Respiratory History Joshua - PowerPoint Presentation

1. Respiratory History Joshua Killlilea4th Year

2. Zoom forward to the day of your OSCE…This is the scenario you see on the door of your Respiratory History Station:Mrs.Smith is a 84 year-old lady complaining of a terrible cough. Please take a focused history from Mrs.Smith to establish the cause of the cough. You have 7 minutes to take the history and 3 minutes to present your findings to the examiner.

3. Objectives

4. How?

5. General Structure of ANY History IntroductionPresenting complaintHistory of presenting complaintSystems ReviewICEInterim SummaryPast Medical HistoryDrug HistoryFamily HistorySocial HistorySummary and closure

6. IntroductionIntroduce yourself, explain your name and roleConfirm the patient’s name and date of birth (mention that it’s lovely to meet them!)Explain that you would like to speak to them ( DO NOT SAY QUICK CHAT!!)Gain consent and make sure they are comfortable before you begin

7. Presenting ComplaintPresenting complaintHistory of presenting complaintSystems ReviewICEInterim SummaryOpen Questions!Give the patient time to respondRepeat the presenting complaint back to the patient before moving onIf they have several complaints- create a plan“What has brought you to the GP today?”“Sorry to hear about that, can you tell me more about this cough please?”

8. Mark scheme

9. CODE – 3579 0789

10. History of presenting complaintWhat is the acronym for this part of the history?Site- Where is the problem?Onset- When did it start? Was it sudden or gradual?Character- What does it feel like?Radiation- Does it spread anywhere?Associated symptomsTime course- Anything that brings the problem on? Is it always there or is it intermittent. Exacerbating factors- Does anything make it worse? Does anything make it betterSeverity.

11. Associated Cardio-Respiratory SystemsBasically, ANYTHING THAT CAN GO WRONG WITH THE HEART AND LUNGS!!!!FLAWSNV: Fever, Lethargy, Appetite loss, Weight loss, Nausea and VomitingIn the case of a respiratory history, these symptoms point towards Lung Cancer, but also TBCough and heamoptysisShortness of Breath (is this positional? Does it occur at night?)

12. Cough:COPDBronchiectasisShortness of breath:PneumoniaCOPDAsthmaHaemoptysis:Lung cancerPEChest Pain:Pleuritic chest pain:PneumothoraxPE

13. Cough DryProductive (sputum AND/OR blood)Acute (< 3 months)AsthmaDrug induced (ACEi)RhinitisUpper Respiratory Tract Infection (URTI) e.g laryngitisPulmonary oedema (secondary to heart failure)COVID!COPDTBLower Respiratroy Tract Infection (pneumonia)Chronic (>3 months)AsthmaGORDLung cancerPulmonary oedema (secondary to heart failure)BronchiectasisTBLung CancerCystic Fibrosis

14. HPC CoughSputum COLOURWhite/clear sputum –COPD Yellow/green sputum – INFECTIVE Green/rusty – PNEUMONIA, bronchiectasis Pink and frothy- pulmonary oedema

15. Shortness of Breath differentials Acute (seconds to minutes) Gradual (hours to days) Chronic (weeks to months)  Angina Dissecting aortic aneurysm Cardiac arrhythmia Heart failure Mitral/ aortic stenosis Heart failure Acute asthmaPE  Inhaled foreign body Pneumothorax Pneumonia  Pleural effusion Post-operative atelectasis Lung collapse (secondary to bronchial carcinoma) Acute respiratory distress syndrome COVID-19 COPD Chronic asthma Pulmonary fibrosis Bronchiectasis Malignancy Pulmonary hypertension Mesothelioma Pulmonary TB Long COVID-19  Guillain-Barre syndrome Myasthenia gravis Motor neuron disease Duchenne’s muscular dystrophy AnaemiaDiabetic Ketoacidosis

16. Shortness of BreathSite- Implied for shortness of breathOnset- When did this start?Character- Can you describe the sensation of being SOB (do they feel that they can’t fill their lungs, are they hyperventilating?)Radiation- N/AAssociated symptoms- Wheeze (?Asthma), Swollen legs (?Heart failure)Timing- When exactly are they SOB? Resting or only when they move? What is their exercise tolerance like? What was their exercise tolerance like before this issue? How has it progressed. Is it gradually getting worse? Worse at night? -- asthmaExacerbating Factors- Movement? Positional (i.e when they lie flat)?- the term for this is orthponea. When it occurs during sleep = Paroxysmal Nocturnal Dyspnea. In English = intermittent breathlessness at night. Worse in different places? --- AsthmaAsk if any inhalers or rest makes it better. Severity- How is it impacting their daily activities- can they shop as normal- can they move around their house?

