Shortness of Breath History

Differentials

Checklist

Explanation

Preparation

Wash, name, explain:

• Wash your hands
• Introduce yourself by name and role
• Check the patient’s name and date of birth
• Explain the task and get consent

“I’ve been asked to speak to you about the breathlessness you’ve been experiencing. I will ask you some questions to help determine what might be causing it. Does that sound all right?”

Presenting Complaint

Begin with an open question to establish the patient’s reason for presentation, for example, “Could you tell me about what’s been going on?”

Try to let the patient speak for 30-60 seconds without interruption. This is referred to as the ‘golden minute’ and can provide valuable information about why the patient has sought medical attention, as well as cues surrounding their ideas, concerns, and expectations (ICE) to explore later in the consultation.

History of Presenting Complaint

Next, you need to gather more specific information about the patient’s presenting complaint to establish the differential diagnosis. You can use a mixture of open and closed questions. 

An example of an open question here would be: “Can you tell me more about this breathlessness?” or “Have you noticed any other symptoms alongside the breathlessness?” Examples of closed questions include: “Do you have a cough?” or “Do you experience breathlessness at rest?”

When taking a shortness of breath history, you may find it useful to use a structured approach to your questioning. For example:

• Onset – when did the breathlessness start? Was there a sudden onset of shortness of breath, or have the symptoms come on gradually over a period of weeks or months? Does the patient remember what they were doing at the time of onset? Acute and sudden-onset shortness of breath may occur with differentials such as pneumothorax, acute asthma attack, pulmonary embolism, and acute pulmonary oedema. Gradual or insidious-onset breathlessness is more in keeping with pulmonary fibrosis, COPD, chronic heart failure, or anaemia. 
• Frequency – how often is the patient feeling breathless? Is there any pattern to episodes of symptoms? Has the frequency changed over time? Episodic breathlessness with exposure to a trigger may make you consider a diagnosis of asthma, whereas a history of near-constant shortness of breath which has worsened slowly over time is more in keeping with a progressive condition, e.g., pulmonary fibrosis or COPD.
• Timing – how long does the breathlessness last? What time of day do the symptoms occur? Any associated triggers? Has the timing of episodes changed since the patient first noticed their symptoms? Diurnal variation (fluctuation of symptoms according to the time of day) is a common feature of asthma and is useful in the diagnostic process.
• Exacerbating and relieving factors – does anything bring the breathlessness on? Does anything make it better? Common asthma triggers include cold, exercise, allergen exposure, infection, and strong emotion; relief is often provided by inhaled bronchodilators. Shortness of breath on exertion is a common feature of conditions including COPD, chronic heart failure, pulmonary fibrosis and aortic stenosis; rest is usually a relieving factor. Breathlessness associated with lying flat (orthopnoea) is reported in chronic heart failure and can be relieved by sitting upright.
• Associated symptoms – does the patient experience any other symptoms alongside the breathlessness? Cough or wheeze may make you consider respiratory differentials, whereas peripheral oedema may suggest a cardiovascular cause. 
• Previous similar episodes – has this ever happened to the patient before? Did it feel the same or different? Was there a common trigger? Symptom diaries can be useful to link episodes of symptoms together. 

System-specific History

After establishing further information about the shortness of breath, you need to gather any relevant system-specific information. In this case, the system in question is the respiratory system. Try to think of symptoms that may occur alongside breathlessness and ask about these.

It is important not only to ask these questions, but also to understand how the patient’s answers help narrow down the differential diagnosis. 

Respiratory system-specific questions to ask include, but are not limited to:

• Cough – is the cough dry or productive? If productive, what colour and consistency is the sputum? Shortness of breath differentials associated with a dry cough include asthma and pulmonary fibrosis. Breathlessness with a productive cough is a feature of COPD, bronchiectasis, pneumonia (purulent sputum) and chronic heart failure (frothy white/pink sputum).
• Wheeze – breathlessness with wheeze is found in asthma and COPD secondary to bronchospasm. Chronic heart failure can cause a ‘cardiac wheeze’ secondary to fluid in the lung fields (pulmonary oedema).
• Chest pain – breathlessness with chest pain may be caused by multiple differentials, some more serious than others. Sudden-onset central crushing chest pain associated with breathlessness may be a symptom of acute coronary syndrome. Pleuritic chest pain may be associated with breathlessness in pneumonia, pneumothorax or pulmonary embolism. Breathlessness and chest pain associated with fear or anxiety can be features of a panic attack.
• Fever – pyrexia associated with breathlessness indicates an infective cause, e.g., pneumonia, TB, empyema (pus in the pleural space).
• Exercise tolerance – has the patient’s breathlessness affected their exercise tolerance? How quickly has this changed? How far can they walk without getting breathless on the flat or uphill? Can they manage the stairs in their home?

