Presentation on theme: "Respiratory System Focused history taking"— Presentation transcript:
1Respiratory System Focused history taking Ishraq ElshamliRespiratory UnitTripoli Medical Center
2History Taking A history is the story of the patients illness. It is the first step in determining the etiology of a patient’s problemLet the patient describe his or her problem.Be a medical detective to establish the diagnosis.
3History Taking > 80% of diagnosis may be made from history alone. Examination and investigations would either confirm or refute the history based diagnosis.
4Skills Needed for history taking The ability to :Understand and be understood.Obtain relevant information.Interview logicallyInterrupt when necessary without inhibiting patient.Look for non verbal clues.Establish good relationship with patients.Be able to summarize the information.
5The patient initiates this by describing a particular symptom which you would use for additional questioning that will help identify the cause of the problem.
6Understanding the Pathophysiology of disease ( Medical Knowledge) as well as Increased ExposureTo Patients and disease will improve theskill of taking a good history.
7The Most Important Symptoms are: Cough.Sputum.Haemoptysis.Breathlessness.Wheeze.Chest pain.
81. Cough Origin cause charactiristic Pharynx Post. Nasal drip Usualy persistentLarynxLaryngitis, tumour, whooping coughHarsh barking painful persistentTracheaTracheitisPainfulAsthmaDry or productive,worse at night, cold exp, or allergenCOPDWorse in the morning , often productiveBronchial carcinomaPersistent, associated with hemoptysisPneumoniaInitialy dry the productiveBronchiectasisProductive, positional changesPulmonary edemaOften at night, frothy sputumPulmonary tuberculosisProductive, wt. Loss, feverInterstitial lung diseaseDry, irritant, distressingOtherDrug inducedACE, B- Blocker
9How To Assess Cough ?It is important to ask about :Frequency: Intermittent OR PersistentSeverity : Diurnal variationCharacter dry or productiveAssociated symptoms e.g chest painWhat is responsible or Triggered by :Sputum in the respiratory tract e.g. in acute infections or Bronchiectasis.Cigarette smoke .Pungent smell.Cold air.
102.SPUTUM TYPES: Mucoid as in Chronic Bronchitis. Green or Yellow in Infection.Bloody in bronchogenic carcinoma, T.BRusty colour in Pneumonia.Pink and frothy in Pulmonary oedema.Foul smelling suggest anaerobic infection.Clear watery, large volume (Bronchorrhea ) in alveolar cell carcinoma.
11How 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.ViscosityBlood stained.
13How 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.
144. BREATHLESSNESS Undue awareness of breathing. Shortness of breath. Unable to get enough air.
15BREATHLESSNESS Pulmonary causes: COPD Pulmonary fibrosis. Days- WeeksHoursMinutesPulmonary causes:COPDPulmonary fibrosis.Pulmonary collapse due toobstructing bronchial carcinomaPneumoniaAsthmaAirway occlusion by FB, laryng. EdemaSp. Pneumothorax.Acute pulmonary embolismOther:Psychogenic.AnemiaPleural effusionPulmonary embolismAcute pulmonary edema due to left heart failure, MI, arrhythmia.
16How 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.TimingEarly morning→ severe asthma and LVFDuring the week→ occupational asthmaWinter→ bronchitisSpring→ atopic asthma
173.Severity or Grade:How far the patient can walk on the flat withoutstopping.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 inasthma)lying flat (orthopnea) in heart failure and severe airwayobstruction.AGGREVATING&RELIEVING FACTORSExercise, cold exposure, Excitement, Drugs.
18SEVERE LEFT HEART FAILURE 5. WHEEZEMusical sound best heard on expirationA 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 inSEVERE LEFT HEART FAILURE
19STRIDOR Noisy respiration, always inspiratory. Indicates central large airway obstruction.Causes:Carcinoma LarynxTracheal stenosisextrinsic compression
206. CHEST PAIN Causes Of Central Chest Pain Tracheitis and bronchitis.Angina.Massive pulmonary embolism.Pericarditis.Acute aortic dissection.Oesophagitis.Large central tumour.
21Causes 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
22SUMMARY CAUSES OF CHEST PAIN STRUCTUREPossible CAUSE of painPleuraInflammation, infarctionMuscleStrain from coughingBoneRib fracture or TumourCostochondral junctionTietze’s syndromenervesHerp. zoster,Pancoast tumourHeart and great vesselsCardiac ischemia, Infarction, aortic dissection, aneurysmOesophagusSpasm reflux
23How To Assess A Patient With Chest Pain Enquire about:Site.Mode of onset.Character.Radiation.Intensity.PrecipitatingAggravating and relieving factors.Relationship to breathing, coughing or movement
24Co-existing Symptoms Fever. Hoarseness of voice. Ankle swelling. Poor appetite and weight loss.Snoring and day time sleepiness.
25OSCE Objective Structured Clinical Examination The curriculum tells the staff what to teach.... The OSCEs tells the students what to learn
26But you will make it if you prepare for it and It is a stressful exam?!..But you will make it if you prepare for itandpractice, practice, practice..!
27WHAT IS OSCE OSCE is objective structured clinical examinations It is standards in clinical exam in Europe and states
28The OSCE increase the fairness by: 1.Increase the range of skills that the students are tested for2. Increase the numbers of examiners by whom the students are assessed3. asking the students the same questions over the same period of time
29Most of exam will get the patients with abnormal finding But we can get normal ..We can get volunteers…
30It 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
31Physical examination skills General History taking skills station Physical examination skills DermatologyPhysical examination skills Cardio/NeurOral exam stationPhysical examination skills Resp/Abd
32What are examiners looking for ? 1. A confident approach 2. A good skill performance 3. Good applied knowledge 4. Clear answers 5. Good communications
331. 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 yourselfReasonPermission
34Focused 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.
35The 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?
36What 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.
371. History taking Skills N 1. History taking Skills N.J is a 29 year old woman who has been diagnosed with asthma recentlyIntroduction: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?
38Questions 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?
39Any Acid reflux? Occupational history? Drugs , inhalers, NSAID, Corticosteroids.Past medical history:Hospitalizations, emergency Rx, ICU admissions, intubation.Social historySmoking duration and amount, alcohol, living conditions, number of children, animals.
412. History taking Skills N 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.timing
42Introduce 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
43Cont’ Chest Pain Provocation: What make pain worse? Exercise, food, emotion, deep breathsCharacter : sharp, dull, heavy, squeezing, tearingDuration of the pain? Describe the course of the pain. (Worsening, intermittent, better),timing of day.Associated features like nausea, vomiting,sweating and breathlessness?
44Objective -PMHx-Previous similar episodes? (past therapy, investigations)Hx: MI, documented CAD, angioplasty, CABGImportant historical risk factorsSmokingHypertensionDiabetes mellitushypercholesterolemiapositive family history