17. Haemoptysis (blood in the cough)Infective Pneumonia Pulmonary TB Bronchitis Lung abscess Neoplastic Primary lung cancer Metastatic lung cancer Vascular Pulmonary embolism Left ventricular failure Inflammatory Wegener’s diseaseGoodpasture’s syndrome SLE (Systemic Lupus Erythematosus)Traumatic Iatrogenic (lung biopsy, post intubation) Wounds (broken rib) Degenerative Bronchiectasis Drugs Warfarin (bleeding diathesis) Crack cocaine use 

18. HPC haemooptysisSite- Make it clear whether it’s in the cough or not- could be a nose bleed or bleeding gumOnset- If long period of time- maybe start thinking about lung cancerCharacter- How much blood? Try and use patient friendly measure (e.g teaspoons etc).Radiation- N/AAssociated symptoms- FLAWS- Lung cancer OR TBTiming- How frequent? Do they cough up blood every time?Exacerbating factors – N/ASeverity – you establish this from seeing how often they cough up blood and how much

19. Chest Pain- 5 Ps of PLEURITIC CHEST PAIN5PsPulmonary embolismPneumoniaPericarditisPneumothoraxPleurisy

20. Systems ReviewPresenting complaintHistory of presenting complaintSystems ReviewICEInterim Summary* Disclaimer- you can also do this towards the end- I like to do it now just in case something big comes up!

21. Presenting complaintHistory of presenting complaintSystems ReviewICEInterim SummaryThese are not just ‘tick-box’ questions- you have to respond otherwise you will not get the marks!!E.G if a patient tells you they are worried- try and establish where this worry comes from- try and see what their support network is like!

22. Interim SummaryPresenting complaintHistory of presenting complaintSystems ReviewICEInterim SummaryPros of doing it now:Summarises the key problem that the patient has come in withIf you have missed something, you have time to address thisGets the key features clear in your head before you move on!How to do it like a pro:Keep it short- only summarise the key positive and negative symptomsLet the patient know you are going to summariseAsk the patient if you have missed anything out

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24. Speaking of interim summaries….Interim Summary:What have we covered so far?Refreshed ourselves on the key components of a historyDiscussed several presenting complaints for respiratory histories.What is left to cover?Past medical history, family history, social historySimulated case

25. Past Medical HistoryPast Medical HistoryDrug HistoryFamily HistorySocial History“Do you currently see the GP for any reason?”- ASK HOW THEY ARE MANAGING THIS CONDITION“Any recent trips to the hospital?”- V important for asthmatics and COPD Patients“Any recent surgeries?”- risk factor for PEEnquire what the surgery was if they say yesIf worried about asthma- ask about eczema and atopyIf worried about PE- ask about clotting historyIf worried about heart failure- ask about diabetes, cholesterol, previous heart attacks

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27. Drug history and allergiesPast Medical HistoryDrug HistoryFamily HistorySocial History“Do you currently take any prescribed medications?”If yes, ask about adherence and side effects“Do you take anything over the counter?””Are you allergic to any medications?”If yes, ask about nature of allergy

28. Past Medical HistoryDrug HistoryFamily HistorySocial HistoryVaccination History:InfluenzaCOVID-19PneumococcalTBDrugs which can cause respiratory symptoms:ACEi CoughAmiodarone and Methotrexate Pleural effusion, Interstitial Lung Disease Beta Blockers and NSAIDs. BronchoocnstrictionOral Contraceptive (oestrogen). PE

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30. Family History Past Medical HistoryDrug HistoryFamily HistorySocial HistoryINTRODUCE THIS SECTION SENSITIVELY!!!“Now, I am going to ask some routine questions about your family members. I appreciate some of these questions can be sensitive, but they can help us out a lot. Please let me know if you feel uncomfortable at any point”.2. Start open: “Do your parents or siblings have any lung problems?”3. Even if they say no, asked closed:“Ok, do you mind if I ask about a few to double check:AsthmaCOPDLung CancerHay fever

31. Past Medical HistoryDrug HistoryFamily HistorySocial HistoryIf there is a positive family history, then sensitively probe about the nature of the condition:How old where they when they were diagnosedHow old where they when they died

32. Past Medical HistoryDrug HistoryFamily HistorySocial HistoryWho’s at home?Can they look after themselves? i.e cook, clean for themselvesCan they move around their house easily?How many cigarettes does the patient smoke? Quantify in pack yearsDoes the patient drink alcohol?If so, quantify a typical week

33. Past Medical HistoryDrug HistoryFamily HistorySocial HistoryEstablish if the patient takes recreational drugs * be sensitive in probing this*Could have allergy to petIf bird-keeping- think about extrinsic allergic alveolitis Travel history:Long haul flight- PEVisited area where TB is endemic?

