24-10-22 - Respiratory and Drug History Taking

Question 1

Learning outcomes

Answer 1

• To demonstrate an understanding of the role of a cardiovascular systems enquiry.
• To demonstrate an awareness of the causes of common cardiovascular symptoms.
• To demonstrate an awareness of risk factors for cardiovascular disease.
• To understand how different body systems can inter-relate.

Question 2

What are the 6 stages of the traditional medical model?

Answer 2

• 6 stages of the traditional medical model:
1) History
2) Examination
3) Investigation
4) Diagnosis
5) Treatment
6) Follow up

Question 3

What are the 5 stages of the Roger Neighbour Inner Consultation Model 1987?

Answer 3

• This model asks the same questions as the traditional method, but in a different order

• 5 stages of the Roger Neighbour Inner Consultation Model 1987:

1) Connecting
• Building rapport
• Identifying patients views beliefs and expectations

2) Summarising
• Explaining back to the patient what they have told you
• Allow for correction/development of ideas and understanding

3) Handing over
• Agreeing on doctor’s and patient’s agendas
• Involves negotiating and influencing shared management plan
• Giving ownership and responsibility of management plan to patient

4) Safety netting
• Providing advice on what to do if things get worse
• Could be a follow up, advice, or referral
• For the benefit of both doctor and patient
• Ensures ill patients stay in the medical system

5) Housekeeping
• Looking after yourself as a doctor e.g coffee or going for a walk
• Ensures you can provide a high level of care for every patient you see

Question 4

What are the 7 stages for the structure of history taking?

Answer 4

• 7 stages of history taking:
1) Presenting complaint (PC)
2) History of presenting complaint (HPC)
3) Past Medial History (PMH)
4) Drug History (DH)
5) Family History (FH)
6) Social history (SH)
7) Systems Inquiry (SE)

Question 5

How do you start the presenting complaint section (PC) of history taking?

What do you then do?

What is it important to do when doing this?

Answer 5

• The presenting complaint section of history taking should start with an open-ended question
• Examples:
1) Can you tell me a little bit about why you have come in today?
2) Can you tell me what brought you here today?
3) What can I do to help you today?

• It is then important to get a description of symptoms from the patient
• It is important to use the patients’ own words, and get everything down in one sentence e.g cough, sore throat, tummy pain, sore chest

Question 6

What is it important to establish during history of presenting complaint (HPC)?

What is it important to do during this section?

How can patient conversation be facilitated?

What 2 questions should be constantly be thinking in HPC?

What is a useful 8-part mnemonic for when patients present with pain during the History of presenting complaint (HPC) section?

Answer 6

• During history of presenting complaint, it is important to establish a timeline of events from the first symptom to the time of the interview
• Is it important to allow the patient to speak, and not jump in during this section
• Also important to facilitate the patient giving their account by asking a mix of open and close questions
* Be constantly thinking:
1) What are the possible diagnoses?
2) What else do I need to know to help decide which diagnosis is the correct one?

• Useful 8-part mnemonic for when patients present with pain during the History of presenting complaint (HPC) section:
  • S – Site – location of pain
  • O – Onset – when the pain started
  • C – Character – shooting, stabbing, dull ache, throbbing pain
  • R – Radiation – see if pain radiates away from source
  • A – Associated symptoms – give examples
  • T – Timing – pain worse at a particular time? Is it constant or intermittent?
  • E – exacerbators/relievers – What makes the pain better/worse
  • S – severity – pain on a 1-10 rating

Question 7

What 7 symptoms might we ask about during HPC of a respiratory examination?

Answer 7

• 7 symptoms might we ask about during HPC of a respiratory examination:
1) Chest pain
2) Dyspnoea
3) Cough
4) Sputum
5) Haemoptysis
6) Wheeze
7) Systemic upset

Question 8

What pneumonic might we used for chest pain during HPC?

What do we consider when dealing with chest pain during HPC?

What does pleuritic pain present with?

What might cause pleuritic pain?

What are 7 causes of central chest pain?

What are 5 causes of non-central chest pain?

What are 6 causes of pleural chest pain?

What are 4 causes of chest wall pain?

