Respiratory SystemFocused history taking IshraqElshamli Respiratory Unit Tripoli Medical Center
History Taking • A history is the story of the patients illness. • It is the first step in determining the etiology of a patient’s problem • Let the patient describe his or her problem. • Be a medical detective to establish the diagnosis.
History Taking • > 80% of diagnosis may be made from history alone. • Examination and investigations would either confirm or refute the history based diagnosis.
Skills Needed for history taking The ability to : • Understand and be understood. • Obtain relevant information. • Interview logically • Interrupt when necessary without inhibiting patient. • Look for non verbal clues. • Establish good relationship with patients. • Be able to summarize the information.
The patient initiates this by describing a particular symptom which you would use for additional questioning that will help identify the cause of the problem.
Understanding the Pathophysiologyof disease ( Medical Knowledge) as well as Increased ExposureToPatients and disease will improve the skill of taking a good history.
The Most Important Symptoms are: • Cough. • Sputum. • Haemoptysis. • Breathlessness. • Wheeze. • Chest pain.
How To Assess Cough ? It is important to ask about : • Frequency: Intermittent OR Persistent • Severity : Diurnal variation • Character dry or productive • Associated symptoms e.g chest pain • What is responsible or Triggered by : • Sputum in the respiratory tract e.g. in acute infections or Bronchiectasis. • Cigarette smoke . • Pungent smell. • Cold air.
2.SPUTUMTYPES: • Mucoid as in Chronic Bronchitis. • Green or Yellow in Infection. • Bloody in bronchogenic carcinoma, T.B • Rusty colour in Pneumonia. • Pink and frothy in Pulmonary oedema. • Foul smelling suggest anaerobic infection. • Clear watery, large volume (Bronchorrhea ) in alveolar cell carcinoma.
How To Assess Sputum ? It is important to ask about: • Colour. • Amount OR Volume, fill a teaspoon, tablespoon, eggcup, a sputum cup. • positional changes. • Taste or Smell. • Viscosity • Blood stained.
3. HAEMOPTYSISCAUSES : Common: • Bronchial Carcinoma. • Pulmonary Infarction. • TB. • Bronchiectasis. • Lung Abscess. • Acute/chronis bronchitis. Other: • Mitral stenosis. • Aspergilloma. • Connective tissue disease. • Goodpasteurs disease. • Forign body. • Anticoagulation • Chest trauma.
How to assess HAEMOPTYSIS? It Is Important To Ask About: • Is it frank blood or associated with purulent sputum. • Is it frank blood or streaks of blood. • Amount ? • Is it coughed up or vomited. • Previous respiratory illnesses e.g.Tuberculosis, Bronchiectasis. • D.V.T, connective tissue disease.
4. BREATHLESSNESS • Undue awareness of breathing. • Shortness of breath. • Unable to get enough air.
BREATHLESSNESS Pulmonary causes: • COPD • Pulmonary fibrosis. • Pulmonary collapse due to obstructing bronchial carcinoma • Pneumonia • Asthma • Airway occlusion by FB, laryng. Edema • Sp. Pneumothorax. • Acute pulmonary embolism Other: • Psychogenic. • Anemia • Pleural effusion • Pulmonary embolism • Acute pulmonary edema due to left heart failure, MI, arrhythmia.
How To Assess A Patient With Breathlessness? • Onset & progession: • ACUTE , sudden OR Gradual over a prolonged period or time. • Progression the time period over which breathlessness developed. • Timing • Early morning→ severe asthma and LVF • During the week→ occupational asthma • Winter→ bronchitis • Spring→ atopic asthma
3.Severity or Grade: • How far the patient can walk on the flat without stopping. • How many steps can be climbed without stopping. • Do you feel breathless when washing or dressing. • Do you feel breathless at rest. • Variability: • Episodic ( intermittent) or persistent. • worse at night and early morning (morning dippers in asthma) • lying flat (orthopnea) in heart failure and severe airway obstruction. • AGGREVATING&RELIEVING FACTORS • Exercise, cold exposure, Excitement, Drugs.
5. WHEEZE • Musical sound best heard on expiration • A common in patients with airways obstruction caused by Asthma or COPD. May be present only: • At night or early morning, On exposure to cold air or Allergen and On Exercise. • Diffuse expiratory wheezes may occur in SEVERE LEFT HEART FAILURE
STRIDOR • Noisy respiration, always inspiratory. • Indicates central large airway obstruction. • Causes: Carcinoma Larynx Tracheal stenosis extrinsic compression
6. CHEST PAIN Causes Of Central Chest Pain • Tracheitis and bronchitis. • Angina. • Massive pulmonary embolism. • Pericarditis. • Acute aortic dissection. • Oesophagitis. • Large central tumour.
