Respiratory History Arwa Hagana - PowerPoint Presentation

Slide1

Respiratory History

Arwa Hagana

Slide2

Structure of a respiratory history

Typical presentations:Shortness of breath

Cough

Exam focus Example history

Aims and Objectives

Slide3

Aims

How confident are you taking a respiratory history?

87 02 05 3

Slide4

How to do a good history?

PRACTICE! History taking is an art that needs to be developed

Actively work through the

differentialsLess likely to forget key questionsBetter clinicians

Impressive in exams

Patient Manner! Be friendly and show empathy

Slide5

Resp History Systems

Cardiac

What are some of the common causes for respiratory symptoms?

Resp

Other

Slide6

Causes of Resp Symptoms

Acute:

PE

PneumothoraxMyocardial infarction

Angina

Anaphylaxis

Panic attack

Chronic:

Asthma

Heart failure

COPD

Malignancy

Pulmonary fibrosis

TB

Anaemia

Sub-acute:

Pneumonia

Asthma

Slide7

Outline of History

Intro

PC

HPCCharacterise symptom (SOCRATES)

Associated symptoms

ICE + Effect

Differentials/ risk factors

PMH

DHFHSH

Slide8

Shortness of Breath

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Introduction

“Hello, my name is …. I’m one of the third year medical

students. I’ve been asked to talk to you about what’s

brought you in to the hospital/ GP, would that be ok?”

“Before we start, can I confirm your name and DOB

Please. It’s lovely to meet you

So, what’s brought you in today?.... Can you tell me more about that?”

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HPC

Site

Onset:

When did this start? Is it getting better or worse?Character: When you say SOB,

what do you mean by that?

Radiation:

Associated

symptoms (at the end)

Timing: QLOBHow quickly did it come on?How l

ong does it last?

How

o

ften do you experience it?

Have you experienced this

b

efore? Exacerbation: What makes it better/ worseSeverity: How bad is it

S

O

C

R

A

T

E

S

Character:

Chest tightness:

Cardiac causes (MI/ angina)

Pleuritic pain:

PE, pneumonia, pneumothorax

Air hunger

: “

Can’t catch my breath

” Asthma, COPD, CHF

Slide11

HPC

Site

Onset:

When did this start? Is it getting better or worse?Character: When you say SOB,

what do you mean by that?

Radiation:

Associated

symptoms (at the end)

Timing: QLOBHow quickly did it come on?How l

ong does it last?

How

o

ften do you experience it?

Have you experienced this

b

efore? Exacerbation: What makes it better/ worseSeverity: How bad is it

S

O

C

R

A

T

E

S

Timing:

Visualise the history

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HPC

Site

Onset:

When did this start? Is it getting better or worse?Character: When you say SOB,

what do you mean by that?

Radiation:

Associated

symptoms (at the end)

Timing: QLOBHow quickly did it come on?How l

ong does it last?

How

o

ften do you experience it?

Have you experienced this

b

efore? Exacerbation: What makes it better/ worseSeverity: How bad is it

S

O

C

R

A

T

E

S

Exacerbations:

Lying flat:

Heart failure, pericarditis

Pillows:

Paroxysmal nocturnal dyspnoea = HF

Asthma specific:

Exercise, cold weather, pets, dust mites, worse at night/ morning, worse in the workplace?

Slide13

HPC

Site

Onset:

When did this start? Is it getting better or worse?Character: When you say SOB,

what do you mean by that?

Radiation:

Associated

symptoms (at the end)

Timing: QLOBHow quickly did it come on?How l

ong does it last?

How

o

ften do you experience it?

Have you experienced this

b

efore? Exacerbation: What makes it better/ worseSeverity: How bad is the SOB?

S

O

C

R

A

T

E

S

Severity:

How far can you walk before you get breathless?

Can you climb one flight of stairs?

Talk in full sentences?

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Associated Symptoms

Signpost:

“I’m just going to move on to check if you’ve been experiencing any other symptoms. Is there anything else that you’ve noticed?”

