What history questions should I ask a patient with wheezing to characterize it and identify the cause?

History Questions for a Patient with Wheezing

When evaluating a patient with wheezing, systematically assess symptom characteristics, temporal patterns, triggers, associated features, and risk factors to differentiate asthma from other causes of airway obstruction and determine disease severity.

Characterize the Wheezing Itself

• Ask if the patient understands what "wheezing" means – many patients misinterpret this term, so describe it as a high-pitched whistling sound during breathing, particularly on exhalation 1
• Determine if the wheeze is audible to others or only felt by the patient – audible wheeze suggests more significant airway obstruction 2, 3
• Assess whether wheezing is continuous or intermittent – the hallmark of asthma is variable, intermittent symptoms 1
• Identify if wheezing occurs primarily during expiration, inspiration, or both – expiratory wheeze is typical of asthma, while inspiratory stridor suggests upper airway obstruction 1, 2

Temporal Pattern and Variability

• Document when symptoms started and their progression over time – acute onset suggests infection or foreign body, while chronic symptoms point toward asthma or COPD 4, 5
• Ask specifically if symptoms are worse at night – nocturnal worsening is characteristic of asthma 1, 5
• Determine if symptoms vary by time of day – diurnal variation with morning or evening predominance provides diagnostic clues 4
• Assess whether symptoms are seasonal or perennial – seasonal patterns suggest allergic triggers 1
• Inquire about symptom-free intervals – complete resolution between episodes supports asthma diagnosis 1

Triggers and Precipitating Factors

• Ask about exercise-induced symptoms – wheezing triggered by physical activity strongly suggests asthma 1, 5
• Identify exposure to allergens including pollens, dust mites, animal dander, and mold 1
• Document response to cold air, weather changes, or temperature fluctuations 1, 5
• Assess exposure to irritants such as tobacco smoke, air pollution, strong odors, or chemicals 1
• Determine if viral respiratory infections trigger or worsen symptoms 1, 6
• Ask about aspirin or NSAID use – these can precipitate bronchospasm in susceptible individuals 1
• Inquire about beta-blocker use – these medications can worsen airway obstruction 1

Associated Respiratory Symptoms

• Assess for accompanying shortness of breath – determine if it occurs at rest or only with exertion 4, 5
• Document presence of cough – ask if it's dry or productive, and whether it's paroxysmal 1, 4
• Inquire about chest tightness – this is a common asthma symptom that patients may not volunteer 1
• Ask about sputum production including color, consistency, and amount 4
• Determine if there's post-nasal drip or throat clearing – suggests upper airway cough syndrome 1, 5

Red Flag Symptoms Requiring Urgent Evaluation

• Ask about hemoptysis (coughing up blood) – this mandates immediate chest X-ray to exclude malignancy or tuberculosis 4, 5
• Document any unintentional weight loss – suggests tuberculosis, malignancy, or severe chronic disease 4, 5
• Inquire about night sweats – particularly concerning for tuberculosis in endemic areas 4, 5
• Assess for fever patterns – persistent or recurrent fever requires investigation 4, 5
• Ask about hoarseness or voice changes – may indicate laryngeal involvement or vocal cord dysfunction 1, 4
• Document any difficulty swallowing (dysphagia) – suggests esophageal or mediastinal pathology 4

Personal Atopic History

• Ask about personal history of eczema or atopic dermatitis – strongly predicts persistent asthma 1, 7, 8
• Document history of allergic rhinitis or hay fever – co-exists frequently with asthma 1, 8
• Inquire about food allergies or anaphylaxis – indicates atopic predisposition 1
• Assess for previous asthma diagnosis or treatment – even if symptoms resolved 1, 8

Family History

• Ask specifically about maternal asthma – the strongest familial risk factor for asthma 1, 7, 8
• Document paternal asthma or atopy – also significantly increases risk 7, 8
• Inquire about sibling asthma or allergies 7, 8
• Ask about family history of eczema or allergic rhinitis 1

Environmental and Occupational History

• Document current and past smoking history including pack-years 5
• Assess exposure to secondhand smoke – particularly important in children and increases wheezing risk 1, 7
• Inquire about occupational exposures to dust, chemicals, fumes, or allergens 1, 5
• Ask about home environment including presence of pets, carpeting, dampness, or mold 1
• Determine if symptoms improve away from home or work – suggests environmental trigger 1

Medication History and Treatment Response

• Review all current medications including over-the-counter drugs 5
• Specifically ask about ACE inhibitors – these cause chronic cough in up to 20% of patients 5
• Document previous asthma treatments and their effectiveness including bronchodilators and inhaled corticosteroids 1, 5
• Assess adherence to prescribed therapies – poor control may reflect non-compliance rather than treatment failure 1

Severity and Impact Assessment

• Quantify frequency of wheezing episodes – daily, weekly, or monthly 1
• Assess limitation of daily activities including work, school, or exercise tolerance 1
• Document sleep disruption – frequency of nocturnal awakenings indicates severity 1
• Inquire about emergency department visits or hospitalizations for breathing problems 1
• Ask about previous need for oral corticosteroids – indicates more severe disease 1

Special Considerations for Children

• Ask about wheezing with viral infections versus wheezing between infections – helps distinguish transient viral wheeze from persistent asthma 1, 9, 8
• Document age at first wheezing episode – onset before age 2 years has better prognosis for resolution 1, 9
• Inquire about recurrent chest infections in early childhood – strongly predicts persistent asthma 7, 8
• Ask about birth history including prematurity and low birth weight 1
• Assess for bronchiolitis in infancy – associated with early childhood wheeze but often resolves 1, 9

Common Pitfalls to Avoid

• Don't assume the patient's self-diagnosis is correct – many patients label any breathing difficulty as "asthma" without objective confirmation 1
• Don't rely solely on the term "wheezing" – describe the sound and ask if it matches their experience, as interpretation varies widely across cultures and languages 1
• Don't overlook alternative diagnoses – consider vocal cord dysfunction, foreign body aspiration, cardiac disease, or localized airway obstruction from tumor 1, 2
• Don't forget to ask about gastroesophageal reflux symptoms – GERD commonly coexists with asthma and can trigger bronchospasm 5