Answer 8

• When dealing with chest pain during HPC, we may want to use SOCRATES
• We want to consider structures where the pain might be coming from
• We may consider pleuritic pain, which presents with a sharp pain on coughing and inspiration
• This can be due to a number of conditions such as pleurisy, where the pleura become inflamed (aka pleuritis)

• 7 Cause of central chest pain:
1) Tracheitis
2) Angina/ MI
3) Aortic dissection
4) Massive PE
5) Oesophagitis
6) Lung tumour / metastases
7) Mediastinal tumour/ mediastinitis

• 5 Causes of non-central chest pain:
1) Shingles - (caused by herpes zoster) - Shingles is a painful condition caused by the same virus that causes chickenpox
2) Lung tumour
3) PE
4) Rib fracture
5) Pneumonia

• 6 causes of pleural chest pain
1) Pneumonia
2) Bronchiectasis – airways of the lungs become inflamed
3) TB - Tuberculosis (TB) is a bacterial infection spread through inhaling tiny droplets from the coughs or sneezes of an infected person. Mainly affects lungs
4) Lung tumour/ metastases/ mesothelioma
5) PE
6) Pneumothorax

• 4 Causes of chest wall pain:
1) Muscular / rib injury
2) Costochondritis - inflammation of costosternal joint
3) Lung tumour / bony metastases/ mesothelioma
4) Shingles

Question 9

What 10 questions do we ask for dyspnoea during HPC?

What 5 things should we consider with dyspnoea?

Answer 9

• Questions do we ask for dyspnoea during HPC:
1) Is there anything that brings it on?
2) Does anything make it better or worse?
3) Are you always breathless?
4) Is it when you walk/ exercise?
5) Do you get breathless lying down? – Orthopnoea/ PND (cardiac causes)
6) How far can you walk normally?
7) How far can you walk now? i.e. exercise tolerance
8) How do you manage walking uphill / upstairs?
9) Is there anything it stops you from doing?
10) Have you noticed any other symptoms?

• With dyspnoea, we should consider:

1) Cough

2) Sputum
• Sputum is a thick substance that accumulates when bacteria or fungi grows and multiplies in the lungs or bronchi.
• As it accumulates, the growing substance can make breathing more difficult and cause coughing

3) Chest pain

4) Palpitations

5) Wheeze

6) Stridor
• Less musical sounding than a wheeze, stridor is a high-pitched, turbulent sound that can happen when a child inhales or exhales.
• Stridor usually indicates an obstruction or narrowing in the upper airway, outside of the chest cavity.
 

Question 10

What are 5 dyspnoea causes that have an onset of minutes?

What are 3 causes of dyspnoea that have an onset of hours to days?

What are 3 causes of dyspnoea that have an onset of weeks to months?

What are 3 causes of dyspnoea that have an onset of months to years?

Answer 10

• 5 dyspnoea causes that have an onset of minutes:
1) PE
2) Pneumothorax
3) Acute LVF
4) Acute asthma
5) Inhaled foreign body

• 3 causes of dyspnoea that have an onset of hours to days:
1) Pneumonia
2) Asthma
3) Exacerbation of COPD

• 3 causes of dyspnoea that have an onset of weeks to months:
1) Anaemia
2) Pleural effusion - sometimes referred to as “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the lungs
3) Respiratory neuromuscular disorders

• 3 causes of dyspnoea that have an onset of months to years:
1) COPD
• Chronic obstructive pulmonary disease (COPD) is the name for a group of lung conditions that cause breathing difficulties.
• It includes: emphysema – damage to the air sacs in the lungs. chronic bronchitis – long-term inflammation of the airways.
2) Pulmonary fibrosis
3) Pulmonary TB

Question 11

What 7 are respiratory causes of dyspnoea?

What are 4 parenchymal causes of dyspnoea?

What is 1 pulmonary circulation cause of dyspnoea?

What are 2 pleural causes of dyspnoea?

What are 2 chest wall causes of dyspnoea?

What are 2 neuromuscular causes of dyspnoea?

What are 2 CVS causes of dyspnoea?

What are 5 non-cardio-respiratory causes of dyspnoea?