WBC

Wheeze

Breathlessness

Cough (blood/sputum)*

Resp

Associated Symptoms: WBC

*Cough needs to be characterised- covered next

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Associated symptoms

FLAWSNV

+

NV: Nausea and vomiting

Add this on to all associated symptoms questioning

2P’s

4S’s

Pain

- pleuritic chest pain?

Palpitations

Syncope

Swelling

Sweating

SOB

Cardio

Associated Symptoms: 2P’s 4S’s

Slide16

Brief Interim Summary

Keep it brief!!

Some mark schemes ask for two summaries (separate marks)

Make sure you do at least one summary in your history

“I understand that you’ve been feeling quite short of breath for the last few days, along with a cough and some calf pain. Is that correct?”

(Example of how short it should be- don’t waste time!)

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ICE + Effect

“Have you had any thoughts about what might be causing this?

Is there anything that you’re particularly worried about?

…..I understand why that might be a concern of yours, I just want

to assure you that we are going to do everything we can to get to

the bottom of this.

What were you hoping to get out of todays consultation? / Aside

from sorting this out, is there anything else you were hoping we

could do?

How have these symptoms been impacting your day to day life?”

I

C

E

Effect

Slide18

Differentials and Risk Factors

This is your chance to impress! You should have a few differentials in mind, so use this to narrow your options down.

TIE TAPS

T:

Travel, long haul flights (TB/PE)

I:

Illness- Have you or anyone around you been unwell? (pneumonia, COVID)

E:

Exposure through occupation (asbestos, ship yards, farming, birds)

T:

Trauma (pneumothorax)

A:

Allergies- Dust, pollen, pets (Asthma)

P:

Pregnant (PE) + COCP, surgery, immobilisation, cancer

S: Smoking - quantify + years (lung cancer)

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Outline of History

Intro

PC

HPC

Characterise symptom (SOCRATES)

Associated symptoms

ICE + Effect

Differentials/ risk factors

PMHDH

FH

SH

Slide20

PMH

Any long term conditions?

Do you see your GP regularly for anything?

Any hospitalizations, any surgeries?Heart problems?

Lung problems?

Specific differentials

Atopy: Eczema, hay fever, asthma

Asthma: Hospitalised? How long in hospital? Did you need oxygen?

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DH

Any regular medications

Anything over the counter

AllergiesIf allergic: What happens when you take it?

COCP (PE)

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FH

Any conditions that run in the family?

Specifically any heart or lung conditions?

Ask sensitively about lung cancer if relevant

Anyone you have been around experienced similar symptoms/ been unwell?

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SH

Smoking

Alcohol

Recreational drugsHome life

Travel

Occupation

Shipyard/ construction worker/ plumber

= Asbestos exposure: lung cancer, mesothelioma, asbestosis

Miner: Pneumoconiosis Farmer: extrinsic allergic alveolitisPets: birds- extrinsic allergic alveolitis

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Presenting to examiner

Practice this!

Should be less than 1 minute

Say important positive AND negative findingsE.g if PE is suspected but no haemoptysis, calf pain/swelling then still mention these negative findings

Opening sentence is important: most important information

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Cough

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Causes of cough

Dry:

Pulmonary fibrosis

Asthma

COPD

URTI

Drug induced

(ACEI)

Haemoptysis:

Cancer

PE

TB

Heart failure

(frothy pink sputum)

Productive:

Pneumonia

Asthma

COPD

Bronchiectasis

Slide27

HPC

Site

Onset:

When did this start? Is it getting better or worse?Character: How would you describe the

cough? Do you bring anything up?

Radiation:

Associated

symptoms (at the end)

Timing: QLOBHow quickly did it come on?How long does it last?

How often do you experience it?

Have you experienced this before?

Exacerbation:

What makes it better/ worse

Severity:

How bad is it?

