Identifying Information

Gather the patient's general identifying data.

Chief Complaint

Elicit the patient's chief complaint.

History of Presenting Illness (HPI)

Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.


  • Duration
    • Acute: < 3 weeks
    • Sub-acute: 3-8 weeks
    • Chronic: > 8 weeks
  • Productive vs. non-productive
    • Volume
    • Colour (mucoid, purulent, clear, bloody, brown)
    • Viscosity
    • Smell
  • Hemoptysis
  • Change in nature from chronic cough
    • Increase in sputum
    • Change in colour
  • Aggravating factors
    • Extreme temperatures
    • Animal contact
    • Exertion
    • Pollutants
    • Cigarette smoke
    • Dust
  • Postural clues suggestive of CHF
    • Orthopnea
    • PND
  • Sinus pressure, post-nasal drip, preceding URTI, rhinitis


  • At rest or with exertion
    • If with exertion, what is their exercise tolerance
    • ≥4 METS if can walk up one flight of stairs without dyspnea
  • Changes with position
    • Orthopnea (dyspnea when lying horizontally)
    • Trepopnea (dyspnea when lying on one side)
    • Platypnea (dyspnea when seated)
  • Relation to stress or anxiety
  • Slow, insidious onset (i.e., with fibrosis) or rapid onset (i.e., asthma attack)
  • Environmental triggers (cold temperature, cigarette smoke, pollutant, animals, dust, pollen)

PE/DVT Risk Questions:

  • Prior DVT or PE
  • Clinical signs/symptoms of DVT
  • Leg swelling, pain with palpation of deep veins of leg
  • Current or previous malignancy
  • Hypercoaguable states (Factor V Leiden, prothrombin mutations)
  • Recent immobilization
    • Bed rest (≥3 days)
    • Long flights or car rides
  • Recent surgery (within 4 weeks)
  • Hemoptysis
  • Concurrent tachycardia
  • Chest Pain
    • Pleuritic chest pain
  • Wheezing
  • Snoring
  • Sleep apnea
    • STOP BANG: Snoring, tired (daytime), observed apneas, high BMI, neck circumference, age ≥50, gender male
    • Positive response to 3 criteria is 86% sensitive and 56% specific for presence of OSA
  • Fever, night sweats, or chills
  • Weight loss
  • Smoking (pack/years)
    • If quit, when and for how long had they smoked prior
    • Exposure to second-hand smoke
  • Sick contacts
  • Travel history/birthplace
    • Tuberculosis exposure
  • Environmental/occupational exposures

Past Medical History (PMHx)

Specifically ask about:

  • General history of previous illnesses, conditions, and hospitalization
  • Asthma
    • Last visit to hospital, previous hospitalizations, prior intubations, triggers, frequency of rescue inhaler use
  • COPD
    • Previous hospitalizations, previous steroid use, home oxygen use
  • Pneumonia
  • Interstitial lung disease
  • HIV
  • Congestive heart failure
  • Lung cancer
  • DVT or PE
  • Autoimmune disease

Family History (FmHx)

Specifically ask about:

  • Asthma
  • Atopy (asthma, atopic dermatitis, allergic rhinitis)
  • COPD
  • Pulmonary fibrosis
  • Cystic fibrosis
  • Alpha-1 antitrypsin deficiency
  • Lung cancer
  • Cardiac disease

Social History (SocHx)

Specifically ask about:

  • Occupational exposures (e.g., asbestos, silica)
  • Potential hazards related to housing
    • Prisons, mold, pets, dust, carpets

Substance Use History (SubHx)

Specifically ask about:


  • Ask about all medications patient is currently taking, and whether they are taken as prescribed
  • Particularly important medications pertaining to the Respiratory System include, but are not limited to:
    • Beta Blockers
    • ACE Inhibitors
    • Oral Contraception
    • Inhalers (Past and present)
      • Adherence and frequency of use
    • Anticoagulants
    • Diuretics
    • Steroids and other immunosuppressants
    • Recent antibiotic prescriptions


    Note allergies and ensure they concord with those listed in the EMR


    Note immunization history as described in the immunization history section.

    Review of Systems

    Conduct a review of systems, keeping other etiologies from your differential in mind.


    1. Bickley LS. The head and neck. In: Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:153-239.
    2. Wells PS, Anderson DR, Bormanis J, et. al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997 Dec 20-27;350(9094):1795-8.