Answer 11

• 7 respiratory causes of dyspnoea:
1) Asthma
2) COPD
3) Bronchiectasis
4) Cystic fibrosis - Cystic fibrosis is an inherited condition that causes sticky mucus to build up in the lungs and digestive system
5) Laryngeal tumour
6) Foreign body
7) Lung tumour

• 4 parenchymal (the functional tissue of an organ as distinguished from the connective and supporting tissue) causes of dyspnoea:
1) Pneumonia
2) Pulmonary fibrosis
3) Sarcoidosis - Sarcoidosis is a rare condition that causes small patches of swollen tissue, called granulomas, to develop in the organs of the body
4) TB

• PE is a pulmonary circulation cause of dyspnoea

• 2 pleural causes of dyspnoea:
1) Pneumothorax
2) Pleural effusion

• 2 chest wall causes of dyspnoea:
1) Kyphoscoliosis - disease of the thoracolumbar spine in which normal curvature is excessively deviated in multiple planes
2) Ankylosing spondylitis - long-term (chronic) condition in which the spine and other areas of the body become inflamed

• 2 neuromuscular causes of dyspnoea:

1) Myasthenia gravis
• Rare long-term condition that causes muscle weakness.
• It most commonly affects the muscles that control the eyes and eyelids, facial expressions, chewing, swallowing and speaking.
• But it can affect most parts of the body.

2) Guillain-Barre syndrome
• Guillain-Barré (pronounced ghee-yan bar-ray) syndrome is a very rare and serious condition that affects the nerves.
• It mainly affects the feet, hands and limbs, causing problems such as numbness, weakness and pain.

• 2 CVS causes of dyspnoea
1) Cardiac failure (LVF),
2) Associated with angina or MI

• 5 non-cardio-respiratory causes of dyspnoea
1) Anaemia
2) Obesity
3) Hyperventilation
4) Anxiety
5) Metabolic acidosis

Question 12

What 9 Questions do we ask about a cough during HPC?

What 6 things might we consider when asking about coughing?

Answer 12

• 9 Questions we ask about a cough during HPC:
1) How long have you had it?
2) Is it a new problem?
3) When does it occur?
4) Is there anything that makes it better or worse?
5) Is it a dry cough?
6) Do you cough anything up?
7) Do you smoke?
8) Has your medication changed recently?
9) Do you experience any other symptoms?

• 6 things might we consider when asking about coughing:
1) Dyspnoea,
2) Weight loss
3) Pain
4) Syncope
5) Vomiting
6) Stridor
• Less musical sounding than a wheeze, stridor is a high-pitched, turbulent sound that can happen when a child inhales or exhales.
• Stridor usually indicates an obstruction or narrowing in the upper airway, outside of the chest cavity.

Question 13

What are 4 causes of an acute cough?

What are 7 common causes of a chronic cough?

What are 3 less common causes of a chronic cough?

What are 5 red flags concerning coughs?

What are 8 different types of coughs and their causes?

Answer 13

• 4 causes of an acute cough:
1) Viral or bacterial infection
2) Pneumonia
3) Inhalation of foreign body
4) Irritants

• 7 common causes of a chronic cough:
1) Common - gastro-oesophageal reflux
2) Asthma
3) COPD
4) Smoking
5) Post-nasal drip
6) Occupational or other irritants
7) medication (ACEI)

• 3 less common causes of a chronic cough
1) Lung tumour
2) Bronchiectasis
3) Interstitial lung disease

• 5 red flags concerning coughs:
1) Haemoptysis (coughing up blood from lungs)
2) Breathlessness
3) Weight loss
4) Chest pain
5) Smoker

Question 14

What are 9 questions to ask about sputum?

What are 4 different types of sputum?

How do they appear? What is their cause?

Answer 14

• 9 questions to ask about sputum:
1) How often do you produce sputum when you cough?
2) How much sputum do you cough up?
3) Has this changed?
4) What colour is it?
5) Has the colour changed?
6) Is there any blood?
7) Is it frothy or thick?
8) Is there any abnormal smell or taste?
9) Have you been experiencing any other symptoms? – E.g. fever, dyspnoea, pain

Question 15

What are 7 questions we ask about haemoptysis?

What is a red flag concerning haemoptysis?