S

O

C

R

A

T

E

S

Character

:

Dry (pulmonary fibrosis)

Wheezy (asthma)

Whooping (pertussis)

Gurgling (bronchiectasis)

Productive:

Amount:

(teaspoons)

Colour:

White/ clear (COPD, Asthma)

White/ pink frothy (Heart failure)

Green/ yellow (pneumonia)

Green-rust coloured (bronchiectasis)

Blood:

Blood streaked (lung cancer, bronchiectasis, TB)

Pink, frothy: (CHF)

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Associated Symptoms

Signpost:

“I’m just going to move on to check if you’ve been experiencing any other symptoms. Is there anything else that you’ve noticed?”

WBC

Wheeze

Breathlessness

Cough (blood/sputum)

Resp

Associated Symptoms: WBC

Lung cancer

signs

+

Hoarse voice

Hand muscle wasting

Pain radiating down arm

Shoulder pain

Horner’s syndrome

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Associated symptoms

FLAWSNV

+

NV: Nausea and vomiting

Add this on to all associated symptoms questioning

2P’s

4S’s

Pain

- pleuritic chest pain?

Palpitations

Syncope

Swelling

Sweating

SOB

Cardio

Associated Symptoms: 2P’s 4S’s

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Rest of history is the same!

Slide31

Presenting to the examiner: Example

“Thank you for asking me to take a history from Jane Smith, a 35-year-old lady who has presented with a 3-day history of a cough. She describes associated haemoptysis with sudden onset of SOB. She also describes pleuritic chest pain.

She is currently 32 weeks pregnant and is otherwise fit and well.

She takes no regular medication, has no drug allergies or relevant FH.

She does not smoke, drink alcohol, or take recreational drugs. She used to previously work as an accountant.

To summarise, this is a 35-year-old lady, presenting with a haemoptysis, sudden onset SOB and pleuritic chest pain.

To complete my assessment, I would like to carry out:

Respiratory and cardiovascular examination

Basic bedside observations

Temperature, heart rate, blood pressure

Oxygen

sats

Sputum culture

Peak flow

X-ray

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Summary

Be systematic!

Follow the basic respiratory history structure

Think through differentialsConsider risk factors

Practice! You can smash the OSCE!!

OSCE blog spot

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Common Respiratory Conditions- Acute

Pulmonary Embolism:

Signs:

Sudden SOB, Cough, haemoptysis, pleuritic chest painRisk factors:Surgery, pregnancy, immobalisation, COCP, malignancy

PMH:

Previous PE

Pneumothorax:

Signs:

Sudden

SOB, pleuritic chest pain

Risk factors:

Trauma, iatrogenic, collagen disorders (

Marfan’s

, Ehlers-Danlos), smoking

PMH

:

Pre-existing lung disease (COPD, asthma etc), previous pneumothorax

Ischaemic heart disease:

Signs:

ACS: Crushing, central chest pain, radiates to arms/neck/jaw, sweating, N&V

Stable angina: Chest pain on exertion, SOB

Risk factors:

Smoking, diet

PMH:

Diabetes, hypertension, hyperlipidaemia

FH

:

Slide34

Common Respiratory Conditions- Chronic

Asthma:

Signs:

SOB, Wheeze, Cough (worse in morning or at night), chest tightnessExacerbations:Viral infections, exercise, occupational triggers, allergies, cold air

Risk factors:

Pollen, dust mites, pets, smoking

PMH:

Atopy history, hospitalisations

Heart failure:

Signs:

SOB, Cough, pink frothy sputum, PND, orthopnoea

PMH:

Cardiac pathology: arrhythmias, valve defects, HTN

New York Heart Association Classification:

No dyspnoea

Dyspnoea on ordinary activities

Dyspnoea on less than ordinary activitiesDyspnoea at rest

Lung cancer:

Signs:

Cough, haemoptysis, chest pain, SOB

Extra: Hoarse voice, Hand muscle wasting, Pain radiating down arm, Shoulder pain, Horner’s syndrome

FLAWS

Risk factors:

Smoking, asbestos exposure

FH

: Lung cancer

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Example!

Any volunteers to do a respiratory history?

You are a medical student in a GP practice, and have been asked to take a history from Susan Walker, a 19 year old.

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Feedback

https://forms.gle/opQkcx3PsroV56dE6