Red Flags

Features in a shortness of breath history that are concerning for serious pathology and should trigger an urgent referral for further assessment include:

• Haemoptysis – may indicate lung malignancy or pulmonary embolism.
• Weight loss is a red flag for malignancy and should be urgently investigated.
• Unilateral leg swelling may indicate venous thromboembolism (VTE).

Relevant Systems Review

A systems review is a useful tool to ensure no important information from the history has been missed. However, it is key to consider which systems to review to keep your questions relevant to the presenting complaint.

Appropriate systems to review when taking a history of shortness of breath include:

• Cardiovascular – symptoms which may lead you consider heart failure as a cause of breathlessness include peripheral oedema, orthopnoea, paroxysmal nocturnal dyspnoea, and the need for increased numbers of pillows to sleep at night.  Associated palpitations may cause you to consider arrhythmia, e.g., atrial fibrillation as a differential, whereas exertional breathlessness with light-headedness may indicate underlying aortic stenosis.
• Haematological – Anaemia may cause breathlessness, often associated with fatigue, pallor, and light-headedness. 

Ideas, Concerns & Expectations (ICE)

Using the ICE mnemonic, you can gather information about how the patient feels about their symptoms, whether they have any specific worries or concerns, and how they hope to move forward after seeking medical attention. 

Try to find your own approach to asking about ICE that suits your personal style. Some examples are included below:

• Ideas – “Do you have any thoughts about what might be going on?” “What do you think might be causing these symptoms?”
• Concerns – “Is there anything that is worrying you about this shortness of breath?” “Have you read or Googled anything about your symptoms that has caused you concern?”
• Expectations – “Was there anything specific you were hoping we would do today?” “Do you have any ideas about what might happen next?”

Past Medical History

Gather information about previous or existing health conditions that the patient may have. Try to note when an existing condition may be of significance in the context of a presenting complaint of shortness of breath. For example, a patient with a history of atopic conditions including eczema and hay fever is more likely to develop asthma.

Ask about previous surgery or procedures the patient may have undergone. For example, a patient who has just undergone major surgery is at increased risk of developing VTE, including pulmonary embolism.

Drug History

Ask the patient about any regular medication they take, not forgetting to ask specifically about medications that the patient may not think to volunteer, e.g., over the counter medications, herbal or alternative remedies, contraception, HRT, or injections such as vitamin B12. 

Try to think about whether the information you are given could be relevant to the differential diagnosis, e.g., a patient taking methotrexate for rheumatoid arthritis is at risk of developing pulmonary fibrosis.

Check whether the patient is compliant with their medication and taking it as prescribed. Pay particular attention to patients presenting with worsening breathlessness who are prescribed inhalers for asthma or COPD. Do they have a correct understanding of how and when to take each inhaler? Are they using a spacer? Check their inhaler technique.

Remember to ask about drug allergies and clarify any reported symptoms to differentiate a true allergy from an intolerance.

Social History

This is the chance to learn more about the patient, beyond their presenting complaint.

• Who do they live with? Do they have a social support network, e.g., if receiving a debilitating diagnosis. Would someone else be at home to witness a symptom episode or to call for help if required?
• What is the condition of their accommodation? Dusty, smoky or damp accommodation may exacerbate underlying respiratory conditions, e.g., asthma.
• Do they have any pets? Pet dander may be an allergen and asthma trigger. Keeping certain birds can be associated with interstitial lung disease, though this is rare.
• Is there any significant dust or allergen exposure? Exposure to certain dusts can trigger or worsen respiratory disease. Exposure may be occupational, e.g., construction, textile, mining, and forestry, or through hobbies, e.g., DIY, woodwork, metalwork, and gardening. 
• Do they work? Are they able to work with their current symptoms, and is it safe to continue working while their symptoms are being investigated? Is there a history of asbestos exposure at work? If so and the patient develops asbestos-related disease, they may be entitled to compensation.
• Do they drive? Does their condition affect their ability to drive or attend appointments?
• Have they had contact with someone with similar symptoms? Infective differentials, e.g., viral infections, pneumonia, TB, may be traceable via a contact history.
• Have they recently returned from travelling abroad? Consider mechanisms of respiratory pathogen spread, e.g., air travel, air-conditioning (legionella). 
• Do they smoke? Smoking is well known to cause and exacerbate respiratory conditions including COPD, lung cancer,  and asthma. Don’t forget to ask about passive smoking, or smokers in the household.
• Do they drink alcohol?
• Do they use recreational drugs? Some recreational drugs are inhaled, e.g., cannabis, cocaine, nitrous oxide.

Family History

Does anyone in the family have respiratory or cardiovascular disease? For example, a family history of atopy (asthma, eczema, hay fever) is a risk factor for a patient developing asthma.

Finishing

Thank the patient and wash your hands. Consider your differential diagnosis and how you might narrow this down further through examination, bedside tests, or further investigation/imaging.

Last updated April 2025

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