Answer 15

• 7 questions we ask about haemoptysis:
1) When did you first notice blood in your sputum?
2) How many times has it happened?
3) How much blood is there?
4) Are there any other colours in the sputum apart from the blood?
5) Have you noticed bleeding or bruising anywhere else?
6) Are you taking any medication to thin the blood?
7) Have you noticed any other symptoms? E.g. breathlessness / chest pain / cough / weight loss

• A red flag with haemoptysis is pleuritic chest pain and haemoptysis, as this could indicate lung cancer

Question 16

What Is the ls the red flag triad of pulmonary embolus?

What are 2 malignant causes of haemoptysis?

What are 3 infective causes of haemoptysis?

What is a vascular cause of haemoptysis?

What are 2 cardiac causes of haemoptysis?

Answer 16

• The red flag triad of pulmonary embolus is sudden onset of pleuritic chest pain, shortness of breath, haemoptysis.

• 2 malignant causes of haemoptysis:
1) Bronchial carcinoma
2) Metastatic lung disease

• 3 infective causes of haemoptysis:
1) Acute infection
2) Bronchiectasis
3) TB

• A vascular cause of haemoptysis is pulmonary infarction or pulmonary embolus

• 2 cardiac causes of haemoptysis:
1) Mitral valve disease
2) Acute LVF

• 2 forms of vasculitis that lead to haemoptysis:

1) Wegener’s granulomatosis
• Granulomatosis with polyangiitis is an uncommon disorder that causes inflammation of the blood vessels in your nose, sinuses, throat, lungs and kidneys.
• Formerly called Wegener’s granulomatosis, this condition is one of a group of blood vessel disorders called vasculitis.
• It slows blood flow to some of your organs

2) Good pasture’s syndrome
• Goodpasture syndrome is a rare disorder in which your body mistakenly makes antibodies that attack the lungs and kidneys

• 3 other causes of haemoptysis:
1) Trauma
2) Anticoagulation (consider warfarin)
3) Clotting disorder

Question 17

What 5 questions do we ask about Wheezing?

Answer 17

• 5 questions do we ask about Wheezing:
1) When does it occur; timing and frequency
2) Exacerbators / relievers
3) Do they have an inhaler for wheeze – how often do they need to use it?
4) Exercise tolerance
5) Severity

Question 18

What 4 questions we ask about systemic upset?

What can systemic upset indicate?

Answer 18

• 4 questions we ask about systemic upset:
1) Change in appetite
2) Weight loss
3) Fever – probably means infection
4) Tiredness / lethargy

• Systemic upset could indicate malignancy

Question 19

What are 6 questions that may be asked during the Past Medical History (PMH) section of interview?

What is the 10-part mnemonic for PMH?

Answer 19

• Information about previous illnesses during PMH:
1) Have they been to their doctor for anything before?
2) Have they ever been in hospital?
3) Have they had any operations?
4) Have they had any investigations/treatments for other health problems?
5) Establish if problems are on-going / resolves fully / managed by medication etc
6) Establish chronology and document in ordered fashion

• 10-part mnemonic for PMH
1) J - Jaundice
2) A - Anaemia and other haematological conditions
3) M - Myocardial infarct
4) T – Tuberculosis
5) H – Hypertension and heart disease
6) R – Rheumatic fever
7) E – Epilepsy
8) A – Asthma and COPD
9) D – Diabetes
10) S – Stroke

Question 20

What 4 types of drugs are considered during Drug history (DH)?

What are the 5 things considered when documenting a drug in drug history?

What must be asked regarding allergies?

What is an important allergy to keep in mind?

What is the difference between allergies and adverse effects?

Answer 20

• 4 types of drugs considered during drug history:
1) Prescribed medication
2) Over the counter medication
3) Herbal medication
4) Consider illicit drug use (recreational)

• 5 things considered when document a drug in drug history:
1) Name of drug
2) Dose
3) Route (e.g oral, intramuscular, per rectum)
4) Frequency
5) Duration

• We want to know why they are taking it and if they are takng it correctly
• Regarding allergies, we must ask “are you allergic to anything/any medicines that you know of?
• Elastoplast/latex allergies are important to keep note of
• Adverse effects are expected known side effects of drugs, and are not the intended therapeutic purpose of the drug
• Allergies to medicine are adverse drug reactions mediated by an immune response
• Medicine that can cause adverse effects (e.g stomach upset) can still be prescribed, but it depends on the severity of the effects.