34. Past Medical HistoryDrug HistoryFamily HistorySocial HistoryWhy is OCCUPATION important in the context of a RESPIRATORY history?Farming- allergic extrinsic alveolitisCoal miner - pneumoconiosisShipyard worker – mesothelioma (asbestos exposure)

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36. Summary and closureSummary and closure Thank the patient for their time!Summarise what the patient told you (PC, key positive symptoms, key past medical, family or social history)Ask if you have missed anything or if they have any questionsWish them all the best

37. Essential Communication Skills to display

38. Group CaseThis is the scenario you see on the door of your Respiratory History Station:Mrs.Smith is a 84 year-old lady complaining of a terrible cough. Please take a focused history from Mrs.Smith to establish the cause of the cough. You have 7 minutes to take the history and 3 minutes to present your findings to the examiner.Let’s pretend you have already introduced yourself!!Jump straight into the PC and HPCThe more you engage the more I will revealSHOUT OUT or type in chat the questions you want to ask

39. Onset --- last weekCharacter – productive, green/yellow sputumAssociated symptoms- SOB, fever, loss of appetite, but no weight loss, no vomiting, no swollen legs, no chest painExacerbating factors- movement makes my shortness of breath worse, nothing else really seems to make it worse or better- paracetamol and cough syrup have not helpedTiming- cough and shortness of breath always there- even at rest- used to be able to walk 2km to shopSeverity- high- not experienced anything like thisPMHx- bilateral hip replacement- two months ago, hypothyroidismDHx- prescribed levothyroxine. Adherent, no side effects. Takes paracetamol and cough syrup OTC. Allergic to penicillin- airways ‘swell’FHX- lung cancer on maternal side

40.  DryProductive Acute AsthmaDrug induced (ACEi)RhinitisUpper Respiratory Tract Infection (URTI) e.g laryngitisPulmonary oedema (secondary to heart failure)COPDTBLower Respiratroy Tract Infection (pneumonia)ChronicAsthmaGORDLung cancerPulmonary oedema (secondary to heart failure)BronchiectasisTBLung CancerCystic Fibrosis

41. Differentials??FHX- lung cancer on maternal sideSHx- smoked 30 a day for the past 20 years. Never drinks alcohol. No recent travel. Retired accountantICE- thinks it’s lung cancer, very worries about it being lung cancer, wants a ‘test’ to se if it is cancer or not

42. Useful structure for summaries to the examinerThank you very much for letting me speak to INSERT NAME, this delightful INSERT AGE AND GENDER.INSERT NAME presented with INSERT PC, INSERT DETAILS ABOUT HPC (SOCRATES)INSERT POSITIVE PMHx, FHx and SHxINSERT TOP 3 DIFFERENTIALS.

43. ExampleThank you for letting me speak to Mrs.Smith, this delightful 84 year old lady. Mrs.Smith presents with a 1 week history of a productive cough accompanied by shortness of breath at rest and fever. Nothing seems to make it better or worse She denies haemoptysis and weight loss.2 months ago, she had a bilateral hip replacement and takes levothyroxine for her hypothyroidism, and currently takes paracetamol and cough syrup OTC. Her airways swell when she takes penicillin, suggesting an allergy.Her family history is positive for lung cancer on the maternal side, she is currently independent at home but is struggling to complete activities of daily living, and has a 30 pack year history of smoking, but does not drink alcohol. She denies recent travel.My top 3 differentials are community acquired pneumonia, but I would also like to rule out COPD and TB

44. MY TOP TIPS and resourcesPractice, Practice, PracticePractice your summaries with doctors on the wardClerk at least one patient a dayOSCE blogspot and geeky medics

45. TIPS for when you are stuckIf you do not know what to say:Go through FLAWSNV and systems review- something may come up!Go through ICE

46. THANK YOU!!!Best of luck with Y3, I am sure you will all smash it!!!Any questions, about anything, feel free to email me JK4718@ic.ac.uk

47. Feedback https://imperial.eu.qualtrics.com/jfe/form/SV_81vEjniMuF0VdOK