12. Demo: Patient Examination Flashcards
Outline the 3 main purposes of a patient consultation
- Diagnosis
- Management plan
- Lifestyle modification
Patients will only share their secrets if they trust you
Patients present their best self to their doctor
You need to be broad enough to get the correct diagnosis and closed enough to capture detail to make a management plan
What do you think is wrong?
How does regular medication / chronic diagnosis make you feel?
Opportunity for lifestyle modification; just by a doctor asking you to quit some actually do
What is the acronym SOCRATES used for?
History taking relative to pain
- S - site
- O - onset
- C - character
- R - radiation
- A - associations
- T - timing
- E - exacerbating & relieving factors
- S - severity
Outline the general process of taking a history
Name, gender, D.O.B.
Presenting complaint:
- Brief and in the patient’s own words
History of the presenting complaint:
- A mixture of open and closed questions; tailored questions to rule in/out certain diagnoses
Past medical history:
- All other medical conditions/operations past and present
Medications:
- Dose and duration; OTC, alternative therapies
Drug allergy
Family history:
- 1st degree relatives
Social history:
- Occupation; smoking, alcohol and recreational drugs; living situation; ADL (activities of daily living); pets
Outline the BTS Asthma guidelines (2016) regarding the diagnosis of asthma
“The diagnosis of asthma in children and adults is based on the recognition of a characteristic pattern of respiratory symptoms, signs and test results and the absence of any alternative explanation for these”
BTS Asthma guidelines 2016
(Asthma symptoms and signs fluctuate over time, therefore there is no diagnostic gold standard)
Outline asthma diagnosis
Presence of >1:
- Wheeze
- Cough
- Chest tightness
- Breathlessness
- Variable airflow obstruction
Also:
- Symptom variability
- Recurrent ‘attacks’
- Triggers
- Diurnal variation (varying levels of levels of a substance over a 24hr period)
- Atopic history
- Recorded observation of wheeze/variable PEF or FEV1
- Absence of alternative diagnosis
Outline PEF
The peak expiratory flow (PEF), also called peak expiratory flow rate (PEFR) is a person’s maximum speed of expiration, as measured with a peak flow meter, a small, hand-held device used to monitor a person’s ability to breathe out air
It measures the airflow through the bronchi and thus the degree of obstruction in the airways. Peak expiratory flow is typically measured in units of liters per minute (L/min)
Peak flow readings are higher when patients are well, and lower when the airways are constricted. From changes in recorded values, patients and doctors may determine lung functionality, the severity of asthma symptoms, and treatment
Measurement of PEFR requires training to correctly use a meter and the normal expected value depends on the patient’s sex, age, and height
It is classically reduced in obstructive lung disorders such as asthma
Outline FEV1
In spirometry, FEV1 is the volume of air that can forcibly be blown out in one second, after full inspiration
Average values for FEV1 in healthy people depend mainly on sex and age, according to the diagram at left. Values of between 80% and 120% of the average value are considered normal
Predicted normal values for FEV1 can be calculated online and depend on age, sex, height, mass and ethnicity as well as the research study that they are based on
Outline spirometry
Spirometry (meaning the measuring of breath) is the most common of the pulmonary function tests (PFTs)
It measures lung function, specifically the amount (volume) and/or speed (flow) of air that can be inhaled and exhaled
Spirometry is helpful in assessing breathing patterns that identify conditions such as asthma, pulmonary fibrosis, cystic fibrosis, and COPD
It is also helpful as part of a system of health surveillance, in which breathing patterns are measured over time
Spirometry generates pneumotachographs, which are charts that plot the volume and flow of air coming in and out of the lungs from one inhalation and one exhalation
Outline some of the main triggers of asthma
Pollution
Dust
Cigarette smoke
Stress
Pets
Cold/flu
Exercise
Cold air
Hormones
Briefly outline the process of taking a tailored asthma history (diagnosis)
History of the presenting complaint
Past medical history
Medications
Family history
Social history
Outline some occupational exposures to asthma
Baking
Pastry making
Spray painting
Laboratory animal work
Healthcare
Dentalcare
Food processing
Welding
Soldering
Metalwork
Woodwork
Chemical processing
Textile, plastics and rubber
manufacture
Farming etc. (with exposure to dust and fumes)
What are the main aims in asthma treatment
Minimal side-effects
No daytime symptoms
No rescue medication
No night-waking
No asthma attacks
Unlimited ADL and exercise
FEV1/PEF >80% predicted of best
Generally review asthma
Asthma control
Frequency of asthma attacks/A&E attendance
Symptoms over last month
Inhaler use
Compliance with medications
Inhaler technique
Lung function assessment (PEFR)
Education
Trigger awareness and avoidance
Smoking cessation
Weight control and exercise
Personalised annual Asthma Action Plan
State 3 good questions which you could ask a patient with recurring asthma,
In the last week or month:
- Have you had difficultly sleeping due to your asthma?
- Have you had symptoms during the day?
- Has your asthma interfered with your usual daily activities? (e.g. work, school, housework, etc.)
What are the 4 classifications of asthma?
Mild intermittent - mild symptoms up to two days a week and up to two nights a month
Mild persistent - symptoms more than twice per week, but no more than once in a single day
Moderate persistent - symptoms once a day and more than one night a week
Severe persistent - symptoms throughout the day on most days and frequently at night
Outline asthma medications
The right medications for you depend on a number of things; your age, symptoms, asthma triggers and what works best to keep your asthma under control
Preventive, long-term control medications reduce the inflammation in your airways that leads to symptoms
Quick-relief inhalers (bronchodilators) quickly open swollen airways that are limiting breathing
In some cases, allergy medications are necessary
Long-term asthma control medications, generally taken daily, are the cornerstone of asthma treatment
These medications keep asthma under control on a day-to-day basis and make it less likely you’ll have an asthma attack
Outline long-term asthma control medications
Types of long-term control medications include:
- Inhaled corticosteroids (anti-inflammatory drugs; e.g. fluticasone, mometasone, etc.)
- Leukotriene modifiers (e.g. Singulair, Accolate, etc.)
- Long-acting beta-agonists (these open the airways; e.g. Serevent, Foradil, etc.)
- Combination inhalers (contain a long-acting beta-agonist alongside a corticosteroid; these may however increase the risk of a severe asthma attack due to the use of long-acting beta-agonists; e.g. Symbicort, Dulera, etc.)
- Theophylline (a daily pill which acts as a bronchodilators by relaxing muscles around the airways; not often used nowadays)
Outline quick-relief asthma (rescue) medications
Quick-relief (rescue) medications are used as needed for rapid, short-term symptom relief during an asthma attack, or before exercise if your doctor recommends it
Types of quick-relief medications include:
Short-acting beta agonists:
- These inhaled, quick-relief bronchodilators act within minutes to rapidly ease symptoms during an asthma attack; they include albuterol (ProAir HFA, Ventolin HFA, others) and levalbuterol (Xopenex)
- Short-acting beta agonists can be taken using a portable, hand-held inhaler or a nebuliser; a machine that converts asthma medications to a fine mist, so that they can be inhaled through a face mask or a mouthpiece
Ipratropium (Atrovent):
- Like other bronchodilators, ipratropium acts quickly to immediately relax your airways, making it easier to breathe
- Ipratropium is mostly used for emphysema and chronic bronchitis, but it’s sometimes used to treat asthma attacks
Oral and intravenous corticosteroids:
- These medications (which include prednisone and methylprednisolone) relieve airway inflammation caused by severe asthma
- They can cause serious side effects when used long term, so they’re used only on a short-term basis to treat severe asthma symptoms