Question 21

What are 6 reasons we ensure accurate medication history?

Answer 21

• 6 reasons we ensure accurate medication history:
1) Improves patient safety
2) Reduces medication errors / near misses
3) Reduces missed doses in hospital
4) Reduces delays to treatment
5) Savings to NHS from prevented errors
6) Improves therapeutic outcomes

Question 22

What are 6 golden rules of medication history taking?

Answer 22

• 6 golden rules of medication history taking:

1) Be structured – methodically collect current meds, allergies and previous adverse drug reactions

2) Engage with the patient whenever possible but find out who knows best about meds – carer?

3) Use more than one source of information to accurately confirm a patient’s medication history.

4) Be alert to use of high-risk medicines (e.g. warfarin, insulin, methotrexate) as accuracy critical in these cases.

• Warfarin can increase haemorrhage risk
• Methotrexate is on a weekly dose, not a daily dose, so a lot of room for error

5) Women of childbearing age – ask about prescribed contraception

6) Are they taking part in any clinical trials?

• Clinical trial medication use/dosage may not appear on medication list

Question 23

What question can we use to start drug taking history?

What 9 questions might we ask about each drug?

Answer 23

• To start drug taking history, we can ask “Which medicines are currently prescribed for you to take?”

• 9 questions might we ask about each drug:
1) Name of medicine?
2) Do you know what it is for?
3) What is the dose/strength?
4) What is the route?
5) Number of tablets or puffs or dose units taken?
6) Type/Form – device type? E.g spacer, auto inhaler
7) How often do you take this?
8) Any recent changes to dose / frequency?
9) Do you think you have any side effects with any of these medications?

Question 24

What are 9 other sources of information we can use about a patient’s medicines?

Answer 24

• Other sources of information we can use about a patient’s medicines:

1) Patient or family/friends/carers

2) Patient’s own medicines – can ask to see their medicines/dosette box

3) Repeat prescription slips/other lists – need to make sure its up to date

4) GP surgery staff / letter/ printout

5) Previous hospital notes/letters

6) Community pharmacy

7) Emergency Care Summary (ECS) Scotland only. (called Summary Care Record in England)

8) MAR chart – Medication Administration Records from care homes, prepared by Pharmacy

9) Substance misuse services – e.g. for methadone doses
• Methadone isn’t prescribed by general practise, but by substances misuse services
• Sometimes, dosage isn’t included, so we may have to contact them to get this information

Question 25

What are 3 questions we may ask concerning allergies?

What else can we do?

What are 3 ways of asking about adverse side-effects?

Answer 25

• 3 questions we may ask concerning allergies:
1) Are you allergic to any medicines?
2) What happened when you had these medicines?
3) Have any medicines caused a rash or difficulty breathing in the past?

• We can also check other sources of information

• 3 ways of asking about adverse side-effects:
1) Have any medicines recently been stopped and if so why?
2) Have you ever had a medicine stopped because the Dr thought it was making you worse?
3) Have you ever stopped a medicine because you felt unwell?

Question 26

What is intentional non-adherence?

What are 4 reasons for unintentional non-adherence?

Answer 26

• Intentional non-adherence– definite decision to not take medicine(s)

• 4 reasons for unintentional non-adherence:
1) Physical dexterity e.g cant reach medicine
2) Reduced vision
3) Cognitive impairment
4) Poor understanding e.g not being taught to use an inhaler properly

Question 27

What are the 2 main inhalers used?

What are 6 inhaler device types?

Answer 27

• The 2 main inhalers used are:

1) Blue
• Acts as a reliever
• Salbutamol acts as a b2 agonist

2) Brown
• Acts as a preventor
• Can contain beclomethasone (corticosteroid)

• 6 Inhaler device types:
1) Mdi = metered dose inhaler
2) Accuhaler
3) Autohaler
4) Easibreathe
5) Handihaler
6) Via spacer / aerochamber

Question 28

What is the purpose of asking about family history (FH)?

What are 4 questions that may be asked?

What may be useful during this section?

What disease might we want to specifically ask about regarding the CV system?

What degree of relative are we most interested about?

What age range are we looking at?

