Red Flags in Respiratory cases

Hello fellow medics,

I hope you are all well.

Below is a summary of a few red flags one should be aware of when taking a respiratory history from a patient. These questions will allow you to rule out any sinister causes of their symptoms (ie cancer) or emergency reasons (ie Pulmonary embolism)

1) Chest pain

Chest pain in any context is not good. In the case of a respiratory station it could mean: Pulmonary Embolism. Also if they have chest pain, it is also a good idea to rule out cardiac cause (ie worsens with exercise, cardiac background, radiation to arm/chin)

“Do you have any chest pain when you take a deep breath in?” (pleuritic chest pain)

“Are you able to replicate the chest pain by pressing down on the chest wall?” (which may indicate MSK related pain)

2) Leg swelling

You can get leg swelling unilaterally which may indicate a DVT or bilateral which may mean cardiac failure. It is best to elicit WHEN they noticed the leg swelling (a short history is more worrying than a longer history) and if it is one or both legs. Leg pain and swelling also together is more worrying.

“Have you noticed any sudden swelling of your legs? If so, is it both or the one leg”.

Also work out where the swelling is- Is it the whole leg or just the ankle/foot.

3) Haemoptysis

A patient with haemotypsis should cause concern and always lead to further questions. You want to know how many times it has occured, for how long and if they have any associated symptoms ie shortness of breath. It is vital to do a smoking history (pack-years) and work history.

There are many causes of haemoptysis, but the main worrying reasons are: cancer, PE, TB. So having these in your mind will allow you to ask further questions to differentiate.

“Have you noticed any blood when you cough? If so, how much approximately and how many times has it occurred?”

4) Night sweats and weight loss

As I have explained in my blog about “Red flags: history taking” this a universal red flag for all cancers. In the context of respiratory causes, you need to think about TB, pneumonia and cancer. There are also rheumatological causes that can lead to this too.

“Have you noticed any night sweats, so much so you have had to change your clothes?”

“Have you noticed any sudden weight loss, if so, how much and over what period of time?”

5) Persistent new cough

A very vague symptom, as can occur in non life threatening conditions but in addition to the other red flag can be worrying. Also for how long have they had this persistent cough.

“So do you have a new cough, how long has it been bothering you for?”

6) Any new respiratory symptom + smoker

Smoking increases risk of all cancers, and so is an important question to ask in the social history. This cannot be ignored when doing your risk assessment for someone you suspect to have cancer.

I hope this was a refresher/reminder of questions and ideas to think about when doing a respiratory history.

The aim is not to teach you the above, but to remind you.

For more details regarding 2 week wait/urgent lung referrals, the best resource for this is: cks.nice.org.uk - which has all the up to date, evidence based guidelines (as it all depends on age and length of symptoms).

Please do follow me on instagram, facebook or twitter for quick reminders and to join the community!

Please feel free to email me if you have any questions or suggestions.

Happy revision :)