertional/ progressive on rest/ sudden onset/ after meals
XI. Nausea and vomiting
XII. Trauma
XIII. Palpitations
XIV. Change with inspiration
 Wheezing/ Stridor

5.  Fever
I. Since
II. Grade
III. Diurnal variation
IV. Medications for the same
V. Urine discoloration
VI. Associated with chills and rigor
VII. Constipation/ Diarrhea
VIII. Burning micturition
 Epigastric pain
I. Since
II. Heartburn
III. Relieved/ Exacerbated on food intake
IV. Stool discoloration
V. History of blood transfusions
VI. History of vomiting
a. Color
b. Contents
c. Projectile/ Non-projectile
d. Presence of blood
e. Duration after food intake

6.  Personal history
I. Smoking bidis/ cigarettes/ hookah/ passive smoker
II. Alcohol intake
III. Abuse of afeem/ charas/ ganja/ cocaine/ bhang
IV. Vegetarian / Non-vegetarian
 Professional history
 Medical history
I. Similar problems
II. Any reported allergy
III. Bronchial asthma
IV. Diabetes mellitus
V. Myocardial infarction
VI. Hypertension
VII. Tuberculosis
• Full treatment
• Category
• Treatment stopped since
• Took medications for
VIII. Any surgery
IX. Any reported poisoning