Causes Of Lateral Chest Pain Pleural Pain: • Sharp and stabbing in character. • Localized or referred to shoulder tip if diaphragmatic pleura is involved. • Worse on deep inspiration or cough, if severe, shallow breathing, avoidance of movement, and cough suppression. • Results from inflammatory or malignant involvement of the parietal pleura. e.g. Pneumonia, Pulmonary infarction, Malignancy, Lung abscess, Rheumatoid arthritis
How To Assess A Patient With Chest Pain Enquire about: • Site. • Mode of onset. • Character. • Radiation. • Intensity. • Precipitating • Aggravating and relieving factors. • Relationship to breathing, coughing or movement
Co-existing Symptoms • Fever. • Hoarseness of voice. • Ankle swelling. • Poor appetite and weight loss. • Snoring and day time sleepiness.
OSCEObjective Structured Clinical Examination The curriculum tells the staff what to teach.... The OSCEs tells the students what to learn
It is a stressful exam?!.. But you will make it if you prepare for it and practice, practice, practice..!
WHAT IS OSCE • OSCE is objective structured clinical examinations • It is standards in clinical exam in Europe and states
The OSCE increase the fairness by: • 1.Increase the range of skills that the students are tested for • 2. Increase the numbers of examiners by whom the students are assessed • 3. asking the students the same questions over the same period of time
Most of exam will get the patients with abnormal finding • But we can get normal .. • We can get volunteers…
It consist of 6 stations over (80 ) minutes • 4 Physical examination skills station. • History taking skills station. • Oral exam station ( Management of common cases, Emergency, Radiology, Instruments). • All are patients oriented
Physical examination skills General History taking skills station Physical examination skills Dermatology Physical examination skills Cardio/Neur Physical examination skills Resp/Abd Oral exam station
What are examiners looking for ? 1. A confident approach 2. A good skill performance 3. Good applied knowledge 4. Clear answers 5. Good communications
1. History taking Skills • Introduction: Good morning Miss. N.J I am Dr. XYZ, senior house officer in the department of (?) I would like to have a small chat with you regarding your (---------) is that all right with you? Introduce yourself Reason Permission
Focused history taking OSCEs (Data gathering station) • Here you will show your medical knowledge concerning the current specific patient and case. Include: • The chief complaint. • History of present illness. • Past medical and surgical history. • Medications and allergies. • Family history and social history. • Occupational history.
The examiner will ask you 2-4 standard questions which are usually: • What is your Provisional diagnosis for this patient? • What is your three most relevant differential diagnosis? • What are the risk factors of this patient? • What is your only / three investigation you are going to order for this patient and why?
What is your initial / short term plan of management? • What is your long term plan of management? • Interpret this lab findings / imaging...etc. • Prognosis? If this patient came back in .. days / weeks with .. what will be your explanation.
1. History taking Skills N.J is a 29 year old woman who has been diagnosed with asthma recently • Introduction: Good morning Miss. N.J I am Dr. XYZ, senior house officer in the department of (?) I would like to have a small chat with you regarding your asthma, is that all right with you?
Questions to be asked in history taking • Wheeze, dyspnoea or cough? Disturbed sleep? • Exercise (quantify distance to breathlessness). • Days per week off work or school. • Diurnal variation? • Precipitating factors: emotion, exercise, infection, allergens and drugs. • Any other atopic diseases like eczema, hay fever, allergy. • Any Family history of asthma?
Any Acid reflux? Occupational history? • Drugs , inhalers, NSAID, Corticosteroids. • Past medical history: Hospitalizations, emergency Rx, ICU admissions, intubation. • Social history Smoking duration and amount, alcohol, living conditions, number of children, animals.
Questions: • Investigations • Management
2. History taking Skills N.S is a 50 ys old employee presented to the Medical OPD complaining of Chest pain, take a focused history.
Introduce yourself and make the patient comfortable in the bed. • Onset: when did the pain start? Sudden, gradual? • Is this the first time? Have you felt similar symptoms before? • Site& Radiation of pain to the jaw, arm or to the back ? • Precipitating .What were you doing when pain came on? • Palliation .What make pain less? antacids, rest, positional
Cont’ Chest Pain • Provocation: What make pain worse? Exercise, food, emotion, deep breaths • Character : sharp, dull, heavy, squeezing, tearing • Duration of the pain? Describe the course of the pain. (Worsening, intermittent, better),timing of day. • Associated features like nausea, vomiting,sweating and breathlessness?
Objective -PMHx- • Previous similar episodes? (past therapy, investigations) • Hx: MI, documented CAD, angioplasty, CABG • Important historical risk factors • Smoking • Hypertension • Diabetes mellitus • hypercholesterolemia • positive family history
D/D • Acute myocardial infarction, angina, pericarditis, myocarditis, aortic dissection. • PE, pleurisy, pneumothorax. • Oesophagitis + spasm, acid peptic disease, cholecystitis and pancreatitis. • Costochondritis, rib fracture. • Herpes zoster.
Hemoptysis • J.T is a 66 year old man who comes to your office complaining of coughing up blood. In the next 10 minutes take focused history.
COPD exacerbation • N.C is 65 year old man known case of COPD who comes to the emergency complaining of shortness of breath for two days. In the next 10 minutes, take a focused history.
Cough • A.H is a 62 year old man who comes to your office with cough for three months. In the next 10 minutes take focused history.