Transcript Respiratory System Focused history taking

Respiratory System
Focused history taking
Ishraq Elshamli
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 Pathophysiology of
disease ( Medical Knowledge) as well
as Increased ExposureTo Patients
and disease will improve the
skill of taking a good history.
The Most Important Symptoms are:
• Cough.
• Sputum.
• Haemoptysis.
• Breathlessness.
• Wheeze.
• Chest pain.
1. Cough
Origin
cause
charactiristic
Pharynx
Post. Nasal drip
Usualy persistent
Larynx
Laryngitis, tumour,
whooping cough
Harsh barking painful persistent
Trachea
Tracheitis
Painful
Asthma
Dry or productive,worse at night,
cold exp, or allergen
COPD
Worse in the morning , often
productive
Bronchial carcinoma
Persistent, associated with
hemoptysis
Pneumonia
Initialy dry the productive
Bronchiectasis
Productive, positional changes
Pulmonary edema
Often at night, frothy sputum
Pulmonary tuberculosis
Productive, wt. Loss, fever
Interstitial lung disease
Dry, irritant, distressing
Drug induced
ACE, B- Blocker
Other
How To Assess Cough ?
It is important to ask about :
1. Frequency: Intermittent OR Persistent
2. Severity : Diurnal variation
3. Character dry or productive
4. Associated symptoms e.g chest pain
5. 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.SPUTUM
TYPES:
 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. HAEMOPTYSIS
CAUSES :
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
Days- Weeks
Hours
Minutes
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?
1. Onset & progession:
• ACUTE , sudden OR Gradual over a prolonged period
or time.
• Progression the time period over which breathlessness
developed.
2. 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.
4. 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.
5. 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
SUMMARY
CAUSES OF CHEST PAIN
STRUCTURE
Possible CAUSE of pain
Pleura
Inflammation, infarction
Muscle
Strain from coughing
Bone
Rib fracture or Tumour
Costochondral junction Tietze’s syndrome
nerves
Herp. zoster,Pancoast tumour
Heart and great vessels Cardiac ischemia, Infarction,
aortic dissection, aneurysm
Oesophagus
Spasm reflux
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.
OSCE
Objective 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
Physical
examination skills
Dermatology
Oral exam
station
History taking
skills station
Physical
examination skills
Cardio/Neur
Physical
examination skills
Resp/Abd
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:
Introduce yourself
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?
Permission
Reason
Focused history taking OSCEs
(Data gathering station)
 Here you will show your medical knowledge concerning
the current specific patient and case. Include:
1. The chief complaint.
2. History of present illness.
3. Past medical and surgical history.
4. Medications and allergies.
5. Family history and social history.
6. 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.
1. Introduce yourself and make the patient comfortable in
the bed.
2. Onset: when did the pain start? Sudden, gradual?
3. Is this the first time? Have you felt similar symptoms
before?
4. Site& Radiation of pain to the jaw, arm or to the back ?
5. Precipitating .What were you doing when pain came on?
6. Palliation .What make pain less? antacids, rest, positional
Cont’ Chest Pain
7. Provocation: What make pain worse?
Exercise, food, emotion, deep breaths
8. Character : sharp, dull, heavy, squeezing, tearing
9. Duration of the pain? Describe the course of the pain.
(Worsening, intermittent, better),timing of day.
10.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
1.Acute myocardial infarction, angina,
pericarditis, myocarditis, aortic dissection.
2.PE, pleurisy, pneumothorax.
3. Oesophagitis + spasm, acid peptic disease,
cholecystitis and pancreatitis.
4. Costochondritis, rib fracture.
5.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.
THANK YOU