Answer 28

• Asking about family history may give clues about possible genetic pre-disposition to illness

• 4 questions that may be asked regarding family history:
1) Are your parents still alive?
• If yes – how old are they? Do they have any health problems?
• If no – When did they die? What age were they? What did they die from?

2) Do you have any brothers or sisters? How old are they? Are they well/any illnesses?

3) Do you have any children? How old are they? Are they well/any illnesses?

4) Are there any health problems that run in your family?

• We want to ask if any 1st degree relatives (parents, siblings, children) have a history of cardiovascular disease at a young age
• 1st degree male relative less than 55 years
• 1st degree female relative less than 65 years
• May be useful to draw a family tree

Question 29

What are the various aspects of social history (SH) asked about?

Answer 29

1) Employment
• Are you working at the moment?
• May I ask what you do?
• What does that involve?
• Have you had any other jobs in the past?
• Has your health impacted your work at all?
• Important to consider occupation exposure e.g asbestos, excessive noise

2) Smoking
• Do you smoke at all?
• Have you ever smoke?
• If stopped, when did you stop?
• Important to calculate pack years – Packs of cigarettes smoked a day x number of years the person has smoked (20 cigarettes per pack)
• E.g 1 pack year is equal to 1 pack of cigarettes a day for a year (1x1)

3) Alcohol
• Do you drink at all?
• If yes – How often do you drink and how much?
• Try convert these to units, and be aware of recommended limits of alcohol consumption
• Men and women advised to not have more than 14 units a week on a regular basis
• Drinking should be spread across 3 or more days if 14 units is consumed regularly in a week

4) Home circumstances
• Who do they live with, or do they live alone?
• Do they live in a house / flat / bungalow, are there stairs?
• DO they have any help at home? How many carers a day
• ADLs (activities of daily living) e.g getting dressed, making food, walking up and down stairs
• This is one of the most important sections, as we want to ensure the patient has access to what they need to live in their home

5) Other questions to consider:
• Exercise/diet
• Do they have any hobbies or interests?
Do they have any pets?
• Do they drive?

Question 30

What is system enquiry?

What is the purpose of the system enquiry portion of an interview?

What are 7 systems that may be asked about?

What are symptoms we may look for?

Answer 30

• System enquiry is a couple of questions for each remaining system, which acts as a quick screening tool

• Examples of systems and symptoms:
1) CVS – palpitations, syncope (fainting/passing out)
2) RS (respiratory) – cough, mucus, shortness off breath
3) GI – change in bowels, abdominal pain
4) GU (genitourinary) – urinary systems, change in water works, LMP (last menstrual period)
5) Endocrine – lumps in neck, temperature intolerance, changes in weight
6) MS – aches / stiffness in joints / muscles / back
7) CNS – headache, fits, collapses

Question 31

What are 3 questions we ask to address ideas, concerns, and expectations of the patient?

Answer 31

• Questions to address ideas, concerns, and expectations of patient
1) Do you have any thoughts as to what the problem may be?
2) Is there anything that you are particularly worried it may be?
3) What are you hoping I will be able to do for you today?

Question 32

What is the purpose of summarising to complete a history taking?

What is important that needs to occur throughout the session?

Answer 32

• Summarising:
• Helps to clarify points
• May highlight questions you haven’t asked or misunderstanding
• Brings up main points of Presenting complaint (PC) and History of presenting complaint (HPC)
• Brings up relevant features in the remainder of history
• Brings up relevant positives/negatives from systems enquiry

• It is important to explain and gain consent for examination as appropriate

Question 33

3 examples of history taking cases

Answer 33

• 3 examples of history taking cases:

1) A 60-year-old gentleman is having chemotherapy for a GI malignancy, he develops pleuritic chest pain, shortness of breath and haemoptysis
• Has triad of PE, so should consider this

2) A 70-year-old smoker develops a fever, wheeze and a cough with mucky sputum
• Older man
• Smoker
• Fever is an infective symptom
• Wheeze could indicate asthma/COPD
• There is a risk factor for COPD here, with the fever indicating infection, so could be infective exacerbation of COPD

3) A 15-year-old girl who is otherwise fit and well develops a nocturnal cough and wheeze exacerbated by exercise
• Young girl who is otherwise fit
• With asthma, cough and wheeze can be nocturnal and exercise induce
• Could be asthma